The stupidification of ACLS.

[Just Plain Ruff]

For what its worth, I had a course audit of our PALS and ACLS courses., There are some new changes coming down that should ramp up the intensity (a little) and the standards (a little) of the ACLS and PALS.

The only problem I see is that the Training Centers dont monitor and enforce things like this as they should, and many instructors will continue to succumb to pressure and pencil whip the courses

In Short, the problem is the instructors as much (or more) than the AHA.

Yep. Remember most instructors are teaching their friends and co-workers. I know this because I used to teach these classes. You name it I taught it, ACLS, PALS, NRP, ABLS, ITLS and others .

I felt incredible pressure from the course organizers as well as the company that I worked for to pass these people. Some couldn't find their way out of a brown paper bag.

You don't want to embarass your friends or co-workers by failing them but then again you don't really want to pass them when they fail. I know many instructors who have lost friends based on failing them in ACLS or PALS. Employers just want their employees to have that card, they really don't care how they get it.

So peer pressure to pass your co-workers is very prevalent in these types of classes. I like the classes where they have a majority of people that I don't work with. I don't have the pressure from management to pass my co-workers. But I've never been one to pass someone I didn't feel like they should pass.

It was well expected that no-one failed ACLS or PALS. Many of the courses I worked in, if I failed someone on a particular station, the faciliators would sit down with the student and do remediation. They would run them through a set of questions and then if they felt that the person needed to retake the station, they would do so but of course not with me but with a 2nd instructor to promote fairness(I am ok with that). 99.99999 percent of the time, that person would do fine, but the odd times that they would do not and I was retesting them, they would fail. The facilitator would remediate one more time and then the would miraculously Pass. Amazing. Again, NO one failed these classes.

Failure to hold the students to a standard? I'm not sure. But a failure to patients, I do think so.

[emtpstar]

Another reason that ACLS has been simplified, not stupificated is because all the current research and studies clearly show that most, if not all the "advanced" treatments we use in cardiac arrest have shown very little or no improvements in outcomes. The only two things that have shown improvements in survival have been high-quality CPR and rapid defib. The Interntional Committee on Resuscitation Guidelines make the statement in the most recent guidelines changes that the use of an advanced airways in the pre-hospital and hospital setting have shown no improvements in outcomes. Also make the statement that there is no evidence that any medications used in cardiac arrest have improved outcomes. Although there is definitely a time and place for both, the emphasis has switched dramatically to basic life support. I remember when drugs and airways were used before we defibrillated (good ole days). Now that we have supraglottic airways (LMA, King, Combitube) their is not need for intubation in most cases until the patient is stabilized. Giving drugs "down the tube" has also been proven extremely ineffective. I for one am glad it has been simplified.

Edited August 25, 2011 by emtpstar

[Just Plain Ruff]

Another reason that ACLS has been simplified, not stupificated is because all the current research and studies clearly show that most, if not all the "advanced" treatments we use in cardiac arrest have shown very little or no improvements in outcomes. The only two things that have shown improvements in survival have been high-quality CPR and rapid defib. The Interntional Committee on Resuscitation Guidelines make the statement in the most recent guidelines changes that the use of an advanced airways in the pre-hospital and hospital setting have shown no improvements in outcomes. Also make the statement that there is no evidence that any medications used in cardiac arrest have improved outcomes. Although there is definitely a time and place for both, the emphasis has switched dramatically to basic life support. I remember when drugs and airways were used before we defibrillated (good ole days). Now that we have supraglottic airways (LMA, King, Combitube) their is not need for intubation in most cases until the patient is stabilized. Giving drugs "down the tube" has also been proven extremely ineffective. I for one am glad it has been simplified.

So what do you think would be the ramifications of just resorting back to BLS/defib/pace with airway support and transporting? If medications haven't shown to improve outcomes then why do something that hasn't been proven to truly benefit patients. I have always wondered why in EMS we continue to do things the "old" way and not embraced evidence based items?

Is it that it's always been done this way so we can't stop it because it would prove us wrong? or what?

[usalsfyre]

Another reason that ACLS has been simplified, not stupificated is because all the current research and studies clearly show that most, if not all the "advanced" treatments we use in cardiac arrest have shown very little or no improvements in outcomes. The only two things that have shown improvements in survival have been high-quality CPR and rapid defib. The Interntional Committee on Resuscitation Guidelines make the statement in the most recent guidelines changes that the use of an advanced airways in the pre-hospital and hospital setting have shown no improvements in outcomes. Also make the statement that there is no evidence that any medications used in cardiac arrest have improved outcomes. Although there is definitely a time and place for both, the emphasis has switched dramatically to basic life support. I remember when drugs and airways were used before we defibrillated (good ole days). Now that we have supraglottic airways (LMA, King, Combitube) their is not need for intubation in most cases until the patient is stabilized. Giving drugs "down the tube" has also been proven extremely ineffective. I for one am glad it has been simplified.

Great, so our presumed primary cardiac arrest scenarios are simple. What about peri-arrest, and arrest of other etiology scenarios (where you can make far more of a difference). Should we continue to dumb these down as well?

[kohlerrf]

Nothing beats a open airway and early defibrillator and or proper continuous chest compression! My last 2 saves I did not even intubate. You don't need an ACLS course to teach you that.

[HERBIE1]

Good one ruff, you almost got me lol. But I would say the difference in the two is that no one is being discriminated against in ACLS, everyone has the opportunity to study for ACLS - using the same book, and the same ACLS curriculum is used nationwide. So if I am taking ACLS in Indiana or Hawaii, and I have studied the material, I have an equal chance in both places (unless the instructors are racist and give me harder scenarios at the mega code to fail me intentionally -which i am not saying that happens). And if ACLS fails me due to that, or has a faulty test, there is a way to appeal. When applying for the job, I have no idea what the winning candidates scored or why they were chosen above me, and there is no way to appeal a bad decision (other than sueing)

When applying for a job it is different in every single city, county, state. I have no idea what they will ask me or what is on the test, so I cannot "study" for it. In big cities, the testing may have been created by a testing company or university, but in most towns and counties it was written by Joe Bob who works for the department. So if you would create a national employment test that would be used by every single department (similar to the National Registry Test for certification or ACLS), then I would have no pity or arguement for the people who fail, regardless of race.

You guys keep wanting to ignore the fact that the court ruled that there was discrimination here. I did not make it up like a scenario. The facts are the facts.

If you were honest about the comparison Ruff made about dumbing down ACLS with the CFD case, you would see they are EXACTLY the same.

I wouldn't be so quick to cite this court case as anything but a court case. It has nothing to do with facts. The way the laws are written have equated anything with a disparate OUTCOME with discrimination- at least in terms of legal recourse, I would not say that makes the 2 concepts equal in anything but a discrimination type lawsuit/court action.

Minorities were adversely affected by the test. The test WAS NOT BIASED, but the results clearly showed the blacks did poorly on the exam. So instead of figuring out WHY they did poorly, they simply played the race card. Congrats- it's lotto time.

Problem is, this will happen on the next exam, and nobody has the guts to offer honest reasons for that. Short of saying- any minority with a pulse will get the job, how do you ensure you get the results you want to see?

Do you have any idea how many concessions are made to ensure they get enough minorities to even take the test? They waive the application fee, they hold special study sessions held only in the black communities, they even have people hand out applications in these neighborhoods so nobody even needs to make the effort to pick up the application like everyone else, and then of course, they dumb down the test, ensure it's not biased, have it written by a black man, and they STILL cannot get the numbers they want. At what point do these ridiculous lengths become too much? At what point do folks start asking the tough questions- regardless if they are uncomfortable or unPC?

Relating this to the ACLS course, I don't know why they dumbed down the test, but I'm thinking whatever the reason, it cannot be justified.

You really don't want to go down this road with me with the bias route, Crochity, you will look VERY foolish.

[Bieber]

Another reason that ACLS has been simplified, not stupificated is because all the current research and studies clearly show that most, if not all the "advanced" treatments we use in cardiac arrest have shown very little or no improvements in outcomes. The only two things that have shown improvements in survival have been high-quality CPR and rapid defib. The Interntional Committee on Resuscitation Guidelines make the statement in the most recent guidelines changes that the use of an advanced airways in the pre-hospital and hospital setting have shown no improvements in outcomes. Also make the statement that there is no evidence that any medications used in cardiac arrest have improved outcomes. Although there is definitely a time and place for both, the emphasis has switched dramatically to basic life support. I remember when drugs and airways were used before we defibrillated (good ole days). Now that we have supraglottic airways (LMA, King, Combitube) their is not need for intubation in most cases until the patient is stabilized. Giving drugs "down the tube" has also been proven extremely ineffective. I for one am glad it has been simplified.

While I agree with most of what you say, I think I have read some studies that say that while ACLS drugs don't increase survival to discharge they do increase return of spontaneous circulation. Maybe the error is not the drugs so much as the post-resuscitation care, which we are beginning to see has been woefully inadequate in EMS. Thankfully that does seem to be changing slowly but surely. Also, I just read a recent study where sodium nitroprusside (in pigs) showed a tremendous increase in survival rates from cardiac arrest. Maybe we're just not giving the right drugs, maybe there is no right drug, either way, the more we study medicine, the more we'll be able to tailor our treatments and provide more effective care.

Probably the most important take home lesson from this surge in evidence-based medicine is that how we treat our patients today is probably not how paramedics will be treating them a century from now. If backtracking our treatments and simplifying them is what works, then that's what we need to do; if they say five years from now that we need to further advance our treatments with new or different medications, a new or different kind of airway, or whatever else, we're going to have to be receptive to those changes as well. Medicine is dynamic and we really can't say what the best way to resuscitate patients in cardiac arrest is until the science reaches the point where we can successfully resuscitate all salvageable patients (those in whom resuscitative efforts of any kind will be futile; i.e. the truly dead). And the same is true for all treatments.

I for one look forward to seeing where we will be when I end my career in EMS; I have a notion it is going to look nothing like the medicine I'm practicing now.

[chbare]

Great, so our presumed primary cardiac arrest scenarios are simple. What about peri-arrest, and arrest of other etiology scenarios (where you can make far more of a difference). Should we continue to dumb these down as well?

We look at other courses that focus on these situations. The FCCS course, for example, focuses on responding to these critically Ill and or injured patients. There exist many other courses as well. I'm not sure why people continue to think ACLS should be something it's not?

[Tom B.]

We look at other courses that focus on these situations. The FCCS course, for example, focuses on responding to these critically Ill and or injured patients. There exist many other courses as well. I'm not sure why people continue to think ACLS should be something it's not?

ACLS does encompass the critically ill periarrest patient. Why do you think it does not? The ACLS Reference Textbook and Experienced Providers Manual is a fantastic resource. The dumbed down video-driven basic ACLS course is an abortion and we should require more of our paramedics than to be resuscitation technicians who can follow a cookbook but are incapable of considering the Hs and Ts. The AHA has FAILED when it comes to prehospital emergency medicine. Period.

[chbare]

I was not talking about ACLS-EP. Also, it's about time (well past actually) that paramedic programmmes quit using ACLS as a standard educational tool. AHA develops guidelines based on a review of the science. The onus for good pre-hospital education sits squarely on our shoulders not AHA.