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Has ACLS become a merit badge without merit? News

July 23, 2013

The Ambulance Driver's Perspective
by Kelly Grayson

Has ACLS become a merit badge without merit?

The science may be good, but the delivery may be lacking

By Kelly Grayson

You can guess the career longevity of an EMS provider by asking them the question, “Do you remember when ACLS was hard?”

Depending on who you ask, you’ll get flashbacks from traumatized students of megacode proctors pulling out IV lines, demanding instant recall of obscure drug dosages, or concocting code scenarios that tread the line between uncommon and laughably improbable. Or you’ll hear wistful tales from the dinosaurs pining for a time “when an ACLS card actually meant something”.

In twenty years of teaching ACLS, I’ve heard them all. Told a few of each type myself, as it happens.

The meaning of the badge
There was a time when an ACLS Provider card was a badge of honor. They were hard to get. Experienced physicians even failed the course, and for a paramedic to pass was proof that you knew your stuff. You were a cut above your colleagues. Only the more experienced ICU and ED nurses held ACLS cards.

Problem was, ACLS courses of that era often became an exercise in proving how smart the instructors were, and learning took a back seat to intimidation. Even experienced providers looked forward to recertification with all the dread normally reserved for IRS audits, and were too stressed during the course to retain much of the information. Inexperienced providers or those only peripherally involved in resuscitations avoided it like the plague.

There was a cottage industry of ACLS prep courses: flash cards, EKG and pharmacology tutorials, and jingles that set the algorithms to music.  How many of you remember Rockin’ to the Algorithms, by 2 Live Nurse?

All that began to change in the late nineties, with the advent of the kinder, gentler ACLS course. ACLS course materials and instructional methods became more student-centered, and ACLS certification was within reach of a far broader spectrum of medical providers. ACLS guidelines began to adhere to the tenets of evidence-based medicine, and we began to discard ineffective treatments and seek better ones, based upon sound scientific research.

Certainly, some therapies persist despite what some critics insist is a lack of proof of benefit, but most reasonable people would agree that ACLS guidelines are far less hidebound and intractable than they were even ten years ago.

But somewhere along the way, in the American Heart Association’s efforts to make ACLS more egalitarian, they’ve made it more, well… pedestrian. It doesn’t take much work to earn an ACLS card these days. To steal a line from the Geico commercials, it’s so easy, a caveman could do it.

Kill the messenger, not the message
That isn’t an indictment of the treatment guidelines. I’m not one of those dinosaurs who pine for the good old days of Bretylium and stacked shocks, and “intubate everybody, and let the respiratory therapists sort ‘em out.” The guidelines these days are based, for the most part, on solid evidence, and it isn’t the fault of the AHA that the only things we know to improve outcomes are good compressions and timely defibrillation. If our goal is to improve cardiac arrest survival rates, then we should rightly focus education on the things proven to work, even if they are absurdly simple.

What I do question, however, is the delivery of that information. Increasingly, the organization’s requirements of AHA Training Centers and their instructors seem more focused on protecting a revenue stream than educating healthcare providers. Instructors who dare to deviate from AHA’s approved course format and materials are disciplined for “teaching outside the guidelines.” Can’t use outside books or materials, must library a goodly supply of provider manuals or require that every participant purchase one outright – no borrowing of books, people! – and God forbid your evaluation of the research leads you to a different conclusion than the officially-sanctioned guidelines. If new research comes to light, we mustn’t mention it until AHA deems it worthy of inclusion in the guidelines, which might take as many as five years.

The meaning of expiration dates
Even when those new guidelines are released, instructors need to keep on teaching the old stuff until new course materials are released much later in the year. The cynical among us would postulate that the timing of the release of those new materials coincides with the day the old, outdated materials are sold out.

That would be the cynical among us. I am not one of them. I believe that money has nothing to do with it. Then again, I eagerly awaited the arrival of Santa Claus until I was fourteen, and I believed that every final episode of The Bachelor would end in a happy marriage.

In my years as an AHA Regional Faculty for ACLS and PALS, my position was always that it was acceptable, even encouraged, to teach above and beyond the guidelines, as long as you didn’t test above the guidelines. In other words, if you wanted to augment the canned course video on a particular case, or discuss a case in more depth than the course required, you were free to do so, as long as the written exam and the megacode adhered to the minimum testing guidelines.

That was the way I taught, the way I encouraged other instructors to teach, and the way I identified course participants with instructor potential. Over the years, it was pointed out to me, subtly at first and then not-so-subtly, that such an approach was not welcome.

The video-based format has managed to achieve AHA’s goal of course uniformity. Every ACLS course, no matter where you take it, is now pretty much the same.

Unfortunately, that means that they’re also uniformly mediocre. Much like the medical director who writes exquisitely detailed treatment protocols that spell out in exact detail how much treatment you must provide, AHA has inadvertently made their course format the ceiling, not the floor. Instead of ensuring that the least talented and experienced ACLS instructor delivers the same content as the most talented and experienced, they have forced the best instructors to lower their teaching standards to that of the guy whose primary qualifications are a brainstem and an index finger to press the PLAY button on the DVD player.

Knowledge, devalued
In their efforts to broaden the reach of ACLS, the AHA has also managed to cheapen it for those who will use it most: ED and ICU doctors and nurses, and paramedics. In past years, in the old AHA instructor courses, instructor candidates were often asked to role-play in scenarios designed to address common classroom problems. One of those scenarios was “dealing with the bored advanced participant.”

In today’s ACLS course, if you’re teaching paramedics, ED or ICU staff, everyone in the class is a bored advanced participant.

This problem was noted by EMS1 columnist and blogger, Tom Bouthillet, in a recent post to the National EMS Management Association’s web forum. Tom’s post read, in part:

“South Carolina is a National Registry state so our EMTs and paramedics recertify through the NREMT. Our department has become increasingly dissatisfied with the American Heart Association's ACLS class to the point where most of us (including our Medical Directors) are agreed that it's ‘non-value added activity.’ We feel like our Pit Crew, Code STEMI, Code ICE, and 12-Lead ECG courses far exceed any benefit obtained from the merit badge courses.”

Tom’s not alone in that sentiment. If you work in a progressive EMS system with a strong commitment to cardiac care, you’ve probably realized, as Tom has, that the standard ACLS course has become a merit badge without merit.

With a little more investigation, Tom discovered what some of you may already know, but a great many likely do not: ACLS and CPR cards are not a requirement for recertification through the National Registry of EMTs.

A certification card from the AHA is merely the path of least resistance taken by most agencies. A certification card from American Safety and Health Institute will work just as well, and ASHI is far easier to work with in terms of course customization. Alternatively, an agency’s medical director may simply attest that the personnel of that agency are adequately trained in CPR and ECC guidelines. If your employer’s training exceeds those guidelines, and your state doesn’t impose more stringent recertification requirements than NREMT, you’re golden.

AHA does still offer a course that is more challenging and in-depth than the traditional ACLS refresher: ACLS for Experienced Providers. I was once an ACLS EP instructor, and the course was everything I wanted ACLS to be; challenging, informative and intellectually stimulating. Mastery of the resuscitation guidelines was considered a baseline requirement.   Unfortunately, the utility of the in-depth case discussions and challenging scenarios was negated by unrealistic faculty requirements and a total absence of prehospital content. It was nigh impossible to find the people required to teach an ACLS EP course in many areas.

My sources at AHA, however, inform me that those two flaws have been addressed. Not only does the new ACLS EP course include prehospital-focused information and scenarios, but it is also far easier to set up and conduct a course.

If you’re a new nurse or medic, take the standard ACLS course. It poses no intellectual challenge, but at least it establishes a baseline level of instruction to keep your risk managers happy.

But once it’s time to renew, and your practice environment requires you to perform resuscitations and advanced cardiac care on a regular basis, take ACLS for Experienced Providers instead.

I think you’ll find it a far better use of your time than trying to stay awake through a series of videos that, increasingly, bear little resemblance to the care you provide.

About the author

Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (, or email him at

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Kevin Budig Kevin Budig Tuesday, July 23, 2013 11:29:50 AM Speaking truth you are. We do EP course for mostly Residents or MDs..Never Medics or Nurses here. Not sure why, but then I just help as the Head Instructor rules the who, why and what can take it with an iron fist.. Bretylium.... Shock, Shock, Shock em into something you recognize... Students still stress out..Even the ones whom have been around awhile...
John Oscar John Oscar Tuesday, July 23, 2013 2:33:08 PM I think NAEMT should be looked at as the money making merit badge company before the AHA.
Chris Dye Chris Dye Tuesday, July 23, 2013 3:04:26 PM The truth, and well-stated.
Kelly Grayson Kelly Grayson Tuesday, July 23, 2013 3:12:03 PM As holder of most of the merit badges, and an instructor at one time or another in all of them, I agree. But in my AMLS, PHTLS, etc. merit badge courses, I was still allowed to challenge my students and use some creativity in course design. Not so with ACLS.
Donald Rogers Donald Rogers Tuesday, July 23, 2013 3:17:45 PM What do you think?
Kelly Grayson Kelly Grayson Tuesday, July 23, 2013 5:15:18 PM Rhetorical question, Donald? ;) What do I think about what?
Alan W. Rose Alan W. Rose Tuesday, July 23, 2013 5:55:41 PM ACLS et al "alphabet cards" is a bunch of BS. Learn it in class, relearn it in recert class, learn and relearn it again some more for ACLS which never syncs with state recert. How many times do I need to learn what I already know, and do? Once per recert cycle should be sufficient. I used to work for an EMS agency that did not require alphabet cards but now I do. Luckily they also provide the classes for free. I certainly remember when the classes were more strenuous. Also when they switched to "everybody passes." Other than a general dislike to being forced to keep these cards under threat of suspension and termination, the biggest complaint I have is that the classes should be restructured to address the needs of the provider. A Paramedic does not need to be group tested to the end of the scenario that involves hospital'physician only interventions.
Ben Dowdy Ben Dowdy Tuesday, July 23, 2013 8:03:46 PM Not sure I agree....ACLS seems to have morphed into a checklist-oriented class. In and of itself, I don't think that's a bad resuscitation, rapid, aggressive steps need to be taken for folks to survive. But I agree that the stock ACLS doesn't address the whole story. I've not taken the EP course yet (scarce in my neck of the woods), but it seems to teach the critical thinking behind it all, which is equally important in the prehospital setting. I think we need both in EMS; a combination of Chuck Norris and Columbo, if you will. We need to be able to think the case through, but also have a checklist of things to keep us busy while we sit back and punt.
Tuesday, July 23, 2013 10:09:50 PM Bravo Sir
Vince Warde Vince Warde Wednesday, July 24, 2013 12:08:22 AM I am a real dinosaur having worked from 1976-1985. I can tell you that our ACLS classes were anything but easy. Folks, I graduated from Daniel Freeman in Spring of 79. I was one of the thousands of people who got into EMS because of "Johnny and Roy". We lost close to 40% of our class in the first 8 weeks of classroom training. The academics were brutal. and well over 50% was ACLS. I worked until my back ended my career, and almost all the people I worked with are no longer working. We had to work hard to gain trust and acceptance - it's sad to hear that the standards have been lowered. I am glad that other organizations are working to keep them high. BTW, as you work off of standing orders we could only dream of (we had to call in to do almost anything), remember that you benefit from the trust we established. Care for it well, for many of us, it came at a high price.....
Mark Caplin Mark Caplin Wednesday, July 24, 2013 6:01:57 AM I am an EP instructor. Many of the things in that class should be in the basic ACLS class. But most people don't run codes and need the "checklist" mentality in time of crisis. Come to SF in October, we are putting on a class.
Melinda Teaster Williams Melinda Teaster Williams Wednesday, July 24, 2013 7:35:16 AM I have found that the ACLS-EP class makes you think outside the box, not only do you get the how you get the why behind the problem, I would never sit through the regular ACLS recert. again. For those of you that think taking 2 days from you life to sit through an EP class, well maybe you should consider a new line of work, Going through the motions is no longer what EMS does. But this is just my opinion.
Barbara Furry Barbara Furry Wednesday, July 24, 2013 10:15:38 AM I have been an ACLS EP instructor for 15 years. One of the originals! I do agree with what Mr Grayson has written. I would like to add though whether you take a regular ACLS course or ACLS EP, you really need to make the course work for you. We are human beings taking care of other human beings.We are not taking care of computers. Being able to push a button with a voice assisted manikin and sitting in front of a computer to "take ACLS" is a travesty for education. With ACLS EP, you learn the why's behind the science and the course truly provides a critical thinking experience. It does take a certain type of instructor to be able to teach ACLS EP in a meaningful manner. We provide excellent ACLS EP classes on a regular basis! My instructor team consists of Emergency Department physicians, critical care nurses and paramedics.We provide a balanced approach to education using all involved with resuscitation. Director at The Center of Excellence in Education.
Ben Dowdy Ben Dowdy Wednesday, July 24, 2013 2:31:45 PM Oh God, I'd love to. I'll have to see if I can get time off from the university for that :)
Chris Hardcastle Chris Hardcastle Wednesday, July 24, 2013 2:59:40 PM An interesting article with some interesting comments, here are the points that I would agree with: Yes, ACLS has gotten easier. Yes, the ACLS Algorhythms are easier to follow. Yes, the course structure is now about the curriculum, not how smart that faculty is. You say the ACLS course has become a merit badge without merit. I disagree. The AHA ACLS course is designed for multiple medical disciplines, Nurses, Paramedics, Doctors, Respiratory Therapists, etc. It is not designed for one specific medical discipline but for medical disciplines that respond to cardiac events. I believe the new merit behind the ACLS program is now about being part of a team. It is not about being smart enough to impress a group of instructors. It is teamwork that saves lives, and one of the main functions behind ACLS & PALS training programs is to give the “Team” the ability to work from the same playbook. _______ You state that the knowledge is devalued, again I disagree. I often teach classes full of advanced practitioners and rarely ever do I have issues with them being bored. Part of our jobs as instructors is to believe in the message that we are delivering if you can’t or don’t believe in the message, it is time to reevaluate your position as an instructor. _________ Lastly you complain about the fact that AHA discourages individual instructors from adding value to the course by adding in content that has not been verified. My argument against that is just because a new study comes out in favor of one treatment or another doesn’t necessarily mean that we should implement it into the courses. Many of the studies that I came across as a clinical educator aren’t worth the paper they are written on. Every five years ILCOR reviews all of the relevant studies surrounding cardiac care and determines which ones should and shouldn’t be included in the ACLS curriculum. The other part about adding content outside of the course curriculum is, who is now responsible should that information be wrong. What if some practitioner takes this extra information that you have added, used it on a patient, and that patient has a poor outcome. The first thing that that practitioner is going to say is “That is what I was taught in ACLS”. And now the bloody lawyers are all over the AHA and you the instructor. ________ While I do agree that there is no such thing as a perfect educational program, the AHA courses do put a better effort in to their programs then a good majority of the educational developers. I don’t thinks it is proper to devalue the AHA program just because it is not as hard as it was 20 years ago. At the end of the day, what you get out of a program is only as good as what you put in to the program.
Suzi Bernert Suzi Bernert Wednesday, July 24, 2013 6:44:23 PM As a paramedic and a retired AHA Training Center Coordinator, I could not agree more. When I took paramedic class, our ACLS was tough, it was supposed to be. When I became an instructor, I tried to be fair, but I did not want to have my name on a card if they did not know the material. Now AHA seems more interested in "churning out" more students ($) than quality. They are researching ways to cut out Instructors entirely so they can get all the money, too. They are discouraging any deviation in the name of standardization.
Ernie Sharp Ernie Sharp Thursday, July 25, 2013 7:04:22 AM There are so many certifications that it is ridiculous: GEMS, AMLS, PALS, ACLS, BLS, TCCC, etc. Yet even though they have been dumbed down, I still have students that can't pass a recert class. One nurse even told me that she regretted taking my ACLS recert class, because her RN friends knew a guy that would sell them the card for $75. What sucks is that ASHI is not an alternative in my neck of the woods, because employers won't accept it. Them claim that "anyone can be an ASHI training center."
Scott Brown Scott Brown Thursday, July 25, 2013 4:41:50 PM Do you not agree that the inclusion of seemingly EVERYBODY in any sort of medical capacity needing an ACLS card for their facility to be able to adhere to some idiotic reg has something to do with this? The VAST majority of people I teach ACLS to work in clinics, home health, dentists offices, chiropractors...L&D... Since they started requiring everybody and their gramma to have a card, absolutely it's a merit badge that's meaningless. I wasn't aware that there was controversy about this?
Alan W. Rose Alan W. Rose Thursday, July 25, 2013 4:44:13 PM As far as the team concept goes, I have yet to have any doctors, nurses, or respiratory therapists in the back of my medic when I utilized my ACLS skills. What I do have are teams of EMTs that have never taken an ACLS course, and would not benefit from the course in it's present form.
Greg Natsch Greg Natsch Thursday, July 25, 2013 5:05:40 PM I remember ACLS in 1976, physicians were failing, but we still used the standards.Passing was an achievement. It meant you knew your cardiology skills and arrhythmia treatment. In 1980-1982 we had to prepare for the class since ACLS has never been a teaching course but a skills validation/testing program. The whole issue of "the perfect strip" was always a bit bogus.We never had a patient with lights and a metronome.Standards changed back and forth, creating a need for classes. Then the courses went from no stress to no use. As an instructor it seemed that we were mirroring schools. Everyone's a winner, no one fails, then the gold stars and cards were given out. Maybe it should be left at the service level to validate paramedic's skill annually with input from the medical director. Teamwork is good, but in many cases their is one medic directing the team of BLS assistants. A team is individuals working together towards a goal.Like football the quarterback is calling the shots. Simple thinking? Sure is. Why make it harder than reality dictates. ACLS has run its course. Let it go.Keep it local to fit your needs.
Christina Hunt Christina Hunt Friday, July 26, 2013 6:56:31 AM I'd like to see an ACLS-EP class in Georgia sometime soon.
Sam Needleman Sam Needleman Friday, July 26, 2013 7:02:00 AM I remember my first ACLS class... Nurses passing out waiting to do their megacode from the stress. My first megacode was three medic sitting behind a table grilling me on drug dosages, there was no dummy, except me, and the cardiac monitor was a lifepak 5...
Steve Jacobi Steve Jacobi Friday, July 26, 2013 8:28:33 AM It is when the agencies use ACLS as the sole teaching device where it becomes a problem. Accrediting agencies like something which is standardized nationally. This is why AHA classes have remained as a requirement for HH, clinics and some hospitals. But, those who are involved in resuscitation in hospitals and clinics are also well trained by that facility in "ACLS" and do not rely on just the card. Those who are in EMS agencies who have good medical oversight and do extra training would know this is just a routine to follow to test for a simple understanding of the changes in the algorithms and isn't much more. Those here who still rely on an ACLS class to teach you "ACLS" are the ones who have been in the dark about the purpose of this class. AHA announced its changes and purpose many years ago. Too bad so many don't keep updated and don't understand its purpose. Unfortunately even so Paramedic schools still believe ACLS is a teaching class rather than a review and testing tool.
Barbara Furry Barbara Furry Friday, July 26, 2013 10:46:52 AM We would love to come and teach an ACLS EP class for you Christina!
Garry Watkins Garry Watkins Monday, August 26, 2013 6:17:25 AM CPR = "push hard & fast in the middle of the chest", "at least 100..", "at least 2 inches". Resusi Anna would crap herself if she knew the strip coming out of her side was no longer relevant. ACLS is painfully easier - has it been 'dumbed down"? Hmmm.

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