Has ACLS become a merit badge without merit?

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

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.

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