Everyone Gets a Card! The Diminishing Importance of ACLS

When I was twelve I managed to earn my official First Aid Merit Badge from the Boy Scouts of America. I passed the week-long class over the time I spent at Camp Loud Thunder under the teachings of the irascible, yet charming, Mr. Charlie Walker. The class met in the “Kiva” which was the “campish” name for the shelter next to the flag poles in the center of the camp.

I took the class for roughly an hour each day alongside around 30 or so of my fellow campers. We learned all of the classical first-aid techniques that Boy Scouts need to know including how to apply bandages, how to use direct pressure to staunch severe bleeding, how to perform mouth-to-mouth “rescue breathing,” and other equally vital pieces of information. I’ve often said that over the years I’ve spent as a paramedic I’ve used my Boy Scout First-Aid merit badge training as the basis for quite a bit of the treatment I’ve provided including the one time that I responded to a 911 call for a fish hook in a drunk man’s finger at a river side tavern.

The class had a small booklet that we all had to purchase from the camp store that complimented the knowledge contained in the Official Boy Scout Handbook (which I still have in my bookshelf, by the way). In order to pass the class and earn our badges we all had to dutifully check off the procedural checklists in the back of the book as we were tested in our knowledge by Mr. Walker via both verbal tests and scenarios.  We went through the scenarios in teams and answered the questions in teams as well. I suppose that some of the kids in the group learned and retained more knowledge than others, but we all passed the class and got the fabric patch to have someone sew on our sashes. I can only guess as to how many of my fellow students actually put their first-aid knowledge to the test since that time, but I would say that a small percentage used their knowledge compared to the rest of the class who most probably never had to.

As an adult paramedic I get to re-live this experience so vividly that I almost expect Ol’ Charlie himself to pop up and test me about once every two years when I take my American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) recertification class. The similarities are striking. There’s a small booklet of knowledge that everyone has to purchase, the class is tested in teams using watered-down testing methods, and darn-near everyone gets a card no matter their level of actual participation in the scenario-based testing. The fact that students come out of the class with varying levels of knowledge and ability to apply the things they’ve learned is just as similar to the fact that most of the students probably will never have to take a lead role in treating a patient in cardiac arrest.

ACLS has become a merit-badge where a level of minimum knowledge and participation in the class is rewarded by a little card with a name printed on it. While the source material and knowledge the course is supposed to impart is important, the class itself and the results it is supposed to gather have become somewhat of a joke amongst those of us who are tasked with actually resuscitating patients. Sure, it is very important for healthcare providers of all stripes to have a base knowledge of resuscitation techniques and the medications and procedures involved, but the AHA has watered the class down to the point where floor nurses, respiratory therapists, hospital environmental services workers, and others who will never carry the burden of being in-charge of managing an actual cardiac arrest are trained to repeat dogmatic phrases that they will never remember when faced with an actual situation.

My opinion of the actual practice of ACLS training has changed markedly over my career. I initially took the class as part of my paramedic education where the card was revered amongst my instructors and classmates as something we absolutely needed to have in order to achieve our licensure and subsequently perform in the field as professional caregivers. It was explained to us that ACLS and patient resuscitation were the “bread and butter” skills of paramedicine and that we needed to know every nuance of what we were being taught in order to do our jobs correctly. As the years and recertifications went by and I took classes put on by EMS agencies alongside mainly other paramedics. This mindset was reinforced and strengthened. The occasional nurse or physician that took the classes with us told me that they enjoyed going through their recertifications with paramedics because we always seemed to know what we were supposed to and they were happy to let us take the lead in the scenario-based testing. As my career progressed, however, I found myself increasingly in the hospital environment taking my ACLS recertifications alongside nurses and other allied-health professionals. While they were all exceptional people who knew their slice of the healthcare world every bit as well as I know my own, they were not nearly as aggressive in learning and applying the knowledge contained in the ACLS class as I was. The teaching methods used by the instructors seemed as watered-down as the testing methods used, and the allowance of students who hadn’t mastered the subject matter to achieve success and receive their card was rampant. I would walk out of the classes each cycle happy that I had done my duty to renew my card but absolutely sure that I would not trust many of my classmates to resuscitate a patient should they have to do so.

I’m not sure at what point in time I began completely regarding ACLS as a joke wrapped in a pointless waste of time, but I surmise that it was around the time I began working for an ambulance service under a medical director that emphasized cardiocerebral resuscitation and pushed excellence in all-things cardiac arrest. We trained, researched, educated, and practiced resuscitations so many times that we could regurgitate every nuance of what we were supposed to be doing in our sleep. We took a team-approach and learned the responsibilities of every position within the team. We practiced with our colleagues, talked with each other about the subject often, and then debriefed ourselves to learn from each and every time we put our skills into practice. Everyone learned, everyone trained, and everyone mastered the techniques we needed to save peoples’ lives. Should my coworkers not have mastered the subject matter there would have been failure, with consequences imposed, but everyone worked very hard and was very motivated to succeed.

Consequently, our cardiac arrest survival rates at that small service jumped from 15% to 48% measured by people who had died once but then were able to walk out of the hospital in witnessed arrest. The research, pioneered in our area by our medical director helped us save people who would not have been saved in the past. There has been much documentation of this fact in medical journals and elsewhere.

It has been my experience, anecdotally speaking, that EMS providers and services that rely solely upon ACLS classes and certification to assure their competency in cardiac arrest resuscitation have lower survival rates than those who adopt additional measures to train, educate, and perform the task. I have seen services that educate their providers in techniques such as cardiocerebral resuscitation and the “Pit-Crew” method produce staggeringly higher rates of survival than those that do not. While I can point to no studies that adequately address the particular topic of provider education affecting rates of survival and patient outcome it would seem to be a common-sense suggestion that people who train to the minimum standard of education achieve the minimum standard of results.

I’d wager that among educated and experienced healthcare providers who have given the issue significant thought one would be hard pressed to find a person who didn’t consider ACLS in its present form to be anything more than a minimum standard.

I have friends and colleagues who have provided varying degrees of input to the current ACLS class in various roles with the AHA and I am not attacking them nor their work. I support the mission and vision of the AHA and am not wishing to bring them discredit when I assert that the current model of ACLS needs revisiting, if not a complete overhaul.

My recommendation to EMS services and other healthcare providers who provide resuscitation services is to realistically look at ACLS at what it actually is, the minimum standard of initial education. It’s a merit badge course that can be used as an initial metric in testing for basic competency. I have no problem with ambulance services, for example, putting their EMT-Basics through an ACLS class after they receive prerequisite training in cardiac anatomy and physiology. While these EMT-Bs wouldn’t subsequently be able to perform the skills taught in the class, they would be no less able to perform them than a lot of the students who currently are passing the class and earning their cards. Paramedics who are responsible for actual patient resuscitations need great amounts of additional knowledge, training, and testing in order to be competent at the skill of bringing people back to life and ACLS does little more than provide an “awareness” of these skills. It cannot be considered the end-point of education for people who are actually responsible to determine a course of action and give orders to others and it cannot be the sole education required of those ultimately responsible for resuscitation.

Nor do I believe it is intended to be.

I do not believe that ACLS should be abandoned. However, without significant changes I do not believe that it is as useful as it once was. As it stands, I cannot recommend that it be considered the standard of education in cardiac arrest resuscitation and I do not recommend that EMS providers or services use it as their sole metric for assuring competency in this vital, life-or-death set of skills. Train yourselves and your people above the minimum standard. Your patients deserve it.

I welcome your thoughts on this subject as well.


As usual, I’m not the only person saying things like this. Last year, the venerable Kelly Grayson posted his thoughts on the subject in this column on EMS1.com

  • mr618

    Last year, I went through the “ACLS for Basic EMTs” class, and found it very useful. Of course it wasn’t the full ACLS class you take, but it did give me a much better understanding of what you do, and why. It also introduced me to the contents of your drug box — I’m with a BLS non-transporting service, so we don’t often have a chance to ride with medics — so I can find what you’re asking for a little bit more easily (which, in turn, hopefully makes your job a little easier).

    No, I can’t do what you and Grayson and Morse and Schorr can do. “All” I can do is try to keep the patient viable till you arrive, then assist you in whatever way I can. It seems to me, though, that that is exactly the way they system is supposed to work… lay responder to basic to medic to facility.

    • Christopher

      The didactic portion is always good for EMT’s, but the honest answer is all we need from EVERYONE is hands on the chest. The ideal ACLS for OOHCA would teach that an airway is a death sentence and that the body will blow up if you drop below 100 compressions per minute or go above 125 compressions per minute!

      Resuscitation from out-of-hospital cardiac arrest (OOHCA) is boring these days, and rightfully so. Nothing paramedics do have any shred of proof it is worth spending any time on. Most of our medications perform no better than a 10cc flush!

      What does this mean? It means you really don’t need to know what the paramedic is going to do next, because it isn’t substantiated by any known evidence. We’re literally making it up as we go along. You should be horrified leaving an ACLS if your instructor covered Levels of Evidence.

      We need EMT’s running their own show in the CPR Triangle (waist up), rotating thru compressors to ensure fresh hands are on the chest every 2 minutes. We need you guys actively critiquing your own CPR. We need you guys monitoring the capnography waveform and ventilation rates like hawks (faster than 6/min? they probably didn’t have anything worth living for I guess). We need you yelling at any man, woman, or child who would dare ask you to take your hands off the chest for anything but appropriate defibrillation.

      The honest truth is you guys own the code, paramedics just get in the way. Push hard and fast and the second a paramedic steps into your CPR triangle, you should put them in their place.

      • mr618

        I guess we’re really fortunate up here in Maine. We have a few “paragods” who think we’re lower than worm turds, but for the most part, we all work well together. I wouldn’t say that we “own” a code… we stabilize till the medic gets there, then we all take turns on compressions till they’re ready to roll. We critique compressions back and forth: basic to basic, medic to basic and basic to medic, even medic to medic. We’ll even yell at a medic if necessary (had a medic on the feet try to call a count for sliding a trauma pt out of a car… THAT lasted about half a second*)

        Sure, BLS may save more lives than the Johnny and Roy magic, but I can’t give epi (well, not for cardiacs). We need to all work together to give our patients the best chance for survival. There are things medics can do that we can’t — pain control springs to mind — so if we can help you with finding stuff that you need, we’re all for it. What’s that the Red Cross says in their CPR Healthcare course? Oh, yeah, “… all part of a healthcare continuum that starts with the lay responder and ends with definitive care…”

        And you know, most of us don’t even mind a little constructive criticism… and we certainly don’t mind learning something new.

        * Turned out the two medics wanted to see if we had the cojones to yell at them… they set it up en route and agreed they weren’t going to move the pt if we didn’t correct them. They were pleasantly surprised to see we wouldn’t put up with BS that might affect a patient.

        • Christopher

          With our current dosing scheme epi probably kills as many or more people than it “saves” in a cardiac arrest, so don’t feel left out. In fact, you should celebrate that you don’t kill people like paramedics do (“Spinal immobilization” itself is a huge myth we’ve perpetuated onto ourselves, but another topic for another day).

          I’m glad to hear you guys have a working tiered model for OOHCA! We spent a lot of time locally ensuring our first responders and EMTs really did feel ownership of the code. Sure, we provide the “code commander” and manual defibrillation, but honestly it should run roughly the same way if you had all BLS vs mixed BLS/ALS.

          What’s missing from the chain of survival is the notion that you can’t actually move it forward without the initial links. (I think I’m going to work on a better metaphor this afternoon)

  • medic1518

    “Where do we go from here…..now that all of the children
    have grown up” Sorry, this is the song that popped into my head while I was
    reading your article.

    ACLS used to be intra-cardiac epinephrine and central lines. I remember a physician standing over the examination and I was nervous, failure was not an option. This was over 20 years ago. Times change.

    I would argue that we have changed the entire teaching methods as it revolves around EMS. This change is not because we are pioneers, it is because we have become sheep. We are now no different than the soccer games are kids played ten years ago when “Everybody” wins. We have taken away losing because, well, it doesn’t feel “good.” I say losing or
    failing is good!

    How many people want a pilot that passed aeronautics only
    after the class was changed to take out the parts that many people failed. We do not want the pilots to have a bad self-image. I mean, where does it end?

    Chris, your article speaks about the ACLS card being your starting point funny thing is, so is your paramedic license. There is no end point in emergency medicine education. Well, there is an end point
    when the practitioner retires or expires. Everyone needs to constantly push, learn, and evaluate their own performance. This is the only way we
    will advance our profession.

    End of transmission.

  • Andrew Tucker

    When I went through paramedic school we had to take the ACLS course and waste money on the book to learn “advanced” practices for cardiac emergencies. I say the money was wasted, because the funny thing was that every thing that was in that “holy” book was in the primary book for the course. All I could think of during the course was, “Why is a broke student being made to pay for a different form of something he already has?” Ten years ago my opinion of ACLS started out as, ‘It’s a useless course’ and as I’ve worked through various services with different protocols, many exceeding the ACLS standard, my opinion of it has not changed.

  • Mike

    I disagree with the previous commenters who contend that ACLS is “useless.” ACLS is a useful course when correctly implemented. Making Paramedics or Emergency Medicine Physicians–who frequently run codes and who must keep up on the most recent science as part of their primary clinical practice–take ACLS every two years makes very little sense to me.

    To me, ACLS is a survey course for those healthcare professionals who do not regularly participate in cardiac arrest resuscitation or who do not keep current on the literature. As Scott Weingart says, “if you are following the protocols, your care is 5 years old.”

    Take a course like Advanced Burn Life Support for example. ABLS is not designed for burn nurses or surgeons who work in a busy burn unit. It’s a overview of the current treatment guidelines for providers who may see occasional burns but don’t treat them regularly or exclusively. So too ACLS is not intended for providers who are regularly treating life threatenings dysrhythmias/cardiac arrests.

    • I really like the ABLS analogy you bring up. I couldn’t imagine someone working in a burn unit using ABLS as their only measure of competency. We shouldn’t look at ACLS as the only measure of competency for people who are responsible for managing cardiac arrest either.

  • Serg

    This article is absolutely spot on. As an EMT on an ALS transport service and required by our Chief to attend/audit an initial AHA ACLS and PALS courses and to “recertify” (i.e. required to attend) every 2 years with the paramedics, I have witnessed the “certification” or “recertification” of students (ER RNs, RTs, MDs/DOs) without mastery of the actual skills and knowledge. It’s unnerving and I think I would rather have me running the code than many of those in the class who actually get the card. Failing IS an option (or at least it should be and then maybe everyone will take it more seriously). Seems to me that each student should need to successfully lead & complete every mega-code scenario, not just one. Maybe the card shouldn’t say “certification,” rather a certificate of attendance. Leave the “certification” up to someone else who has a vested (legal and financial) interest in making sure that certification translates to proficiency.

  • That’s a tough one. I know that ACLS has changed significantly. You can still watch veteran providers come into the classroom with a look of fear on their face because they have memories of the old ACLS. However, it seems like everyone is required to have ACLS these days. I’ve taught my share of techs and CNAs who do even know how to pronounce some of the drugs because it’s way beyond their scope but their employer requires them to have it.

    Do I really care if they know the algorithms? Not really. I just want them to be able to recognize a person in cardiac arrest, call for help, and remember to do high quality compressions with immediate, early defibrillation.

    As for the higher level healthcare providers, I try to scale my classes to the different people in my classes. So, I’m tougher on an ER doc, but they’re still getting a card at the end of the class. It may take some one-on-one remediation after class, but these cards are a necessary evil…regardless of the current class difficulty level.

    • It’s great that you’re teaching to their level and honestly, I can appreciate that. However… this is ACLS. The people that need only to manage the early phases of a cardiac arrest and who are people who are in the group that “Call for help” rather than being among the group of responders who *are* the help should be fine taking BLS.

      Maybe both classes need an overhaul. Maybe ACLS in its current incarnation should be “ACLS-Awareness Level” and ACLS-EP should be for experts.

      I’m not sure, but it needs to be changed.

      • saboats

        ACLS-EP is not really that much different. I found it to be a waste of money to take the course – though I may have taken ‘something’ away from it, it wasn’t an in-depth course like I had hoped. ACLS, and all AHA courses have become DVD driven seminars that promote the AHA, and not much more. To teach ACLS “at there level” isn’t ACLS – CPR, AED, Call for Help is BLS CPR. You are doing the students no favors decreasing the knowledge they need, nor their patients in the future. If someone is required to have ACLS for their jobs, they should know ACLS…

        • Christopher

          The new ACLS-EP is pretty decent (bias alert: I teach it). In fact, the new ACLS-EP book should be the standard ACLS book for paramedics.

        • The classes aren’t the problem, the problem is the instructors. Your experience depends completely on them. I can pop in a DVD and let it run, or I can interject a substantial amount of lecture and student-based learning.

          As far as me only emphasizing BLS, that’s not true. Like I said, if it’s a CNA who is required by the hospital to have it (stupid), I just want to make sure they know the basics. If it’s an ER doc, that’s a totally different story and you better believe I’m throwing everything I’ve got at them.

          • saboats

            Agree to disagree I guess. From my AHA TC today, “adherence
            to AHA educational policy: All AHA classes require that the instructor
            follow the approved AHA format for teaching. This includes use of the
            video (DVD), written exams (when required), allowing the entire time frame specified for the class (no abbreviated or short-cut classes),
            no substitution of AHA materials with outside or
            unapproved materials, maintaining the AHA required student to teacher
            ratio (6:1), and professional conduct in class. Instructors can
            “personalize” classes, but cannot modify or delete any part of the
            curriculum. ” They need to do everything that everyone else needs to to get the card; agreed it stupid to have CNAs take the course, but… I am also an EP instructor, and it’s slightly better, but my paramedic students are held to a higher standard in class then EP holds them to in that course.

          • AHA leaves a lot of wiggle room in the PAM. I can stick exactly to their rules. I might not modify the class, but I’ll contribute to it. There’s also no one making me ask students certain questions in the megacode. So, I’m able to significantly scale the course based on who I’m dealing with without compromising any standards. When it comes to the written test, they’re on their own (thank goodness for multiple choice for those CNAs).

  • Paradise Island

    So many elements from this article is reflective of my own history with ACLS and PALS. I witnessed the watering down of a great course and of course the scientific push that tweaks the course from year to year. Here in American Samoa our protocols almost mirror ACLS and PALS. Of course to stay current with the Registry these courses are a requirement. My question to the author is is there any other curriculum that is science driven that we can use as an addition to these staples of our Paramedic diet? Thanks for your input.

    • Christopher

      If you read the actual ACLS or ACLS-EP texts they have a lot of science in them. Levels of Evidence, classes of interventions, all good things. The problem is the video and algorithms do not necessarily cover these in any manner! You’ve got to dig to find them.

      • EMS Artifact

        This is the second time that ACLS-EP has come up on a blog post today. Or at least a blog post that I read today. Looking at the AHA description of the course, it’s pretty much the old ACLS class in terms of science and required knowledge.

        What the AHA calls ACLS, I think of as ACLS for Dummies. I think Mike has it right when he points out that all of the merit badge classes are meant for people who aren’t doing what is in the content on a regular basis.

        The problem is that EMS does all of that, except pedi stuff, on a daily business. Burns? Check. Cardiac? Check. Medical emergencies such as COPD, Asthma, Diabetic Emergencies? Check. Trauma? Double check!

        We do that stuff and our paramedic programs cover them. If they don’t cover them in enough detail and depth, then the answer is to improve the content of paramedic programs and raise the bar of EMS education.

        The solution is not to have add on courses that line the pockets of putative “non profit” organizations and bore us to death.

        Well, that shouldn’t be the solution, but apparently it is.

        For some reason EMS education never seems to miss an opportunity to miss an opportunity to improve.

  • granny17

    Reading these comments make me wonder what people really expect of ACLS classes. Seriously- I would very much like to hear opinions as to what the classes should include, where the benchmarks should be set, and what the objectives should be.
    I am hearing lots of frustration about classes that are too simple, people who can fake it without any chance of making it, and disdain for self promotion on the part of the AHA. So, what should the classes look like, how hard should it be to pass, and what objectives absolutely should be met before certification is granted?

    • Midwest Medic

      I want: more of the physiology/reasons behind what we’re doing, less reliance on DVDs which fail to capture the attention of the participants, practicals that actually make us think about what we’re doing instead of rote memorization and spitting back algorithms.

      The objectives should be to actually learn something from the class, meaning it should either be re-certified less often (when the new AHA guidelines come out), or the guidelines should be updated more often. And since it still may not be feasible to actually learn something for everyone in every class, the objective could be to ensure that the provider gets a refresher in an area of cardiac care that they don’t see very often (WPW, torsades, it is an advanced cardiovascular life support class, NOT resuscitation specific class, and they only briefly touch on those subjects).

      When they broach the subject of strokes, perhaps they could dive deeper into the tpa guidelines, because I work somewhere that we have a MINIMUM transport time of 10 minutes, and that’s on the fringes of our district where we don’t get many calls, and I could have all kinds of checklists and information for the hospital ready when I arrive. Our closest hospital also doesn’t handle neuro very well, and the nearest stroke center is too far to bypass to, so the more information I gathered, the less time they would have to spend there and could go to a comprehensive neuro center. But ACLS just wants to teach Cincinnati Stroke Scales and drive fast.

      They could teach actual 12-lead interpretation (even in small doses) and minor cath lab prep so that when we do find an MI in a patient, we could have more done for the hospital in advance. Not many EMS personnel know how ERs handle MIs. While STEMI care is different from system to system, and involves more than just ACLS class, maybe since nurses, doctors, and paramedics are all taking these classes together, a trust could build as they work together and learn how both sides operate. Simply bringing up certain subjects could spawn all kinds of interesting discussion.

      I’m all for making ACLS hard and involved if they want us to keep taking it.

      • granny17

        It seems after reading lots of these comments, that the AHA would do well to be more clear about the course objectives. ACLS is not meant to teach cardiac physiology. That’s a whole different class that could never be taught in an 8 or 12 hour class. It is not meant to teach to any particular audience. It is (as has been pointed out) meant to be the common approach to a patient in an arrest situation, with a few variables. It is meant to ensure a standardized treatment plan with standardized drugs and doses. We must recertify every two years because memories fail, practice patterns drift, and again, we all need to be on the same page. Of course, an argument can be made that the AHA has other agendas, etc., etc. But until something better comes along, this is what we do. It is backed by evidence (again, the strength of that evidecne can be debated) but until another organization with better evidence steps up, this is what we do.

  • I swear we are the only ones who have to follow ACLS. Everyone else at the ED does whatever they want.

    Just tell me the updates and let me go to lunch.