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