ACLS 2018: Did You Hear the One About the Medic and the ABG?

GUEST EDITORIAL

Whenever it’s time to refresh my ACLS credentials, I get all nostalgic. Mostly I remember those megacodes from paramedic school 24 years ago, when evil instructors used diabolical rhythm generators to assault helpless manikins. Even worse, we students were complicit. We hastened the demise of Rescue Annie and her anatomically ambiguous friends by inflicting intubation, stacked shocks, lidocaine, bretylium, sodium bicarbonate, and other pseudoscientific therapies on lifeless and legless torsos, while calling for chest compressions only when convenient.

Fast forward to 2018, and bretylium isn’t even a word anymore, according to my dictionary. Bicarb amps sit unused at the bottom of drug bags until they break or expire. Those are just two examples of how much cardiac arrest protocols have changed since the ’90s. Today we believe long-term survival mostly depends on uninterrupted CPR and prompt defibrillation. Intubation? Only if you have time. Ventilation? All you need is a BVM. Medications?

Medications? Anyone?

That’s what irks me most about my 2018 ACLS update. There’s still no evidence epinephrine or antiarrhythmics offer pulseless patients anything more than slightly slower death, yet those drugs remain at the core of AHA cardiac arrest algorithms. Why? Is there nothing more useful we could offer impressionable clinicians during 16 hours of minimally invasive learning? How about some practice with supraglottic airways or an IV clinic focusing on meds for the living? And shouldn’t we be hearing something about ECMO?

I could write a much longer article than this one about the frailty of ACLS; how we spent decades doing resuscitation wrong and are still wasting our time with therapeutics short on evidence. That wouldn’t be news to most of you, though, so here’s your headline: There’s nothing new in ACLS 2018, other than a couple of re-engineered videos starring computer-generated avatars as brave paramedics. Yes, these are exciting times for androids.

It’s easy to find humor in ACLS if you don’t get too bogged down by science. We’re talking about a course that tries to teach one set of stilted algorithms and rote responses to doctors, paramedics, nurses, PAs, respiratory therapists, dentists, pharmacists, athletic trainers, and anyone else who can memorize 15–20 unambiguous EKGs in time for the pretest. It’s absurd to have a common curriculum for every kind of healthcare professional.

Try spending a couple of days playing “manikin down” with caregivers who’ve never run a real arrest, and the jokes will write themselves.

Blood Work for $200, Alex

The AHA wants us to consider “H’s and T’s”—10 presumptive diagnoses beginning with those letters—whenever we have nothing else to do during hopelessly contrived scenarios, which is often. I get the part about mulling etiologies, but when I mentioned PE as one cause of PEA, that didn’t mean I knew which labs to order. ABG? CBC? MTV? You have to go to a different school for that. Here’s a clue for my fellow street medics: D-dimer is a blood test, not a rapper.

Hurry Up and Wait

The most frustrating part about practicing the AHA’s special brand of bogus megacodes is the artificial regimentation that enforces two minutes of CPR (timed by the preceptor) and little else between shocks. You’re allowed to start an IV/IO or push one med—but not both—during each interval. And don’t even think about intubating unless your imaginary partner is having imaginary problems with the BVM.

After verbalizing the one intervention you’re permitted per defibrillation attempt, there’s not much else to do, so you get silly. At least I did. I’d tell my five-member team—you know, just like the one on the ambulance—to draw up adenosine and atropine in case my polyurethane patient woke up with either bradycardia or SVT—two rhythms we were told to expect. It definitely helped to know outcomes in advance.

Everyone Gets a Save

Speaking of survival, my instructor displayed exceptional optimism: Every megacode ended with ROSC. You might think you’re home free when you’re told there’s a pulse, but not so fast—you must verbalize targeted temperature management. That’s the new name for therapeutic hypothermia, which we now know is not so therapeutic prehospitally. And don’t forget to call for an “expert consult.” In the field you and your partner would have to decide which one’s the expert.

Advice for Those With Plenty of Liability Insurance

Some of the most entertaining moments in ACLS are when hospital-based educators go off script to share unique insights. For example, while reviewing signs and symptoms of unstable tachycardia, our teacher told us “a little bit of chest pain is OK.” That’s probably based on the theory that coronary perfusion is overrated. My favorite tidbit, though, was how third-degree heart block is like “two people getting divorced.” Trust me, it’s not that simple.

It’s healthy to laugh at ACLS while you’re still playing paramedic. Here’s why: Someday, after you’ve answered all the calls and carried all the patients your body can take, you’re going to wake up one night tallying the pros and cons of your career. You’ll remember how good it felt running your first code, but you’ll wish someone who’d skipped ACLS had been there to warn you, “That’s not how this works—that’s not how any of this works.”

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.