I can recall, though it seems quite long ago, my first basic life support (BLS) course as a first-year medical student. The instructor dutifully demonstrated on a mannequin to eager young medical students what to do if someone is found unresponsive. Shaking the unmoving mannequin she said loudly, “Sir, are you OK?” Then hearing no response she showed us how to check for a pulse and spontaneous breathing. “If not present,” she said, “call for help and start CPR.” Me, ever the smart-ass, took my own approach. “Sir, are you ok?” Then, grabbing the mannequin tightly to my chest, “Nooooo! Why? WHY?!”
This didn’t enamor me to the instructor very much and earned me most of the difficult clinical scenarios of the day.
Classes like these are now mandatory for those working in hospitals. Just about all employees have to go through BLS training, and many employees in more advanced clinical settings are also required to take advanced cardiac life support (ACLS). ACLS is an advanced skill set taught to medical personnel who work in areas of the health care field who may have encounters with patients that require interventions beyond the scope of BLS.
Those of us in the medical field who are required to recertify ACLS have long dreaded the process of ACLS recertification. Part of that is because it can be an intense course that makes many feel nervous. Part of it is also because it is expensive and time-consuming. But the greatest reason why most who undergo ACLS training object to it is for a different reason entirely: They feel that is simply unnecessary.
Like many of you, I’m a busy and dedicated professional. So are thousands of other ER physicians, cardiologists, and critical care physicians. Our knowledge goes well beyond the basics of ACLS certification. In fact towards the end of the ACLS algorithm comes a directive; once the options have been exhausted in an unresponsive patient, the algorithm directs providers to call an expert for further input. “Seek expert consultation,” as the algorithm puts it.
I’m that guy. As are other critical care, anesthesiologists, cardiologists, and emergency medicine physicians.
I’ve been through 3 years of residency, followed by another 3 years of training in my field, after which I became board certified in critical care medicine. For physicians in such advanced practice fields, the 1-day ACLS certification is simply, well, whatever the opposite of overkill is. Underkill. Like sending firemen to fire extinguisher recertification or NBA players to basketball dribbling recertification. It’s not that the skills are not important, it’s more that the skills are elemental to what we do.
As I make the argument here that ACLS certification is unnecessary for those with advanced training, let me also make the case that it is unnecessary for those without training. But in this case, for the opposite reason. It truly is overkill. Why would an operating room assistant need to know ACLS? Do they need to be ready in case both the surgeon and anesthesiologist take a bathroom break at the same time? Do we expect the assistant to do anything other than start CPR and call the code team if there’s an emergency?
No, the truth is that it would be unfair to both the hospital worker and the patient to ask an untrained individual to apply what they learned in a one-day class 18 months ago to rescue a crashing patient. And while we’re talking truth, here’s another one: This is no longer the golden age of limitless health care spending. Our industry is now searching for every shred of lean efficiency to stretch our health care dollars. And while it costs regulatory bodies and insurance companies nothing to make rules requiring ACLS life support certification mandatory, it costs our society dearly in a time that we can ill afford it. In this new age, we simply can not justify the time, expense and lost productivity of sending people to ACLS training if we don’t really believe that it is going to be useful. Period.
I am not discounting the importance of life support training. I’m simply stating that at some point those responsible for administering health care facilities and insurance companies made a decision that ACLS life support guidelines should be taught to many who will never use it. It would not appear that this decision has been recalibrated for modern times. It has instead become a universal requirement, a target that regulators can use to demonstrate the proficiency of their workforce.
So here’s how we recalibrate our expectations regarding life support certifications. Everyone working in a health care facility should have BLS (basic life support) training, and many in the public should, too. As many as we can train, in fact. BLS training should become as ubiquitous as flu shots, and we’ll all be better off because of it.
Nurses working in settings such as the ICU, ER, and other areas where death lurks, should certainly know ACLS and continue to recertify as per current AHA recommendations. There are other doctors without any sort of critical care training who can benefit from ACLS training. Many learn valuable skills and can save lives, and should be encouraged to participate in ACLS.
However, others take away little other than how to disappear when someone who knows what they are doing arrives. To those I say this: “Don’t sweat it, I understand. This isn’t what you do, that’s why I’m here.” There is little value in teaching ACLS to those who are not comfortable with it. A simple one-day course is not going to prepare them to care for a crashing patient any more than it could have prepared me as a medical student.
For those in critical care-type fields like myself, I think we should all undergo the initial ACLS certification once. This can be followed by an online course every 1 to 2 years. The current practice of maintaining BLS certification for those who are already ACLS certified is superfluous. Any recent changes to BLS protocol can be covered in ACLS recertification.
Instituting these changes could save our industry millions of dollars in lost productivity. In doing so, we could also spend more time focusing our energy on getting better at doing the things we do every day to help our patients. And perhaps less time wasting the time of hapless life support instructors.
Deep Ramachandran is a pulmonary and critical care physician, and social media co-editor, CHEST. He blogs at CaduceusBlog and ACCP Thought Leaders, and can be reached on Twitter @Caduceusblogger.
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