Monday, June 25, 2007

ACLS Recertification Issues

I recently recertified in Advanced Cardiac Life Support, and really wasn't doing to say much, but then, I blog.

Sooooo, I thought it might be informative to discuss a few issues I had with my ACLS recertification process this year.

The American Heart Association provides a course for health care professionals to learn the latest techniques for Advanced Cardiac Life Support in the event an individual collapses of cardiac or respiratory arrest. The certification process is partially performed by company called CardioConcepts (although now it looks like its called 'Scitent') based in Virginia. The recertification process demands a fee for their course and includes an online registration where doctors must now surrender their most personal information (address, phone number, e-mail) to their website on an electronic registration form. You can bet this information is sold, but I digress...

I have some constructive (I hope) criticisms.

If a company is going to teach ACLS instead of doctors, then either the members of this company must first learn EKG's - especially is I have to PAY for the priviledge of undertaking this experience every two years - or else the American Heart Association needs to do a better job proofing the work for hire for which they have contracted.

For the student's pre-test (available on a CD within the ACLS provider book), we find this tracing:

Click to enlarge

So what is this rhythm? The publishers of the student pre-test for ACLS would have you believe it was "Reentry Supraventricular Tachycardia." I wonder if these guys know basic medical terminology. The correct term should be "reentrant supraventricular tachycardia." *Sigh*

But that's not the real problem with this tracing. My guess this tracing is not even reentrant. (I'm open to what other cardiology and EP docs think, here). Look carefully at how this arrhythmia initiates - a slightly premature beat that looks quite similar to the sinus beat - followed in rapid succession by other P waves with a sudden onset with a "warm-up" phenomenon. See the small indentations in the T wave? These suggest a superimposed P wave. I have placed lines above the P waves below:

These findings seem most consistent with an atrial tachycardia to me. Atrial tachycardias usually have an automatic mechanism, not a reentrant one.

And don't get be started about this tracing of Torsade de Pointes which appears on the Student pre-test:

The correct answer (according to their student pre-test) was "Coarse Ventricular Fibrillation." Wrong again. Most texts and online resources I've seen have classified this as arrhythmia as one form of "Polymorphic Ventricular Tachycardia," not coarse ventricular fibrillation. Certainly the treatment for Torsades is very different (consider magnesium, pacing, isuprel, lidocaine, etc.) than for "coarse ventricular fibrillation" (shock, drugs and shock again) and should be recognized by everyone who cares for heart patients.

And I was surprised procainamide was removed from the Tachycardia with Pulses algorithm, especially for irregular, wide tachycardia algorithms as well. I've already discussed my preference for this drug (and why) in an earlier post (See Part I and Part II). Instead, they've decided a "Phone a Friend" option (actually, it says, "expert consultation advised") works best. But sometimes experts aren't there right away...

I do appreciate the folks at the American Heart Association's efforts. I can't imagine what an undertaking organizing the training of the nation's doctors must be like. But we must assure that we train folks correctly and give good examples.

After all, people's lives are at stake.


Image credit.


Anonymous said...

Well, defending the AHA is the last thing that occurs to me, but those strips are probably from the company in question and not the AHA. Our in-house AHA ACLS does not even include a static rhythm test, although we still give the old one just for fun.

So, locally at least (and I'm not that far from you), the emphasis is not on differential diagnosis of EP, as much as it is "fast and sick", "fast and not sick", etc.

And if your place of work is anything like ours, if the floor staff is actually touching the patient when the code team arrives, it's money in the bank.

(anonymous for obvious reasons)

Ambulance Driver said...

Anonymous, those are indeed questions on an ALCS test. The current version of the test includes arrhythmia recognition. My only question is how Dr. Wes got a hold of the strips to post, since the tests are supposed to be secured.

Sadly, ACLS has become a strictly merit badge course, and a fairly meaningless merit badge at that. All it takes these days to become an ACLS instructor is a functioning brainstem and an index finger to press the PLAY button on a DVD player.

The AHA course materials, riddled with inaccuracies and ambiguities, are somehow supposed to make up for the lack of knowledge of the instructors.

Can you tell I'm a bit jaded with the AHA?

Long time ACLS Regional Faculty
Ambulance Driver

DrWes said...

My only question is how Dr. Wes got a hold of the strips to post, since the tests are supposed to be secured.

It was pretty simple: pay for the course and you're given a CD with the "Student Pre-test" which, by the way, will only work on a PC and not a MAC. Then enter your name as the course auto-boots. Find the question you want, right click on the screen. Save the Adobe image to a file, then import to Photoshop, remove the question and annotate as needed.

BTW - if it's secured, the security stinks. I'm not a computer genius and even I could do it...

Ambulance Driver said...

"BTW - if it's secured, the security stinks. I'm not a computer genius and even I could do it..."

Ah, that explains it - the Student Pre-test.

The post tests are secured. Of course, they are every bit as inane.

mikixmiami said...

In fairness the web site is quite good, the simulations as good as I have seen online, I agree with your comments about registering precious personal info with a third party, also about the strips.
About drug choices I guess they've tried to simplify them (decisions made way above us by the guidelines writers), so they can apply to all ACLS providers, Paramedics, Technologists, Nurses, and all kinds of physicians. As physicians, especially cardiologists, we can opt to deviate from the guidelines as the clinical situation warrants, they are guidelines, not mandates.