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Monday, May 14, 2012

Re-certification in Advanced Cardiac Life Support--the ethics and practicality of wrenching people from the jaws of death

My Advanced Cardiac Life Support (ACLS) certification expires in June of this year. At least that's how it used to be. Now my card says that June 2012 is the "recommended renewal date." These re-certification dates always sneak up on me, and if I go over two years between certification I need to take a two day class rather than a one day class, which is more expensive and time consuming.

ACLS is a protocol based set of guidelines published by the American Heart Association to standardize the treatment of cardiac arrest, heart attacks, strokes and heart rhythm disturbances. The first guidelines were published in 1974 and have been updated 6 times since then, most recently in 2010. ACLS is meant to help physicians deal with situations that require very quick action in order to have good outcomes, sort of like soldiers used to need to be able to take apart and reassemble a rifle quickly. ACLS often follows bystander cardiopulmonary resuscitation (CPR), also known as Basic Life Support (BLS.) Neither BLS nor ACLS is particularly intellectual or subtle. In BLS (as of 2010), when a person has ceased to respond (usually they are on the ground, could be in bed) the responder checks to see if they can talk or wake up and if they are breathing, then  calls for help and for a defibrillator, then checks for a pulse, then starts chest compressions if there is no pulse, with rescue breaths every 30 compressions if that is practical. Compressions with no rescue breaths also works, almost as well, and is recommended for very inexperienced providers and when rescue breathing puts the provider at risk. If an automatic defibrillator is available, that is attached as soon as possible and it recommends and delivers shocks to the heart when appropriate. ACLS is done by either EMTs or physicians, and involves administration of medications, continuing cardiac compressions and delivering more shocks as appropriate. To certify in ACLS one must be proficient in both ACLS and BLS.

So when I heard that my certification was (sort of) expiring, I first called my hospital and found out, as usual, that there was a class in ACLS but that it was already full and I would have to wait for a few months for another one. I got online and started to look for other classes within driving distance or in places that I was going to go anyway and found that the American Heart Association website has a central location for finding ACLS classes. This is the site: I went on the site, found a class that I could take, signed up for it and was contacted by the instructor about a week later saying that it had been postponed to a time when I couldn't take it. I then looked further and found several sites that looked legit that offered certification fully online. I became suspicious of these when they said they required no in-person demonstration of skills. The most difficult and relevant part of ACLS for me is the "megacode" part of the test in which the course instructor takes me through an scenario with a manikin and a cardiac rhythm generator and makes me demonstrate that I know what I'm doing and can respond to the usual flow of a cardiac arrest situation. This hands on evaluation has also involved demonstrating that I know how to use a defibrillator, know how to intubate a plastic person and know how to provide effective chest compressions.

The question exists, then, regarding the legitimacy of these sites. There are actually several of them, and they have nothing to do with the American Heart Association. This is one: Although ACLS guidelines are heavily researched and involve hard work and creativity of many doctors and nurses via the Committee on Emergency Cardiovascular Care, the committee did not copyright the algorithms or the recommendations. I may be wrong in my thinking, but it seems to me that anyone could legitimately teach from the text of the recommendations and provide certification of proficiency, and it would be up to the hospital or clinic or emergency medical provider agency requiring certification to decide whether that certification is adequate. For me, doing an online course just sounded too flaky so I went back to the American Heart Association. For some providers, especially emergency physicians who are doing this stuff all the time, less than the full deal might be quite adequate.

It is possible, through the American Heart Association at this website: to buy a really well designed online course called Heartcode ACLS, part 1, which provides video teaching of all of the components of ACLS including actual simulations of dying patients. It is also possible to buy the official ACLS book from which the course material is drawn and a little spiral bound handbook that has the grubby essentials, called "2010 Handbook of Emergency Cardiovascular Care". After completing the heartcode thing, I can take my certification to any of the folks at any of the hospitals who teach ACLS and they can put me through parts 2 and 3 which are the hands-on tests, including the megacode. Then I will be set, again, for 2 years.

Certifying for ACLS is something I have to do, but I'm not entirely sure that it is a good thing to have my hind brain hardwired to start pummeling and shocking someone who, unmolested, may actually be beginning their final rest. We attempt resuscitation of nearly anyone whose heart stops, even though most of these attempts come to no good end. Response to resuscitation varies, but a recent review article quoted about 6.4% survival after out of hospital cardiac arrest and 17.6% for in hospital cardiac arrest. This is to say nothing of the level of disability or brain damage after recovery. Some cultures, specifically I have been reading about Tibetan culture, believe that death is an important transition and that an opportunity for peace and contemplation at the time of death is important. Even though I am not at all sure about either reincarnation or the existence of an immortal soul, it does seem that major transitions in our lives, such as birth and death for instance, should ideally be associated with some level of dignity. When we attempt resuscitation, as physicians, we think of that one in 20 (or 1 in 6 in hospital) who goes on to live a longer life and we count the brutality of the procedure, with its broken ribs and myriad tubes and helplessness, as a necessary cost. It is also true, conversely, that many more people lose the opportunity of a peaceful death than have a chance to walk out of a hospital, and they will never again have an opportunity to do that death over. ACLS and resuscitation are the defaults. Barring a specific request of a patient not to have these things, we do them. But ACLS is also a procedure, similar to an appendectomy or chemotherapy. Statistics as dismal as the ones for ACLS would certainly make us think several times before doing surgery or starting a new medication.

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