At EP Monthly, there is an interesting article – Merit Badge Courses: Who Benefits?

I will address this in several parts. First is the quality of the merit badge courses.

Why do we object?
After years of residency training and days of grueling written and oral boards, many EPs find ACLS and BLS to be kindergarten-level courses. The classes address an aspect of clinical practice that we handle on an almost daily basis. When somebody from The Joint Commission asks for your updated ACLS card, but ignores your board certification, it is at very least out of order in importance and frankly insulting to the effort required to obtain the latter. Certainly, ABEM and AAEM agree on this and both organizations have position statements indicating that ACLS or ATLS certification should not be required of board certified Emergency Physicians.

I disagree about the kindergarten-level. That depends on the instructor. If all you are getting is a memorization of guidelines, then it is kindergarten-level, but that is not the way ACLS should be.

That is not the way I have taught ACLS. I certainly did not fit in at every hospital where I taught, but I fit in very well at others. The administrator of the program has a lot to do with that.

If you read much of my blog, you should realize that you would leave my course with more questions than when you arrived at the ACLS class. That is the way it should be. We are faced with guidelines based on expert opinions of inconclusive research, or even based on expert opinion without research.

Anyone who tells you that there are more than a handful of definite answers to be drawn from the research is lying to you. Or they don’t know what they are talking about.

The guidelines are based on thousands of studies.

A lot are animal studies, which are important, but more often than not do not work out as well when applied to real human patients. One of the obvious reasons is that the human patient has a cardiac arrest due to underlying medical conditions, that are not easily recreated in a mouse, pig, or dog. The surrogate arrests we create in animals are no more relevant than the surrogate endpoints that are promoted as answering questions about survival.

A cardiac arrest due to ligation of an otherwise healthy coronary artery in a pig is not the same as a cardiac arrest due to an occlusion of a diseased coronary artery in a human.

The Return Of Spontaneous Circulation (ROSC) is not any better than the animal studies at indicating that a treatment will improve survival to discharge.

Both are necessary intermediate steps in arriving at a treatment that works.

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What we know:

1. Chest compressions are important.

2. Fast compressions and deep compressions.

3. Interruptions to compressions are bad.

4. Defibrillation is important.

5. Therapeutic hypothermia also seems to be good.

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If I try to tell you that anything more than that is definite, I am telling a lie.

We may even have to revise some of what I have listed as definite.

Revise, not remove.

We may have to revise something, but I don’t think we will have to remove any of it.

Some people will tell you about information that goes well beyond this. They will present it as certain.

They will be either lying, ignorant, or both.

Does epinephrine improve survival to discharge?

We need much larger placebo controlled studies to answer that question. If can’t tell without these extremely large studies to show an effect, then the effect is not large.

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Why are we forcing the use of epinephrine?

If we are doing something, we convince ourselves that we are helping.

It is hard to have a bunch of us stand around and just watch someone doing chest compressions, especially if we are trained to give drugs and to do invasive procedures.

We can’t have doctors, nurses, and medics not using their ALS (Advanced Life Support) skills. There has to be something we can do that is better than what a 70 year old spouse can do. There has to be. Something other than those sweaty compressions – that’s what techs are for.

F*&# the research – I’m doing something! Give me an epi!

Look! A pulse! I did it!

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If you feel like you are taking a kindergarten course, you should look at the way instructors are taught, hired, and paid.

Most of the ACLS teaching I have done has been for less per hour than what I would make working as a paramedic. Not only that, but it is for fewer hours. Never mind overtime, this is less than straight time. This is great for a single parent, which is a big part of why I did so much teaching, but it is not a way to get people who are not limited by daycare hours (or school hours). If I am making less per hour as a medic, what incentive is there for someone who makes more than a medic?

How many residents are mandated to teach ACLS as part of their program requirements? How many of them are any good at teaching in a classroom? If you want a kindergarten environment, put a mandated resident, with no interest in teaching, in front of a class with a PowerPoint. Ativan does more for your memory.

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Here is an important video about the necessity of capturing the imagination of children at a young age for science education. Without scientific literacy, what future do we have? Dr. Tyson is a great speaker and shows the importance of putting things in perspective. Less than 5 minutes.

The half a penny on a dollar is a reference to the budget of NASA being only one half of one percent of the federal budget. This is not to say that we should not critically examine anything that is only a half of a percent of the budget, but to say look at how much we get for so little. We should also not ignore NASA’s tiny sibling, DARPA (Defense Advanced Research Projects Agency).

In EMS, our problem seems to be that we capture the imagination of the children who never grow up. We need to get them to understand, as they grow up, that it is about much more than just the noise and the toys.

In a similar vein, Dr. Tyson presents a view of the role of politics in science. Not what most people might expect.

h/t Bad Astronomy.

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In today’s news there is a story about mandatory voluntary national standards for education. These are not EMS standards/protocols, but the issues are not significantly different. I will specifically address EMS standards/protocols in other posts, but the parallels should be pretty clear.

The Patrick administration will not adopt national academic standards if they are lower than those established in Massachusetts, long championed as having among the most rigorous expectations, according to the state’s education secretary.^[1]

That is a sensible response, but maybe we need to consider it from the opposite direction. Is any other response sensible?

There is an advantage to being able to move from state to state and have a child transfer directly into the same grade. As a parent, I have moved across state lines several times. In my case, this advantage would have been minimal. The advantage does not seem to justify a national standard, unless that national standard produces very little harm in its unintended consequences.

“We are trying to sound the alarm,’’ said Jim Stergios, the institute’s (The Pioneer Institute, a conservative-leaning public policy research organization in Boston) executive director. “Massachusetts has the highest standards in the nation. Why would you want to change course?’’^[1]

That is the big problem with the idea of national standards. National standards seem to place more value on uniformity, than on quality.

As with EMS, there are plenty of advantages to national standards. There is a big drawback when statewide standards, or nationwide standards, are proposed. Promises of benefits are the focus, but when the everybody standards are enacted, a mindless devotion to uniformity replaces many of the benefits.

Rather than have the standards raise up the places with lower quality, there is a backpedaling on raising the standards. The new goal is to prevent the standards from becoming a hardship for those who might benefit the most from standards.

The result is often a set of standards that makes improvement for the places of low quality optional. After all, it would somehow be elitist to insist that poor educators significantly improve their quality.

Here is an important point on standards from the article.

While adopting the standards would be voluntary, the Obama administration has said that it intends to withhold millions of dollars in grants for low-income students in states that refuse to join the effort — regardless of the quality of their existing standards.^[1]

We’re here to offer you some protection. There are some dangerous people in the neighborhood. We would really hate to see anything bad happen to your nice store. Of course, this is completely voluntary.

What kind of miscreant would possibly decline an offer to join the effort?

Or decline to volunteer?

I avoid the left wing/right wing political parties because I could hurt myself from laughing too hard. This is just another example. The left wing trying to improve schools by cutting off funding for low-income students. Are they trying to put The Onion out of business?

You will lower your standards, so that you are just like all of the other states. Otherwise we will deprive you of your share of education funding for low income students. We will cut your budget until you lower your standards. Of course, this is completely voluntary.

The administration also says states that embrace the standards will have a better chance of receiving potentially hundreds of millions of dollars in its “Race to the Top’’ competition, which rewards education innovation. Massachusetts has applied for $250 million from that program.^[1]

A quarter of a billion dollars of bribery incentive. This does not even include the grants for low-income students being threatened redistributed to more worthy causes. Causes more worthy than keeping the poorest children from growing up too ignorant for anything more than jobs as political appointees.

Of course, it would be ignorant, vulgar, and completely unfair to label these tactics as anything other than helpful.

One member — Sandra Stotsky, a former associate education commissioner who oversaw the development of the state’s standards — ridiculed the national benchmarks, saying they rely too heavily on broad “empty skills’’ and lack rich academic content at each grade level.^[1]

Empty skills. As in skills testing devoid of any context? It is as if she is referring to the National Registry of EMTs examination. If uniformity were the quintessence of education, NR would produce excellent beginner medics, since NR places uniformity above all else.

It is unclear whether states would have to adopt the national standards word for word or whether they could augment them with existing ones so long as the state standards were higher. Adopting new standards is unappealing in lean economic times because it can require the wholesale replacement of textbooks and additional training for teachers.^[1]

Don’t worry. These will always be flexible standards. We would never change a policy after everyone is committed to using this standard.

Trust us.

We’re from the government.

We’re here to help.

Trust us.

Then there are the educators, the ones supposed to be familiar with reading comprehension. Such a person is Glenn Koocher, executive director of the Massachusetts Association of School Committees. Maybe not an educator, but a spokesperson for administrators of educators?

“The rest of the nation will finally march to the same beat as Massachusetts,’’ Koocher said.^[1]

Inflexible standards will force everyone to march to the same beat, but it is unlikely to be the same beat that Massachusetts is currently marching to. All A is B may not be the same as All B is A.

If the standards are completely inflexible, it is not clear that Massachusetts will agree to the offer to voluntarily use the national standards. That offer is beneficent, and clearly without the possibility of any ulterior motive. Depending on how much Massachusetts has come to rely on these federal grants might profit from the generosity of those redirecting low-income education funds, Massachusetts may feel compelled to cooperate with these voluntary tactics.

Glenn Koocher may not be rejoicing once Massachusetts is marching to the same beat as the rest of the nation. Glenn Koocher may even develop a better understanding of syllogism, although I wouldn’t count on it.

Metaphor-wise,^Huh? Harrison Bergeron^[2] is essential to any discussion of standards that are potential ceilings.

Footnotes:

^ ¹ State firm on school quality. Will reject US standards if they don’t measure up.
By James Vaznis
Globe Staff / March 15, 2010
The Boston Globe
Page 1
Page 2

^ ² Harrison Bergeron
Wikipedia
Harrison Bergeron is a short and excellent story in the collection Welcome to the Monkey House by Kurt Vonnegut. It has been turned into a film, but the story is much better in print. This is one story that should be mandatory reading in all schools. Kurt Vonnegut has created perhaps the most horrifying, most banal dystopia.
Article

^ ^Huh? The Apartment
I blame Billy Wilder (and/or I. A. L. Diamond) for this not-so-new neologism method.
1, 2, 3 and 4, 5, 6 and 7 and 8.

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