Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Merit Badge Courses: Who Benefits? 1

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.

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.

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.

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!

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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Comments

  1. Last “merit badge” course I took was Advanced Stroke Life Support and man was that a well taught course. Granted there is no algorithm they are trying to get you to memorize, so in that regard it was more focused on the academics.

    • I am not familiar with the ASLS course, but one of the things Dr. Shoenberger objects to with ACLS is this –

      The huge stroke chapter seems to cater to emergent tPA-based treatment of acute stroke despite the fact that scientific controversy continues regarding this issue. Lawsuits have been mounted against EPs both for giving tPA and for failing to give tPA. In 2009, the AHA accepted over $17 million from pharmaceutical companies and device manufacturers. This does little to reassure EPs that the standards are purely evidence based.

      This does little to reassure EPs that the standards are purely evidence based.

      While epinephrine does not appear to be making anyone a lot of money, there is the same problem with the lack of evidence to support the recommendations.

      Some people think that tPA is great, while others think exactly the opposite. Hardly what would be expected from definitive evidence.

      • The course is focused on the MEND exam (love it), completing a reperfusion checklist, and the transport to an appropriate facility (with the appropriate report). They covered tPA, but also hospitals in our area that are doing more aggressive care including the Merci Retriever and other tools.

        Really the biggest benefit was the targeted knowledge and boost in confidence for care of stroke patients (and the identification of concerns I should have that I didn’t before).

        • Christopher,

          The course is focused on the MEND exam (love it), completing a reperfusion checklist, and the transport to an appropriate facility (with the appropriate report). They covered tPA, but also hospitals in our area that are doing more aggressive care including the Merci Retriever and other tools.

          With the disagreement over the interpretation of the NINDS data, and more recent data, how comfortable should we be with aggressive tPA use by the receiving hospitals?

          I have no problem with receiving tPA within an hour and a half of the onset of symptoms, especially at my age. Do the data support a 3 hour window? Extending it to 4 1/2 hours, or 5 hours, is the latest thing, but if we are going to keep extending the window without convincing evidence, why stop at 5 hours, or 5 days?

          Really the biggest benefit was the targeted knowledge and boost in confidence for care of stroke patients (and the identification of concerns I should have that I didn’t before).

          How much did they spend on being specific about what is actually the onset of symptoms? The first noticeable symptom to someone else? The last time seen without any symptoms, but what is a symptom, when it comes to stroke?

          Being more forgetful than usual?

          Is it because I did not sleep well last night? Or is my not sleeping last night the first symptom? Or is the stroke being brought on by not sleeping last night.

          I can’t decide.

          Is that a stroke symptom?

          What about a TIA followed by a stroke?

          If we are treating with tPA within 24 hours (I hope that is not considered the window) and symptoms resolve, how do we differentiate among TIA, stroke with improvement due to treatment, and some combination of the two?

          You used the word confidence, but if we are instilling confidence, but the confidence is misplaced, are we helping out patients?

          • I think part of the audience needs to be pre-hospital providers with increased education on stroke care. After this class I realized just how much was lacking in initial Paramedic courses with respect to strokes and TIAs.

            The vast majority of the class was the pathophysiology and patient presentation. The last hour was on stroke treatment. We touched on current prehospital research, mostly related to Mag administration (FastMAG trial) as well, which was nice. Since this class was focused on prehospital providers (it can have additional sections added for nurses/doctors) we were given more of an overview of how the hospital may treat the patient, rather than how the hospital should treat the patient.

            But I agree, the other audience is the public–our patients–with the responsibility to teach partly lying in the hands of providers, but also primary care physicians, other healthcare professionals, and organizations with mandates to improve patient education.

            If I don’t have the confidence in my knowledge of stroke recognition and management, I probably won’t effectively educate my patients or their families.

        • Here are links to the MENS checklists.

          MEND Prehospital
          Preview . . . . . . PDF

          MEND In Hospital
          Preview . . . . . . PDF

  2. Without any knowledge of this article in EP Monthly, here’s a comment I left on the Physio-Control FB fan page on Wednesday:

    “The training materials available from the AHA (with the possible exception of the ACLS Reference Textbook and Experienced Provider Manual) are horrendous and should not be the basis of EMS protocols.

    My suggestion would be to use the actual published guidelines, including the editorials, with special attention to articles like Controversial Topics from the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations – Resuscitation 2005; 67: 175-179.

    I can’t help but wonder if it would have taken so ridiculously long for EMS to embrace continuous chest compressions if paramedics (and Medical Directors) had actually read the rationale for the guidelines and figured out that the 30:2 ratio was invented because of concerns that laypersons (as opposed to professional rescuers) could not distinguish sudden cardiac arrest from asphyxial arrest.

    Major ball drop between the guidelines and the people responsible for developing the educational materials for PROFESSIONALS?

    YOU BET!”

    The merit badge courses are horrific, particularly the video-driven ACLS course. As insulting as I find it as a paramedic, I can only imagine how insulting it is for an emergency physician!

    Tom

    • Tom,

      My suggestion would be to use the actual published guidelines, including the editorials, with special attention to articles like Controversial Topics from the 2005 International Consensus Conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations – Resuscitation 2005; 67: 175-179.

      That is considered acceptable. I don’t remember all that clearly back to when these guidelines came out, but I think the AHA representative encouraged that approach. I was spoiled, my boss was National Faculty, so I could get answers to anything I wanted pretty easily. He is still National Faculty, but we both work at different places.

      I can’t help but wonder if it would have taken so ridiculously long for EMS to embrace continuous chest compressions if paramedics (and Medical Directors) had actually read the rationale for the guidelines and figured out that the 30:2 ratio was invented because of concerns that laypersons (as opposed to professional rescuers) could not distinguish sudden cardiac arrest from asphyxial arrest.

      Having had this debate with a lot of EMS people, I assure you that some people just have no interest in understanding why something is done. They are convinced that whatever way they do it must be best. I expect that they have eventually started using the new guidelines, but have come up with some sort of psychological mechanism for convincing themselves that the improved outcomes with the 2005 guidelines are due to the quality of that EMS person, rather than the improved methods.

      The 2005 guidelines are the first guidelines that have actually led to improved outcomes.

      The merit badge courses are horrific, particularly the video-driven ACLS course. As insulting as I find it as a paramedic, I can only imagine how insulting it is for an emergency physician!

      All paramedics should find the ACLS course insultingly simple. Medics should be able to do this stuff in their sleep. The same for emergency physicians, anesthesiologists, cardiologists, and even internal medicine specialists. That is the whole purpose of the article at EP Monthly.

      The experienced provider course may be better, but the idea that you have to take this one specific course (and all of the other merit badge courses) every so many years ignores our ability to come up with more appropriate courses, especially if more challenging.

      the same can be said for any recertification course, such as National Registry. Even more so for these, since they require a certain amount of hours before they will even test you. Right there they are admitting that their testing has no ability to assess anything. If the test were valid, it could easily discriminate between the competent person and everyone else. New York State was even worse on theirs back when I recertified there.

      Either the testing process has validity or you need to demonstrate the completion of classroom hours, but not both. The requirement for classroom hours is like the psychic putting a partner in the audience to tell him what people have been saying.

      Both are frauds.

      In EMS, we are happy to be deceived on a regular basis – at least every recertification.

  3. Intresting take on things RM. I would like to attend a true ACLS:EP course for my own edification.

    Locally, having a BLS Instructor card isn’t even good enough – I’ve got to have a current CPR for Healthcare Provider card on file with the County to get/renew my Medical Command status every year.

    • Jon B.,

      Thank you.

      I have not attended an ACLS EP class, but I have heard mostly good things about the class.

      You have to wonder about people who require a provider card from someone who teaches the course.

      I know of several people who would carry blank cards just so they could fill one out in front of the bureaucrat and say, Do you see this instructor card? This authorizes me to fill this provider card out and my signature makes it valid.

      These bureaucrats run EMS and make it hard to get rid of the incompetent people, because it is more about jumping through hoops than about patient care.

      The patient is only an abstraction to these clowns.

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