Controversial post for the week

Time to stir up some controversy here.

If I was an EMS medical director (Yes, I know, scary thought in and of itself.), I would no longer require any resuscitation “card courses.”  No more ACLS, CPR, or PALS.   Why?  Several reasons.

1) The “current” science behind the current ACLS/PALS/BLS-CPR standards is already dated.  New science is regularly coming out about cardiac arrests.  What about dual defibrillation?  Therapeutic hypothermia initiated during the arrest?   Nope, not in the current standards.  Mechanical CPR devices?  Barely mentioned Heck, the “pit crew” model of CPR which is rapidly becoming the de facto standard of care for EMS CPR isn’t even accepted by the AHA yet.  If you think John McCain and Ted Cruz are conservative, the AHA’s resistance to new changes is legendary.  Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.

2) Between the AHA and JCAHO wanting/encouraging virtually every nurse, physician, and respiratory therapist to have a current ACLS card, the ACLS standards have become a laughing stock for those people who are actually expected to perform resuscitations.  The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.

3) And besides, for those of us in the EMS world, our local protocols are going to override a “canned” card course anyways.  Thank goodness for that in most cases.  I’d rather work a code the Austin/Travis County EMS, Wake County EMS, or Harris County Emergency Corps way than the already-dated, hospital-oriented “card course” way.

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS).  Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.   It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science.  Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.  I know for certain that Austin/Travis County EMS no longer requires BLS-CPR cards in recognition of their higher standards with “Pit Crew” CPR training.  Similarly, Cypress Creek EMS (near Houston) no longer requires ACLS cards of their paramedics in recognition that some of their clinical standards exceed current AHA guidelines.  Take the plunge — and free yourself from the tyranny of sitting through the same biennial DVD presentations.   We’re EMS.  Cardiac arrest is a huge chunk of why we were created in the first place.  We’re supposed to OWN resuscitation.  Let’s show it — by educating ourselves ABOVE the standard.

Thoughts, y’all?





  1. PHTLS and AMLS exist only to make money for NAEMT. The fact that some people consider them necessary just means that EMS education falls short in areas that absolutely should be included in the basic curriculum of BLS and ALS programs.

    • lone medic says:

      TOTW, the NAEMT exists to lobby for EMS, similar to how the NRA lobby’s for gun rights. Do you begrudge the NRA its gun safety courses? Especially when they are good at what they do. AMLS and PHTLS are worthwhile education that benefits EMS as a whole. Isn’t that worth it?

      • If the NAEMT were 1/100th as successful as the NRA, I’d agree. Please name one major accomplishment of the NAEMT in Washington? Please tell me how long they have had a full time lobbyist.

        When I was first a member of the NAEMT in 1982, they made a conscious decision NOT to be involved in politics in any way. It was only recently that the decision seems to have been reversed.

        I don’t notice the IAFF or the IAFC running any courses to support their lobbying efforts.

  2. I would require review of resuscitation (medical, trauma, pediatric) evidence based research on a regular basis and if it passes merit, introduce into EMS practice with training provided. It takes a lot of work but it is how we need to do it.

  3. I agree! We should be model for cardiac arrest managers if you will. Speaking of assessment based cards. I preach assessment in all my lectures. Without sharp assessment skills you won’t need the bells and whistles we carry. What happened to proficiency in order to obtain a “card”?

  4. NomadMedic says:

    While I understand where you are coming from, I’m going to have to present a counter argument. I feel (initial certification) ACLS/PALS offers a sort of “boot camp” style training needed to quickly and effectively respond to a cardiac arrest incident. While the “cookie cutter” mentality certainly does not work with most systems, I think it IS appropriate to have a starting point, and from there each medical director can implement their own changes. In reality, each cardiac arrest case is different, requiring a provider to look at the reversible causes of arrest…so really the difference between lidocaine vs amiodarone or active vs passive oxygenation is more personal preference than anything else. That being said, I feel the ACLS Experienced Provider course is a step in the right direction. Providers get to discuss cases and come up with a treatment plan that meshes with their current guidelines, rather than just regurgitating AHA algorithms.

  5. Although the material is not very advanced, the comparison should be to “nothing” and not to a superior educational model unless such a model is available. At the moment, if the average EMT/medic stops taking his CPR refresher, he will probably stop learning about CPR, period.

  6. Do we need to revisit the meaning of “controversial”?

  7. Excellent post. My only quibble is that I suspect the ‘everyone gets a card’ mentality has more to do with legal requirements and ass-covering (“everyone we have is certified!”, they say as if it means anything when the patient hits the floor) than ‘everyone gets a trophy’. Although it seems like many of these standards have been so watered-down as to become meaningless.

  8. Medic4721 says:

    AHA has made ACLS and PALS so easy that anyone can watch the videos and memorize and flow chart. They have done away with the lectures and I don’t agree with that. As a coordinator for both AHA as well as NAEMT courses I much rather put on NAEMT courses. I prefer the interaction with the students in the different skills stations. They get hands on skills as well as giving and getting input. The new curriculum in PHTLS has addressed the board, no board policy. (That will probably spur a new topic in itself.) How long would it take AHA to move it that direction if they had overview of trauma. I was teaching AHA courses long before NAEMT courses but with the way PHTLS, AMLS, and EPC classes are structured, I prefer to teach those since it makes the students actually think.

    • How long did it take PHTLS to address that issue? There were people discussing how futile most back boarding was as far back as the early 1990s. The State of Maine implemented an evaluation policy for all levels of providers in 1995 and has been updating it ever since. PHTLS and the rest of the so called standards setters are playing catch up almost 20 years later.

      • Medic4721 says:

        I agree it was long in coming, but like everything in this country its science based and money based. EMS curriculum is out dated and SUCKS! You go from state to state and nothing is the same. What a EMS provider can do in one state is not allowed in the boarding state in many places. NY has scraped their EMS curriculum and Georgia will hopefully follow suit soon. We are teaching 1970’s stuff in 2013.

        • Medic4721 says:

          And for the record, I don’t agree with the alphabet cards, I think its become to easy but in the same note I have and will continue to fail people in AHA courses. I don’t just give out cards and is shocked at times that a Paramedic can’t pass a ACLS course that is way to easy now.

  9. Skip Kirkwood says:

    I agree in part. I have done my best to do away with “alphabet” courses for the last 20+ years. They are nothing more than “re-packaging” of what should be baseline knowledge for any professional paramedic, and they take money that could be used for necessary and good continuing education and divert it to the bank accounts of the “certifying” organizations – who really don’t “certify” anything except that you sat through the course.

    We can do better than this.


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