It’s Time to Move On From ACLS Certification.

I can recall, though it seems quite long ago, my first Basic Life Support (BLS) course as a first year medical student. The instructor dutifully demonstrated on a mannequin to eager young medical students what to do if someone is found unresponsive. Shaking the unmoving mannequin she said loudly,  “Sir, are you ok?” Then hearing no response she showed us how to check for a pulse and spontaneous breathing. “if not present” she said, “call for help and start CPR”. Me, ever the smart-ass, took my own approach. “Sir,  are you ok?” Then, grabbing the mannequin tightly to my chest “NOOOO! why? WHY?!”

This didn’t enamor me to the instructor very much and earned me most of the difficult clinical scenarios of the day.

Classes like these are now mandatory for those working in hospitals. Just about all employees have to go through BLS training, and many employees in more advanced clinical settings are also required to take Advanced Cardiac Life Support (ACLS). ACLS  is an advanced skill set taught to medical personnel who work in areas of the healthcare field who may have encounters with patients that require interventions beyond the scope of BLS.

Those of us in the medical field who are required to recertify ACLS have long dreaded the process of ACLS recertification. Part of that is because it can be an intense course that makes many feel nervous. Part of it is also because it is expensive and time consuming. But the greatest reason why most who undergo ACLS training  object  to it is for a different reason entirely: they feel that is simply unnecessary.

Like many of you,  I’m a busy and dedicated professional. So are thousands of other ER physicians, cardiologists, and Critical Care physicians. Our knowledge goes well beyond the basics of ACLS certification. In fact towards the end of the ACLS algorithm comes a directive; once the options have been exhausted in an unresponsive patient, the algorithm directs providers to call an expert for further input. “Seek expert consultation”, as the algorithm puts it.

I’m that guy. As are other critical care, anesthesiologists, cardiologists, and emergency medicine physicians.

I’ve been through 3 years of residency,  followed by another 3 years of training in my field, after which I became board certified in Critical Care Medicine. For physicians in such advanced practice fields, the 1-day ACLS certification is simply, well, whatever the opposite of overkill is. Underkill. Like sending firemen to fire extinguisher recertification,  or NBA players to basketball dribbling recertification. It’s not that the skills are not important, it’s more that the skills are elemental to what we do.

As I make the argument here that ACLS certification is unnecessary for those with advanced training, let me also make the case that it is unnecessary for those without training. But in this case, for the opposite reason. It truly is overkill. Why would an operating room assistant need to know ACLS?  Do they need to be ready in case both the surgeon and anesthesiologist take a bathroom break at the same time? Do we expect the assistant to do anything other than start CPR and call the code team if there’s an emergency?

No, the truth is that it would be unfair to both the hospital worker and the patient to ask an untrained individual to apply what they learned in a one day class 18 months ago to rescue a crashing patient. And while we’re talking truth, here’s another one: this is no longer the golden age of limitless healthcare spending. Our industry is now searching for every shred of lean efficiency to stretch our healthcare dollars. And while it costs regulatory bodies and insurance companies nothing to make rules requiring ACLS life support certification mandatory, it costs our society dearly in a time that we can ill afford it. In this new age we simply can not justify the time, expense and lost productivity of sending people to ACLS training if we don’t really believe that it is going to be useful. Period.

I am not discounting the importance of life support training. I’m simply stating that at some point those responsible for administering healthcare facilities and insurance companies made a decision that ACLS life support guidelines should be taught to many who will never use it. It would not appear that this decision has been recalibrated for modern times. It has instead become a universal requirement, a target that regulators can use to demonstrate the proficiency of their workforce.

So here’s how we recalibrate our expectations regarding life support certifications. Everyone working in a healthcare facility should have BLS (basic life support)  training, and many in the public should, too. As many as we can train, in fact. BLS training should become as ubiquitous as flu shots, and we’ll all be better off because of it.

Nurses working in settings such as the ICU, ER, and other areas where death lurks, should certainly know ACLS and continue to recertify as per current AHA recommendations. There are other doctors without any sort of critical care training who can benefit from ACLS training. Many learn valuable skills and can save lives, and should be encouraged to participate in ACLS.

However others take away little other than how to disappear when someone who knows what they are doing arrives. To those I say this: “Don’t sweat it, I understand. This isn’t what you do, that’s why I’m here.” There is little value in teaching ACLS to those who are not comfortable with it. A simple one day course is not going to prepare them to care for a crashing patient any more than it could have prepared me as a medical student.

For those in critical care-type fields like myself, I think we should all undergo the initial ACLS certification once. This can be followed by an online course every 1 to 2 years. The current practice of maintaining BLS certification for those who are already ACLS certified is superfluous. Any recent changes to BLS protocol can be covered in ACLS recertification.

Instituting these changes could save our industry millions of dollars in lost productivity. In doing so we could also spend more time focusing our energy on getting better at doing the things we do every day to help our patients. And perhaps less time wasting the time of hapless life support instructors.

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To Reform Healthcare, America Needs to Look to its Doctors.

Our healthcare system is sick and dysfunctional. A vicious cycle of blame is happening between Washington, health insurance companies, and the patients. And it is quickly demoralizing this nation and simply increasing costs with more administrative regulations. It is raising questions regarding the future of healthcare in the United States.

And we need answers.

Surprisingly, in all of this, doctors are rarely mentioned.  As if doctors do not know the intricacies of how the health care system works.  As if doctors are not there for their patients 24 hours per day, ordering tests or doing procedures that can benefit a patient’s well-being.  As if doctors are not dealing with denials from the insurance companies on a daily basis, losing valuable hours to menial paperwork that could be spent caring for our country’s sick.

Doctors have a duty to care for their patients and are the engines that put health care into motion. They yearn to maintain that physician-patient relationship that is important to the care of our patients.

Unfortunately, doctors are not being directly involved in the health care reform debate despite being on the front lines of care.  They have an opportunity to provide valuable insight into the day-to-day operations of this health care machine. Continue reading

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New Series: EMR Diaries.

Golive PicIt’s time. After thousands of hours of hard work by the IT department, and lots of fretting by pretty much everyone else, the time has arrived. Our hospital is going live with it’s EMR Stage 2 meaningful use system. And it’s starting during my turn in the hospital rotation. (I want to believe that this is purely coincidental, but if I see my office scheduler walking around with a new pair of shoes, I might have to say something.)

What is Meaningful Use? As part of the nearly $800 billion economic stimulus bill known as ARRA (American Recovery and Reinvestment Act) of 2009, the government sought to  electronify (yes, that’s a work, look it up!) medical records. To accomplish this CMS (Medicare/Medicaid) began giving out incentive payments to physicians and hospitals for electronifying their medical records, which would eventually transition into fines for not complying.

By now you’ve probably looked up “electronify” and found that it’s not really a word. My bad. But in a way, Medicare did the same thing. They realized that “electronic medical record” does not really have a definition, either. So they said “our bad” and came up with a set of parameters that would determine if your medical record could be used in a meaningful way, or whether it was just a note pad with a reading light attached to it. Continue reading

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“When I Was a Resident”: Duty Hour Rules Do Not Define Me

Recently, Rebecca Ulep wrote a rebuke of recent resident duty hour restrictions and their potential negative effects on physician education in a post entitled “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. Many practicing physicians agreed with these sentiments, while most residents did not. Our expanding #PulmCC community brought me  into the acquaintance of one the latter, who agreed to write a post taking the other side of the argument. Scroll down for the article, and hit the link above to read the original post. And follow the #PulmCC hashtag on twitter to keep up with relevant material and participate in future #PulmCC twitter chats. 

I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.

He sometimes expresses views similar to those written in a previous article, “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.

The field of medicine has undergone many changes (yet we still carry pagers…that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations.  I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: the pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article. Continue reading

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“Doctor, can I record this conversation?”

It’s happened to me a couple of times already. But the question in the title of this post was never asked. Rather I was informed later on that my conversation with a patient or family was recorded without my knowledge. Smart phones have made it all too easy for patients to secretly record conversations with their healthcare providers. Simply hit a button,  lay it innocently down by your side in the office or hospital, and patients get an instant video or audio capture of a conversation with their physician.  When my medical team and fellow physicians found out about the unauthorized recording of our conversation, the news was met with a combination and anger and disgust.

That reaction, it seems,  is typical of what most physicians would feel in the same situation. Why would a physician be upset about a patient secretly recording a conversation with them?

Well, simple, really. Most physicians are in chronic fear that the next person to hear/view that recording will be a malpractice lawyer, dissecting it,  consonant by consonant,  probing for potentially actionable material. The recording, in the physicians mind, changes the nature of the physician-patient relationship. It makes the patient a potential adversary, it makes the doctor feel as if they are in front of a jury and can not speak frankly, it makes them feel as if they are unworthy of trust. In other words, physicians do not like being recorded because they assume that the person recording them has negative motivations.

But let’s pause for a moment and look at this a different way. . . what if they don’t have negative motivations? Continue reading

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The PROCESS Trial: End of the Line for Central Lines?

A lot of things change for doctors once we’re done with training. Most of us leave behind the ivory tower that is the academic medical center to plow the common fields of private practice. We no longer have the weekly journal clubs, the Grand Rounds, the CME lectures. But what we gain is practical hands-on experience with what works, and what doesn’t. A nuanced knowledge of what’s accepted vs. what’s acceptable.

One such area has been the approach to sepsis. Manny Rivers et al published  their game changing study on early goal directed therapy (EGDT) in the treatment of septic shock in 2001, and the result became scripture in the field of Critical Care Medicine. The knowledge that tying sepsis resuscitation to the measurement of central venous oxygen saturation (ScvO2) and central venous pressure (CVP) using a central venous catheter, lead to a surge of recommendations.

The brain trust spewed forth these recommendations in various forms;  Surviving Sepsis Campaign, Sepsis guidelines, Sepsis bundles, Sepsis video games and Sepsis action figures. Somewhere in that sentence I may have transitioned to hyperbole.

Those of us in clinical practice didn’t always follow the drumbeat. Many of our patients with sepsis it seemed, did just fine without a routine central line or blood transfusions, or dobutamine drips. Why use invasive measures when we don’t really need them, and we’re not really sure that they’re helping? Still, when I talked to my ivory tower friends, the response was same, “We always use central lines and follow the EGDT”, they would say.

In case you’re thinking that I’m a maverick, well, it wasn’t just me. Surveys/studies that have looked at compliance with EGDT show compliance anywhere from as low as 0.1% to just above 50%. Clearly people were pushing back against the guidelines, and many began to publicly question whether results of EGDT could be generalized to the general population with sepsis. Continue reading

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How to Fix Healthcare, From a Doctor on the Frontlines: Part 3.

This is the last of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 2.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In post, I look at the last of three central  ideas that would lead to better and more affordable care.

3. Health Savings Accounts.

The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs.  This could be accomplished with health savings accounts.  These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status.   With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services.   This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones. Continue reading

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How a Journal Club and a Blog Challenged the Mighty NEJM

Could this be end of the Tonka-Scope?

Much has been written about how Web 2.0 tools can change the healthcare landscape.  It would appear a recent set of circumstances has upped the ante.

This story begins with a recent study that attempted to tackle the problem of ICU infections. ICU infections are a challenging problem, patients who are admitted to the ICU are at risk of worsening illness and death from infections such as MRSA which can be acquired while in the ICU setting. To counteract this risk, current practice is the performance of surveillance cultures on people who are admitted to intensive care. If the person tests positive for certain infections they are placed in isolation (and health care providers are asked to wear silly gowns and share a useless stethoscope).

The success of this strategy is dubious, ranging from successful in some studies to nearly useless in others. Based upon my personal observations of my own hospital’s isolation practices, my only conclusion has been that yellow is not a good look for me.

But I digress. In this study, patients underwent “universal decontamination” with chlorhexidine, a commonly used antiseptic. The study found a dramatic drop in the numbers of MRSA infections and bloodstream infections. The study was peer reviewed and published in the flagship of medical publishing, the New England Journal of Medicine (sorry JAMA). Continue reading

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A Dream About U.S. EMR’s; A Reality in th U.K.

I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.

A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).

In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it.  There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.

But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects.  They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading

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How to Fix Healthcare, From a Doctor on the Frontlines: Part 2.

This is the second of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 3.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In this post, I look at the second of three central  ideas that would lead to better and more affordable care.

2. Tort reform.

We as doctors have a calling to help patients.  But, as we all are human, mistakes can happen. It is very important that patients who are injured by mistakes be compensated in a way that the law is supposed to provide.  However, the point of law is to provide reliable decision-making that can sort good health care from bad health care.  Instead, currently, it is run ad hoc jury by jury with no set standards. The system currently favors a doctor if in fact something was done wrongly or it may favor a patient even if no mistake was made.  This unreliability leads to defensive medicine, ordering tests and procedures just to prove that you did something, or excessively documenting trivial facts to prove you looked at everything.  The estimates for defensive medicine has been estimated up to $200 billion per year.  The current laws neglect both the patient and the doctor and drives up costs with administrative and attorney fees.

Here is an example of the evolution of defensive medicine. If a family physician determines a patient’s headache is likely due to tension and there are no warning signs for something serious, the doctor may choose not to order a CT scan and have the patient follow up if symptoms do not improve. Rarely, a tumor or bleeding in the brain could present in such a way despite a normal clinical evaluation by the doctor.  If that patient ends up having a tumor or bleeding, they can sue the doctor for not ordering the CT scan earlier.  In turn, that doctor doesn’t want that to ever happen again, even though he did everything right by using his clinical knowledge to determine nothing serious was likely going on. Continue reading

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