I have a card that says I am an expert!!!

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Late last week I was once again involved in a discussion of card courses. You know them as BLS, ACLS, PALS, NRP, ATLS, etc.

 

For many years I was an instructor for many of these courses. Officially I am still an instructor for some of them, even though I have almost no time to teach them anymore. When I worked as a paramedic, I had more “training cards” than I did credit cards. It was always an activity to copy them all for employers every couple of years (front and back) and keep them on 2 printed pages of paper. I can recite their guidelines as easily as The Lord’s prayer.

 

I think this is a good comparison, because these classes are largely like church. The Instructor says their part of the prayer, and the “students,” as they are erroneously referred to answer with their part. Check- off sheets are completed, cards are issued, and for at least 2 years, sometimes as many as 5, these (re)newly minted providers march off as if they really know what to do.

 

It has been my role many times to delicately explain to various specialist physicians (some who are directors or professors of their profession) that they failed the check-off, and in no reflection of their ability, must remediate on the guidelines and “re-test.”

 

While my education in medicine continues (read goes on forever without respite) every day I am faced with a tragic reality about these “courses.” Despite being mandated by a host of healthcare accrediting agencies across the globe, the courses are really not beneficial or even useful to people who are otherwise expert at the material.

 

For many years I advocated that these courses were beneficial for not experts as an interim measure until an actual expert could be engaged. It seems reasonable right? We ask non-experts to do CPR. We ask non-experts to call for and use a defibrillator early. Then we start talking about “fluid boluses”, “life- saving medications,” and all sorts of other interventions. Some of the courses teach providers skills like umbilical vein catheterization or diagnostic peritoneal lavage, as if equipment for these procedures just lays around waiting to be used. Like the provider who rarely or has never performed a procedure is in time of emergency and great stress going to take up arms and fight the rising tide of inequity in order to save a life! (You see where these courses break down yet?)

 

But perhaps the biggest flaw with all of these card courses is that they confer the illusion of expertise and knowledge. Think of the fancy sounding names, “advanced trauma life support”, “advanced cardiac life support”, etc. sounds a lot more important than “physical exam in an emergency” and “CPR with a couple of hospital toys” don’t they?

 

Since I have friends across the healthcare spectrum, all over the world, not a month goes by where there is not some reference or discussion of these guidelines. Sometimes the most basically trained providers not only recite these guidelines as gospel, they actually call subject matter experts stupid, ignorant, uneducated, a menace, etc., for not placing these guidelines as the one and true, omniscient, omnipotent, deity. That anyone who does not follow their hallowed tenants is somehow, un-expert and lacking the most basic knowledge and skills to provide patient care in these realms.

 

But it has been fairly obvious to me by being involved with various experts and research that most of these “guidelines” and therefore “courses” and “certificates of training” are actually not really worthy of more than saying “I know CPR.” Whether as part of a surgical service or the ICU, past BLS, many of these guidelines work on a small minority of patients. Furthermore, some experts, like the American College of Emergency Physicians, have actually, and rightfully, come out with position statements declaring their knowledge superior to these courses and should not be subject to them.

So why don’t say…Trauma surgeons come out with the same position? Why don’t cardiologists? Intensivists? Pediatricians? Why does everyone who take these classes actually think they are expert? Using the example of trauma, when I went to paramedic school, I had about 20 hours of education on trauma. Another 2 “days” of PHTLS, and eventually audited another 2 “days” of ATLS twice before medical school. Did that make me an expert? Did it make me more of an expert that I could cite the studies these guidelines came from?

 

Some years later I now realize just how feeble that knowledge is. I understand how “consensus” guidelines are formed. I witness how “small changes to maintain credibility” are considered superior to broad and sweeping changes. Especially by actors who make money off of marketing or teaching these courses. (I made more money teaching some of these courses than I ever did as a field medic) I still supplement my residency income by teaching them.

 

But I do not believe them anymore. In fact, I don’t even believe in them. I see how those “initial steps” past CPR and defibrillation make resuscitation and restoring function to the critically ill and injured more difficult in surgery and the ICU. Almost every day when a patient that appears to be a complete train-wreck I am reminded that the practitioners earlier in the “chain of survival” were following the “guidelines”. I have a silent laugh about the irony of Humpty Dumpty and all the King’s horses and men and realize that it would be easier to put him back together again if everyone prior did as less as possible, because their interventions often do make it worse.

 

I really wish people with these card courses would stop pretending to be subject matter experts and calling people with far more knowledge and insight derogatory names for not adhering to them. I wish hospitals actually cared about patients enough to come up with their own in-house curriculums than forcing their staff to repeat these mindless information in a can courses every couple of years. I wish I got paid to actually teach people what I have learned about my subject matter than I do to teach these non-sense guidelines.

Maybe one day…

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