It always makes my heart sink when the CPR guidelines change.
In 1980 I became a provider of advanced cardiovascular life support (ACLS) as certified by the American Heart Association. This was a great move. Through my internship and the many years that followed, it proved comforting to know that I would act decisively and with confidence in the setting of a cardiorespiratory arrest. The ACLS course dictated dogmatic protocols – the proper response to airway obstruction or to a fibrillating ventricle. No hemming, no hawing, no hedging: the professors professed. Debate the merits of coronary artery bypass surgery all you please, but during a code, depress the sternum two inches with each compression. Re-certification exercises reinforced the ACLS gospel.
A physician must adapt to regional antibiotic resistances, local referral patterns, and varied lab-request forms when changing hospitals or moonlighting in an unfamiliar emergency room. But when a heart stops, all ACLS initiates speak a common language and know the universal drill. During the ultimate medical crisis, the course of action is perfectly clear. Emergency cardiac care is to be administered the right way; the only way.
Alas, nothing in medicine is sacred. The ACLS guidelines and procedures periodically change! Once upon a time, rescue breathing began with four “staircased” ventilations; then it was two distinct ventilations; then it was never mind, just focus on compressions; then it was a 30:2 ratio of compressions to ventilations. The trusty opening line, “Let’s give an amp of epi and an amp of bicarb,” went by the wayside when sodium bicarbonate fell out of favor. And woe to the asystolic victim. Now that bicarbonate, calcium, and atropine have been removed from his protocol, he gets only epinephrine and a prayer. It feels like they might as well have abandoned a few of the Ten Commandments and gone on to endorse coveting thy neighbor’s spouse. Perhaps the next version of CPR will declare some new cranial nerves.
I guess I should have known that this could happen. A medical school professor once related his astonishment upon reading that the number of human chromosomes had been revised upward to 46. A fundamental “fact” had changed, and he evermore doubted the verity of his lecture material. During my career, I have seen many developments: new antibiotics, novel cancer treatments, robotic surgery, etc. Atrial natriuretic factor was identified, and I had to reenvision the heart as a gland as well as a pump.
Yet changing “Old Faithful,” the ACLS algorithms, always comes as a rude awakening. There is no doubt that in medicine, old dogs and puppies must continually master new tricks.
David A. Goodkin is a nephrologist.
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