Gautam wrote: 'A senior colleague who couldn't be 'bothered with his/ her
ALS/ATLS/PALS etc.' Is this a mistake? shouldn't it read 'etc. etc. etc.
etc.'? Therein lies the problem. Also assorted prehospital and major
incident courses and the new MedicALS; ideas for airway management courses;
case for A and E docs doing the equivalent to basic surgical skills etc.
You've got to prioritise. Use of the phrase 'couldn't be bothered' rather
than 'had excellent time management skills; after careful personal SWOT
analysis drew up a list of suitable professional development and prioritised
appropriately' (OK, it doesn't have the same ring to it)could be taken to
imply an attitude that these courses are the best without having to prove
themselves. 

John Ryan wrote: 'as the numbers of our nurses who are ALS certified has
increased so has the standard of our resuscitations.' Glad to hear it. My
experience is the same. The only fly in the ointment is that my survival to
independent living rate has stayed the same, as I'm sure that of other A and
E departments has. Bearing in mind that NICE considers £5,000 per life saved
(GP IIb/ IIIa inhibitors, high risk patients) acceptable, but £30,000 (lower
risk patients) not, are all these courses cost effective for A and E? 
OK, I know I'm selectively quoting, ignoring the periarrest and post arrest
resuscitation, but my point on that is that time spent studying arrythmias
and antiarrythmic agents or rotating to ITU would be more useful for A and E
doctors than ALS, particularly if we're talking about senior doctors-
there's a lot of adenosine wasted on inappropriate rhythms by people who
don't understand the physiology and pharmacology. For more basic training,
how does 'DC shock any patient who arrests' sound? Doesn't take 2 days and
250 quid to teach; easy to remember; difference in patient outcome cf ALS
miniscule; can recertify by random telephone check ups; cuts out fine print
so people remember safe use of cardioverters rather than coming away knowing
mnemonics for drugs that don't work and debating what exactly the
compression rates mean.

The problem the ALS test is that it is often carried out by people with no
real understanding of the subject who can't deal with deviations from the
script (indeed are not allowed to). Understanding the subject in depth will
not pass you. Rote learning will. The trouble is that rote learning is
quickly forgotten, and does not allow adjustment for changed circumstances.
If we want to make this type of thing compulsory for consultants, include it
in the FFAEM exam so it can be examined by people with a broad and deep
understanding of the subject. Pass those who understand and can formulate a
reasonable plan of action; fail those without sufficient understanding even
if they have memorised the algorithms.

If we recognise these courses for what they are- a way of teaching people to
work in teams and stopping them from panicking about serious, but easily
treatable (just because someone dies does not mean they were not easy to
treat) disorders; rather than the best way of dealing with individual
patients, then they become more acceptable. As things stand, however, we are
spending a lot of money and time training people for insignficant effects on
outcome (not every group. Training CCU nurses is a Good Thing. Career grade
staff- if doing it regularly maybe OK already, so marginal improvement
slight; if not doing it, how relevant is it?. A and E- prehospital arrest
without ouput on arrival survival rare regardless of quality of treatent. I
believe there's one department that won't let you through the door without
an output- if you arrive dead, you leave dead. In any case, what does ALS
teach you that paramedics can't do but works?) If we're doing it for morale
purposes, lets be honest and say so.

Matt Dunn
Warwick


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