NEWS AND PERSPECTIVE

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Introduction

nnals News and Perspective explores topics relevanto emergency medicine, in particular those in whichur specialty interacts with the political, ethical,ociologic, legal and business spheres of our society.

resentation, you Photo used by permission of the Ame

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anagement will be rare. By design, it will not be a‘breaking news’’ section with the latest (andndigested) developments, but instead a reflectivenvestigation of recent and emerging trends. If youave any feedback about this section, please forwardt to us at feedback@acep.org.

Discussion of specific clinical problems and their

0196-0644/$-see front matterCopyright © 2006 by the American College of Emergency Physicians.

EMERGENCY PHYSICIANS’ VOICE IN THE ACLS PROTOCOL:GUIDELINE’S ECLECTIC COMMITTEE SHOULD SERVE AS MODEL

Eric BergerSpecial Contributor to Annals News and Perspective

More emergency physicians than ever before were involvedin the development of the 2005 Advanced Cardiac Life Support(ACLS) protocol in what should serve as a model for thecreation of guidelines commonly used in the emergencydepartment (ED), experts said.

Every 6 years, the American Heart Association (AHA)publishes a new set of ACLS guidelines, which is no simpletask. For the 206 pages of guidelines published last year, 600reviewers prepared worksheets on more than 300 topics.They consulted 25,000 references. And after 18 months ofwork, a committee of leading doctors met in Dallas to reacha consensus on how best to draft the detailed medicalprotocols for lifesavingcardiac care.

Dr. RobertO’Connor, director ofeducation and researchat Christiana CareHealth System inDelaware, chaired theACLS subcommittee.Himself an emergencyphysician, O’Connorsaid emergencymedicine was the best-represented specialty onthe committee, andplayed an integral role indrafting the guidelines.The reason, O’Connorsaid, is obvious.

“By having increased

increase buy-in by doctors using the guidelines,” saidO’Connor, who served as Delaware’s Emergency MedicalServices director from 1990 to 1998. “You will only getguidelines as diverse as the composition of your committee. Andthe more diverse it is, the more relevant the guidelines will be toall disciplines.”

The widespread involvement of emergency physicians indrafting the ACLS guidelines for the AHA has made the processan admirable model for the development of similar guidelines,published both by the AHA and other organizations, said Dr.Judd E. Hollander, clinical research director in the Departmentof Emergency Medicine at the University of Pennsylvania.

“The participation ofemergency physicians inthe current guidelines isa reflection of theimportant role we playin caring for cardiacpatients,” Hollandersaid. “Clearly, foremergency medicine tobe reached out to byanother society is only agood thing. . . This is arecognition that someportion of their care, avery important part,happens in theemergency department.”

It hasn’t always beenthis way.

Until 1947 there wasPhysicians from sundry specialties gather in Dallas to examine theevidence and update the Advanced Cardiac Life Support guidelines.

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little that doctors couldican Heart Association.

Annals of Emergency Medicine 457

News and Perspective

do for heart attacks other than advise rest and providenitroglycerin for the pain. But then, for the first time, ClaudeBeck successfully revived a patient in an operating room usingan open-chest defibrillator. And 9 years later, Paul Zoll and hiscolleagues at Harvard University used a more powerful unit toaccomplish the first closed-chest defibrillation. Later, the AHAand other organizations began establishing methods for savingthe lives of people whose hearts had stopped.

The first emergency cardiovascular care guidelines wereestablished by the AHA in 1974, and they have been updated,based upon the best available scientific evidence, in 1980, 1986,1992, 2000 and, most recently, last year. (See table for majorchanges in 2005 ACLS guidelines.)

THE BIRTH OF CARDIAC LIFE SUPPORTAt the time of the first set of guidelines, the field of

emergency medicine was in its cradle. The first ACLS protocolswere developed by cardiologists and anesthesiologists. Thatdidn’t really change until the early 1980s, said Dr. Allan S.Jaffe, a professor of medicine at the Mayo Clinic College ofMedicine. Jaffe, a cardiologist, became chairman of the ACLSworking group in the mid-1980s.

“At that point in time, the committee structure wasdominated by anesthesiologists and cardiologists,” he said. “Ibegan to think it was important to widen the nature of thecommittee. I thought people like emergency physicians had theappropriate skills to contribute. I don’t remember anyonestanding up and saying ‘How can you bring those SOBs in?’ but

Table. Major changes in 2005 ACLS Guidelines.

1. Emphasis on high-quality CPR with minimal interruptions.30-2 compression–to–rescue breath ratio for single rescuersin all ages except newborns.

2. Increased information about the use of laryngeal maskairway and esophageal-tracheal combitube (Combitube). Useof endotracheal intubation is limited to providers withadequate training and opportunities to practice or performintubations.

3. Confirmation of endotracheal tube placement requires bothclinical assessment and use of a device (eg, exhaled CO2detector device). Use of the device is part of (primary)confirmation and is not considered secondary confirmation.

4. The algorithm for treatment of pulseless arrest wasreorganized to include VF/pulseless ventricular tachycardia,asystole and pulseless electrical activity.

5. The priority skills and interventions during cardiac arrest arebasic life support skills, including effective chestcompressions with minimal interruptions.

6. Insertion of an advanced airway may not be a high priority.7. If an advanced airway is inserted, rescuers should no longer

deliver cycles of CPR. Chest compressions should bedelivered continuously (100 per minute) and rescue breathsdelivered at a rate of 8 to 10 per minute (1 breath every 6to 8 seconds).

8. Providers must organize care to minimize interruptions inchest compressions for rhythm check, shock delivery,advanced airway insertion, or vascular access.

there was definitely a sort of quiet exclusion. That was just the

458 Annals of Emergency Medicine

way it had always been, it was sort of like a good-old-boysnetwork.”

Jaffe knew of emergency physicians like the University ofWashington’s Dr. Mickey Eisenberg, who were contributingimportant research to the field of sudden cardiac death, and hedesired their input. So he sought to broaden the panels.

“You have to remember, emergency medicine was in itsinfancy back then, as opposed to now, where there is a greatdepth of high quality people,” Jaffe said. “But I was looking fortalented people to help write the guidelines. Their designationsdidn’t matter to me, their skill sets did. I’m sure I wasn’t perfectat finding people, but that was the motivation. So we beganfinding these skills in emergency physicians. I’d love to tell youthere was this great conspiracy against emergency physicians andthat we fought a tooth-and-nail battle to win a great victory forcivil rights. Most people just realized it was a natural fit. That’snot to say there weren’t some tensions. There were. But thetrend that started then has continued through today.”

The editor for the 2005 emergency cardiovascular careguidelines, Mary Fran Hazinski, a registered nurse, said theresearchers from different professions worked together almostseamlessly.

Yes, there was plenty of debate, she said. A typical issue wasweighing the effectiveness of certain drugs in laboratory or staidclinical settings, versus their potential efficacy in a more hecticout-of-hospital setting or an emergency department. Emergencyphysicians weren’t always ready to accept that all drugs wouldbe as effective in both settings. Debates such as these lendthemselves to requiring all perspectives, Hazinski said. And ifthe debates became a little passionate, ultimately, that was bestfor the guidelines.

“The people that become involved in establishing theguidelines are both knowledgeable and dedicated,” saidHazinski, a senior science editor for the AHA. “They arepassionate about their specialties, and they’re passionate aboutgetting the science right. They want the guidelines to be asaccurate and practical as possible.”

A SHINING EXAMPLE OF INCLUSIONHalf a dozen leading emergency physicians surveyed for

this news article agreed that the modern ACLS guidelines areprobably the most inclusive of all specialties, and thereforeshould be emulated by the American College of Cardiology(ACC) and other organizations that establish medical-careprotocols.

These leading emergency physicians, many of whom havehelped write the ACLS or other similar guidelines, thought itwas appropriate for the AHA to continue publishing them,although the primary user is often an emergency physician.They noted the AHA’s broad efforts to disseminate thefindings freely in the journal Circulation, and that a copy wasrecently mailed to every member of the American College ofEmergency Physicians. As long as the process to develop theguidelines remains inclusive, the doctors contacted for this

article said the AHA should continue to publish them. When

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asked directly, not one of the emergency physicians tookissue with another professional organization, the AHA,getting credit for guidelines that govern work in emergencymedicine.

“What matters is that our patients get the best care,” saidHollander.

THE DOLLARS MAKE SENSEThe AHA does derive considerable revenue from the sale

of textbooks and course materials. The ACLS ExperiencedProvider Course, for example, requires that studentspurchase ACLS: The Reference Textbook, which costs $25,and “strongly recommends” the ECC Handbook, which costs$13.95. According to the AHA’s 2005 annual report, theorganization earned $34 million from educational materialslast year.

But once again, the emergency physicians contacted forthis article weren’t put off by the AHA recouping fees for theconsiderable work that goes into preparing and disseminatingthe guidelines.

All of this is not to say the ACLS development processcan’t be improved, or that the ACLS model should not beexported to other AHA guidelines and those developed byother professional societies that impact emergency medicine.

Indeed, there have long been disconnects betweenprofessional guidelines for clinicians and the emergencydepartment, said Dr. Brian Gibler, chairman of theDepartment of Emergency Medicine at the University ofCincinnati College of Medicine.

He recalled the protocol for patients, prior to 1991,presenting in the emergency department with a heart attack.Before administering a thrombolytic agent such as tissueplasminogen activator, or tPA, an emergency physicianwould have to consult with a cardiologist. Gibler, whoparticipated in the development of the National HeartAttack Alert Program launched in 1991, helped change theemergency department rules.

“It seems pretty logical that the first physician competentto read an EKG ought to treat the patient right away,” saidGibler, who is also director for the Center of EmergencyCare of the University of Cincinnati Hospital. “But havingan emergency medicine physician involved in those types ofdiscussions was still pretty novel at that time.”

Gibler has been involved in efforts to make certainguidelines more user-friendly for emergency physicians,protocols such as those published jointly in 2000 by theAHA and American College of Cardiology for theManagement of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction.

vIn that effort, he has been joined by Dr. Charles V. Pollack,chairman of the Department of Emergency Medicine atPennsylvania Hospital. Pollack has also written other“interpretations” of guidelines, such as the 2004 ACC/AHA

protocols for the Management of Patients with ST-Elevation

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Myocardial Infarction, or STEMI guidelines, for emergencyphysicians.

“Unfortunately, our involvement comes only after theguidelines are finished,” Pollack said. “We really feel like weshould be involved earlier. We can optimize the care ofpatients before they get to the cardiologists. But we need tobe more involved.”

Other emergency physicians contacted for this articleexpressed similar frustrations. At the heart of the arguments:the specialties developing critical care guidelines have a fairlynarrow focus: the heart and arteries, or the brain, ororthopedics, or obstetrics. But the emergency physician mustbe ready to encounter these health problems and many more.

It’s impossible to expect the emergency physician toconsult the specialty journals for every medical discipline,Pollack said. If those specialties want their patients handledin the best possible manner, then it simply makes good senseto bring emergency physicians into the discussion of primarytreatment for their patients. Such participation will likelyalso make the guidelines more legitimate in the eyes of otheremergency physicians, Pollack said, and increase thepossibility that they will appear, in some form, in theliterature that first responders read.

THE LOGIC OF EMERGENCY PHYSICIANINVOLVEMENT

“At some point you have to hope what is really importantto your specialty finds its way into our journals, becausethat’s where emergency physicians are looking,” Pollack said.

Hollander agreed that if emergency physicians are notinvolved in the drafting of guidelines, the entire discipline ofemergency medicine is unlikely to use them.

“The STEMI guidelines are very relevant to emergencymedicine, but they would just get better penetration if theyhad a bunch of emergency room guys involved,” he said.

There’s another way most guidelines could be made morerelevant, Hollander said. The method by which pneumonia,psychiatry and other protocols are written simply doesn’temphasize enough one variable that’s extremely important inthe emergency department–time management.

What’s most critical to an emergency physician,Hollander said, is what must be done for a pneumoniapatient, not a lengthy list of action items in a guideline.That’s because while a doctor in the ED is grappling with apneumonia patient, he or she might also have several heartattack patients.

Having emergency physicians involved in the evaluationprocess, when committee members are poring over data anddiscussing the guidelines, would increase the chances thatparticipants are looking for time-sensitivity in the research,and incorporating it into the final protocols, Hollander said.

As for the ACLS guidelines themselves, there are stillmore ways to diversify the committee membership, said Dr.Lance Becker, a professor of medicine at the University of

Chicago.

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For the 2005 guidelines a concerted effort was made toinclude European ideas. During the January 2005 consensusconference in Dallas, Becker conducted a daily wrap-up onthe most controversial topics. His co-moderator was fromNorway. Among the biggest changes in the emergencycardiovascular care guidelines in 2005 were doing CPR priorto defibrillation and the use of hypothermia, Becker said.Both of those ideas came from European scientists, he said.

When the next ACLS guidelines are drafted, Becker saidthe AHA would do well to continue pushing for still moreinternational participation, looking to China, and the rest ofAsia, for additional input. That’s clearly the next evolution

for the committee, Becker said. After all, it would be hard to

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dramatically increase the participation of US emergencyphysicians who already hold the majority.

“I think it’s a tribute to the maturation of emergencymedicine,” he said. “Emergency medicine now has lots ofpractitioners who are considered by unbiased review to behighly qualified. What you have is the AHA and otherorganizations looking at their qualifications, identifying themas the best people, and putting them on importantcommittees. So what you end up with is a process that is farsuperior to just about every other consensus process that Ihave ever seen.”

doi:10.1016/j.annemergmed.2006.03.017

2006 Medical ToxicologyMoC Assessment of Cognitive

Expertise Examination

The American Board of Emergency Medicine (ABEM), the American Board of Pediatrics (ABP) and the American Board ofPreventive Medicine (ABPM) will administer the recertification examination in Medical Toxicology on Thursday, November 2,2006. This examination will be administered at computer-based testing centers throughout the United States.

Physicians must submit an application to the board through which they hold their primary certification and through which theyreceived their initial certification in Medical Toxicology. Physicians certified by an American Board of Medical Specialtiesmember board other than ABEM, ABP, and ABPM who attained Medical Toxicology certification through ABEM must applyfor this examination through ABEM. Upon successful completion of the examination, continued certification is awarded by theboard through which the physician submitted the application.

Application materials will be available for ABEM diplomates on February 1, 2006, and will be accepted with postmark datesthrough May 1, 2006. ABP and ABPM diplomates should contact their Boards for application cycle information.

AMERICAN BOARD OF PEDIATRICS AMERICAN BOARD OF PREVENTIVE MEDICINE AMERICAN BOARD OF EMERGENCY MEDICINE

111 Silver Cedar CourtChapel Hill, NC 27514-1651Telephone: 919.929.0461Facsimile: 919.929.9255www.abp.org

330 South Wells StreetSuite 1018Chicago, IL 60606-7106Telephone: 312.939.2276Facsimile: 312.939.2218www.abprevmed.org

3000 Coolidge RoadEast Lansing, MI 48823Telephone: 517.332.4800Facsimile: 517.332.2234www.abem.org

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