ACLS megacode fail

Recently, during a private ACLS class for a few members of a local ambulance service, I ran into a scenario which I had never seen before.

I’ve been teaching ACLS for about 4 years now, give or take a few months. I am in the (admittedly bad) habit of using the same scenario for my mega-code. It is the same scenario which my paramedic instructor used the first time I took ACLS.

A husband (or wife, or daughter, or boy/girl friend) was driving his/her wife (husband, father, mother, lover, landlord) to the hospital because he/she was complaining of chest pain. They find your ambulance/fire truck at an intersection/fire station, doughnut shop, and pull up to you. The driver states the patient suddenly became unconscious while enroute to St. Elsewhere. “Go!”

The first few students went through the scenario, and miraculously saved the patient’s life. Well done, ambulance technician, well done. The last two were remarkably different. Once “go” had been uttered, it got strange.

“Okay, lets get him out of the car, and on to the ground. I have my gloves on. Is the patient breathing?”

“No, he is not breathing.”

“Okay, lets put in an oral airway and begin bagging him with 100% O2 at a rate of 14. Call for backup”

“Ventilations are being delivered. Additional help is on the way.”

“Does he have a pulse?”

“He does not have a pulse.”

“Okay, let’s start chest compressions at a rate of no less than 100, 2 inches deep.”

“Compressions are being done, and a pulse is palpable at the carotids with each compression.”

“Let’s put the AED on the patient and press ‘analyze’.”

“The AED is on the patient, and after analyzing, it says “Shock advised.”

“Deliver the shock, and re-check the pulse.”

“The shock is delivered, the AED says ‘no shock advised’ now, and the patient does not have a pulse.”

“Okay, I’m going to have my partner attempt an IV or establish IO access to the anterior tibial tuberosity.”

“IO access is obtained without difficulty, and with good flow noted.”

“Okay, how far away is my backup?”

“Your backup is 4 minutes away.”

“Okay, let’s continue BLS until they get here.”


At this point, I am literally speechless. This is a person with a paramedic license, mind you. I have delivered this scenario literally a hundred different times. Had this scenario been run the way it virtually always is, they would have seen pulseless ventricular tachycardia on the monitor, defibrillated, seen asystole, given epinephrine 1:10,000, then seen ventricular fibrillation, defibrillated unsuccessfully, pushed 300mg amiodarone, defibrillated, then seen a sinus rhythm with a pulse at a rate of 70, then they would have hung an amiodarone infusion, and the patient would have awakened on the way to the hospital. But, alas, that was not done. And the hypothetical patient had a hypothetical bad outcome.


“I’m sorry, could you show me in the ACLS textbook where they advocate continuing BLS until firefighters arrive?”

“Oh, it probably doesn’t say that in the book, but that’s how we do it where we work.”

“Interesting. Unfortunately, I cannot pass you, and suggest that you read the textbook again, and obtain your ACLS card elsewhere.”

I am interested to know where, or if, this student actually passed ACLS, and am also interested to know what the student’s supervisor/training director would have thought had they been there to witness this horrible ACLS failure.


  1. Interesting. Maybe they’re taking to heart the recent guideline shifts that emphasize BLS over ALS. Slightly misguided application IMO, but I could imagine a semi-coherent justification for it.

    • Amazing. Well, not a justification other than a self-justification. In any case, the answer never should be this is how we do it where I come from,” as much as how it is supposed to be done in order to demonstrate ACLS skills.

      On the other hand, I’m not nearly so concerned with respect to whether this person “passed ACLS” or had a card. That’s just a class and a piece of paper. I’m more concerned with the cardiac patients and other patients in the service provision area of this student’s provider. If this is how cardiac care is approached, all things should be suspect.

      I remember judging a competition around 27 or 28 years ago in which we were judging blind. That is, we didn’t know the providers or the service. After watching the performance of two paramedics in the competition, we three judges said, “When this is over we need to find out what county these guys are from so we won’t ever drive through it.”

    • I assure you, these individuals are not intelligent enough to justify their actions. They are just remarkably lazy, and even more remarkably stupid.

  2. We do not have any good reason for doing anything more than chest compressions and defibrillation in the first 10 (or so) minutes of the code.

    When I used to teach ACLS, I would explain that the only treatments demonstrated to improve outcomes that matter (discharge from the hospital with a functioning brain and longer survival) are chest compressions and defibrillation.

    Eventually the people who write the ACLS protocols will recognize this and start applying more science than wishful thinking. Eventually.

    Of course, there is nothing to suggest that this guy has any understanding of what he is doing.


  3. This patient perfectly fits into ACLS protocols. There is more than VT/VF that will give you a pulseless patient. If the patient is in asystole or PEA, the AED will not recommend a shock. It should not be confusing or anything to debate. You just follow another path.

    Do you have epinephrine on your ambulance? Give 1 mg of epi every 3-5 minutes while continuing good quality CPR. Check the AED every 2 minutes to see if a shock is recommended. Get your patient to the hospital.

  4. MedicmanCook says:

    Are you sure he is a paramedic? if he is an advanced or basic EMT manual defibrilation, medications, and most advanced air ways would be out of his scope of pratice. Having said that He realy has no buisness taking an ACLS class. Althow we teack our basic and advanced the basic skills of ACLS so that they have a basic understanding and can better assist us as paramedics.

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