PALS renewal today was downright frightening

[Guest374845]

Our renewal classes have nurses from clinics, wards, heme/onc, EDs and PICU at the same time because we are a tertiary center.

For our scenarios, my group consisted of floor and clinic nurses, some doing their first renewal and some doing the last of their career (one nurse actually stated that).

Now, I wasn't expecting them to come out of the gate swinging and run a flawless megacode but some of them couldn't so much as identify a shockable rhythm!

• We pushed adenosine - not amio- for VT with a pulse, complete with peer-peer confirmation of weight based dosing.
  
• We did unsynchronized cardioversion.
  
• We did 3-4 rounds of epi and compressions for pulseless VT before someone suggested that it was shockable.... apparently several of them misunderstood PEA to generally mean ANY electrical activity without a pulse, therefore pulseless VT was PEA and they simply ran that row in their PALS card.
  
• We gave nebs, fluids and finally Benadryl for what was clear-cut wheezing anaphylaxis.
  

And the PICU instructor allowed all of these f-ups to happen and even gently guided a discussion about the correct approaches afterward rather than prolonging the scenario or pulling anyone aside.

And when it was finally my turn I got sacked with some kind of spontaneous cardiogenic shock nonsense that I had to start on nitro and inodilators before she'd let me quit talking/guessing.

I understand that lower acuity areas don't get the benefit of frequent exposure to critical illness and fulminant deterioration, but A) that is the point of ACLS and PALS and B) this was downright painful and negligent. Hell, I recognized one the nurses as having cared for my daughter during an admission. Now all I'm gonna worry about is whether she's itching to push amio for my kid's SVT or some other made-up treatment.

[JKL33]

I do think the PALS recert classes should place emphasis on the profession of the participants. For instance, I don't think, under any circumstance, a RT would initiate administration of any emergency medication or defibrillate someone. Likewise, I don't think the nurse practice act allows nurses to prescribe medications "unless it's a real emergency and no doctor is available." I've been PALS certified for 18 years so I've been through a few recerts with nurses, RTs, MDs, and Dentists, and I think the patients would be better served if emphasis was placed on the traditional roles and responsibilities in a code. In some instances it seems the only outcome of the megacode scenarios is to feed the ego of the instructor.

An ACLS RN would be following a very specific and well-known protocol that is part of the facility's policy, not "prescribing medications". The whole purpose of the class is for "a real emergency", such as one that happens when the doctor or other key team members is/are tied up or not yet present. I would expect anyone who has passed the class, including an RT, to shock or place pads in anticipation of shocking. I guess there's wide variation in what's expected from place to place.

I don't disagree with the idea that it might be more helpful if roles/responsibilities were emphasized; that would be something different than what ACLS has traditionally been. But what we're talking about right now is people who basically only know and only expect to ever actually perform BLS, being passed through ACLS without being able to recognize the conditions or know anything to do for them besides check a pulse and start chest compressions. People do sometimes get remediated/retake ours.

ED nurses always get the hardest scenarios, but I've never been humiliated by any instructor, even though they have some good-natured fun trying to make us think. They are very helpful to and gentle with those not working with any critical care patients...but still don't let people just watch VT/VF on a monitor for several minutes and not at least verbalize the appropriate tx and try to follow the card (an example from my most recent recert....)

[OldDude]

JKL33, I hear ya, you can mince words when I said "prescribing medicine" but a jury might not be able to differentiate the difference in protocol, nurse practice act, no physician present, etc. As we know, especially in the ED, most codes don't have a positive outcome; especially in pediatrics.

Having said that, as a pediatric nurse and parent, I would do anything and everything within my power and imagination to intervene in any way I can to save a child's life. I answer to a higher authority than practice acts and rules.

My point is PALS puts too much emphasis on being prepared for being struck by lightening instead of how to get through the thunderstorm. I appreciate your opinion.

[JKL33]

I understand the spirit of what you're saying, too.

[OldDude]

I understand the spirit of what you're saying, too.

Yea, I'm thinking you and I would make a pretty good team.