It always breaks my heart when CPR guidelines change.

In 1980, I became an Advanced Cardiovascular Life Support (ACLS) provider certified by the American Heart Association. That was a great move. During my internship and the many years that followed, I found it comforting to know that I would act decisively and confidently in a CPR situation. The ACLS course dictates dogmatic protocols—correct response to airway obstruction or a fibrillating ventricle. No hemming, no hemming, no hedging: the professors professed. Debate the benefits of coronary artery bypass grafting all you want, but during code, push the sternum two inches with each compression. Recertification exercises have reinforced the ACLS gospel.

The physician must adapt to regional antibiotic resistance, local referral patterns, and varied laboratory request forms when changing hospitals or working in an unfamiliar emergency department. But when the 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. CPR must be administered in the correct manner; the only way.

Alas, there is nothing sacred in medicine. ACLS guidelines and procedures change periodically! Once upon a time, rescue breathing began with four “staircase” ventilations; then there were two separate vents; then it didn’t matter, just focus on the compressions; back then it was a 30:2 ratio of compressions to vents. The trusty opening line “Let’s give an amp of epi and an amp of bicarbonates” went by the wayside when sodium bicarbonate fell out of favor. And woe to the asystolic victim. After bicarbonate, calcium, and atropine were removed from his protocol, he received only epinephrine and prayer. It feels as if they may have abandoned a few of the Ten Commandments and continued to condone the desire for one’s neighbor’s husband. Maybe the next version of CPR will announce some new cranial nerves.

I guess I should have known this could happen. A medical school professor once recounted his astonishment when he read that the number of human chromosomes had been revised upward to 46. A fundamental “fact” had changed, and he forever doubted the truth of his lecture material. During my career I have seen many developments: new antibiotics, new cancer treatments, robotic surgery, etc. Atrial natriuretic factor was identified and I had to rethink the heart as a gland as well as a pump.

Yet changing the “Old Faithful,” ACLS algorithms, always comes as a rude awakening. There is no doubt that in medicine, old dogs and puppies have to learn new tricks all the time.

David A. Goodkin is a nephrologist.

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