How I Failed Advanced Life Support

I always tend to write posts before night shifts and this post won’t be any different. There are few things more serene than typing out a nice long article right before a set of four night shifts!

This article is about how I managed to actually fail a two-day £350 course on advanced life support (ALS).

ALS is essentially a certificate that all hospital doctors and paramedics (I think) have to possess that allows them to take part or lead a cardiac/respiratory arrest. If you google “advanced life support” (scroll down to the first image if you use the link) you will see the infamous algorithm that every doctor and paramedic supposedly (apart from me it seems) has ingrained in their minds.

Like most doctors I passed ALS as a second-year doctor or a FY2. For good reasons we have to re-certify once every four to five years so I decided to attend the course on the Thursday and Friday that just passed. From memory I knew the two days were gruelling and they didn’t disappoint. Both days started sharply at 0830 with a couple of lectures followed by pretty intensive simulation scenarios that all of us had to participate in for the remaining 6 or 7 hours. Both days ended at 1800, with the second day ending with a multiple choice question (MCQ) exam followed by a simulation scenario exam, also referred to as CASTest. I have to be honest I’m still not really sure what CAST stands for…

After finishing the MCQ quite comfortably I hadn’t given the CASTest much thought – I passed it four years ago on my first attempt when I hardly knew anything – surely I’d have no problem right? I’m a medical registrar who knows ALS inside out right?

The cardiac and respiratory arrest Gods looked down at me and laughed that day.

I failed the first simulation scenario because after the cardiac monitor changed half-way through the scenario I paused for a rhythm check. You should only ever check the rhythm (+/- pulse) after the end of each high quality CPR cycle. When the examiners asked me at the end when I should check the rhythm, I answered correctly but because I paused the CPR during the scenario I failed.

This was a bit of a shock to the system because I didn’t realise you could fail ALS. It was also frustrating as I knew the answer – my brain just didn’t implement the knowledge.

For my second attempt, I failed even more spectacularly. Despite knowing the answer once again, this time my brain made me give defibrillation shocks after every second cycle of CPR when every healthcare professional and their dog knows that defibrillation occurs at the end of every high quality cycle of CPR.

And the only time you interrupt CPR is when the patient shows signs of life, or for the few seconds you’re delivering a shock. How did I manage to screw up so badly?!

 1. Carelessness – We were sent a 200-page A4 book 4 weeks in advance and I only opened it at 8pm for 2 hours the night before. We also had to complete a pre-course MCQ to compare scores pre- and post-course. I rushed it in 10 minutes despite the material clearly suggesting an hour for the exam. To make matters worse, I managed to pass it with 79% which made me even more complacent.

Like a careless person crossing the road without looking both ways type of thing. I’ve crossed the road hundreds of times before – what’s the worst thing that could happ- CRASH

2. Over-thinking things – Out of 22 candidates (vast majority were new second year doctors) only one girl and myself managed to fail. Whilst good doctors for their amount of experience, most people in the course understandably struggled with some of the details. When I was a FY2 I struggled with the specific drugs too.

It’s easy to know what to do when someone has pulseless VT or VF – just defib them! But what do you do for a tricyclic antidepressant overdose that has resulted in a pulsed monomorphic VT? The answer is 50mmol sodium bicarbonate 8.4% with 300mg amiodarone. The extra experience and knowledge of interpreting arterial blood gases and what I’ve just mentioned does not have any bearing on CASTeach as they only assess the very basics. By knowing all the little details I managed to confuse myself and over-analyse the situations.

Nevertheless there is no excuse.

3. Priorities – More recently, my two main priorities have been to increase my respiratory knowledge and work out more seriously. By going to the gym three times per week and studying more diligently I completely neglected reading the ALS textbook.

4. Fatigue – Not exactly news, but if you take a look at my lead up to the ALS course, I clocked up a few more hours at work than the average person. Working the weekend before with the extra gym and studying sessions was catching up.

8 hours8 hours8 hours8 hours9 hours13 hours13 hours7 hours10 hours10 hoursALSALS

5. Brain-fog – With lifting weights more seriously follows eating much more, and choosing foods much less wisely. I weighed myself in at 81.6kg at 5ft11 which is probably the heaviest I’ve been. I’m strong but also have a big belly. In combination with the terrible diet, my poor sleep and fatigue have resulted in suboptimal mental clarity. Despite knowing the algorithm almost inside out I still managed to mess up.

6. Being too nice (stupid?) – This might sound like a strange point but during the exam, you have two instructors who act as helpers during the cardiac arrest simulation. Your job is to direct them towards tasks but as it’s quite a chaotic scenario, quite often I was asking for 10 things at the same time. I ended up helping them place cardiac monitors and oxygen masks which led to even more cluttering of my already-foggy-mind.

As the course came to a close and everyone left the lecture hall, the “mentors” stayed behind with me and the other girl (separately but within earshot) and told us what would happen next. Because I passed the post-course MCQ with 86% I’m apparently allowed a third and final CASTest before I officially fail. I didn’t see her face but the girl unfortunately had to do the entire course again because she also failed the MCQ. Repeating the course is a prospect that I may also have to face if I screw this up again.

If you were in my situation, how would you approach this last go? Here’s my take on it…

1. Reschedule CASTest during a less busy period and especially not after a 12 days of intensity

2. Read ALS textbook and practice several times prior to the actual exam

3. Clean up diet by using MyFitnessPal again

4. Discuss with examiners regarding standing back and letting them carrying out all the tasks

I’m going to try and arrange my blood tests to be checked because what gets measured gets improved.

I’ll let you guys know whether I pass or not. In the meantime, keep the questions or comments coming!

Edit: Since writing this post, I passed ALS so avoided the need to pay another substantial fee. Hooray!

If you enjoyed the dissection and my approach to re-attempting advanced life support, I’ll let you in on a secret. Almost everything I’ve learned about life (outside medicine) has come from books. We might live in a day and age where time is a limiting resource but like the great Tony Robbins says if you can’t spare 10 minutes per day then you don’t have a life!

I have to admit that reading paragraphs of text after a long day at work isn’t my favourite activity but listening to audiobooks has become one of my hobbies.

I have a special offer for readers of UKdoctoronFIRE where you can get a free audiobook if you subscribe to their 30-day free trial. If you decide you don’t like the service you can unsubscribe at any time at the click of button. You won’t be charged anything and you still get to keep the book.

Ten minutes per day quickly adds up to ten information-dense books in one year.

I recommend starting with this one.

2 thoughts on “How I Failed Advanced Life Support

  • August 28, 2017 at 11:29 am

    Hi Rory,

    Sorry to hear about that – not a good result! As you say though it takes time to read through all the pre-read material and it is easy to be complacent about something that you have done (and passed) before.
    On the plus side (is there one?) – think of it that you failed it on the simulations, and not on a real life person when they needed it….not a lot of comfort I know, but some?

    The run up to the exam is certainly fairly heavy with all that work time, and you need some time to decompress as an individual as well – good luck for the resit!

    • August 29, 2017 at 6:59 pm

      Hi FiL,

      Thanks for the kind words. Hope you’re getting on okay.


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