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PALS 2018: Hooked on Mnemonics

Ah, PALS. Like a couple of old friends, we get together every two years and swap stories: You tell me how pediatric assessment is about algorithms and acronyms, and I tell anyone who’ll listen that it doesn’t work that way. I guess I’m not much of a friend after all.

I just finished my 2018 refresher at a local hospital. My fellow students were mostly nurses, but I didn’t mind. I liked being the class’s pet paramedic. It was heartwarming to watch my stock rise from creepy old guy to ambulance driver to EMT to “How do you remember all this stuff?” Besides, after decades of being force-fed prehospital war stories by cranky chiefs, it’s invigorating to hear about messy ostomies and malfunctioning Foleys from dedicated RNs. Such interdisciplinary bonding is my favorite part of PALS—a course that wants to be practical but in my opinion is much more of an intellectual exercise.

In case you missed the memo, the American Heart Association is replacing its five-year cycles of ACLS and PALS revisions with continuous online updates. The good news is, there haven’t been any significant changes to PALS since 2015. That’s also the bad news because PALS 2018 presents with familiar weaknesses:

One course for all caregivers—PALS should have separate tracks for hospital and prehospital personnel. Nurses hardly ever intubate or run arrests, and most medics don’t order lab work, give antibiotics, or monitor patients beyond admission.


A contrived focus on sequence of care—This is a problem with EMS training too. Students are taught mnemonics and acronyms as if patient care necessarily follows sequential patterns. In PALS, it’s EII (evaluate, identify, intervene), CAB with a side order of H’s and T’s, ABCDE, AVPU and SAMPLE. During practice scenarios instructors wanted to hear what letter we were on, not how we’d use our bedside spidey sense to drive assessment. SMH.


Not enough props for practical exercises—It’s hard enough to do PALS without real patients. Subtract realistic manikins, monitors, and supplies—missing or malfunctioning in every AHA class I’ve attended—and someone needs to ask what the point is. I vote for reimagining the course as a moderated seminar where students sit in a circle, review algorithms, discuss recent developments in their little corners of the medical-industrial complex, and play a few rounds of Name That Disease.


Therapy with little or no proven value—When I first took PALS in 1994, we were taught to give kids in cardiac arrest epinephrine, sometimes in massive doses. Here’s what the AHA warns about that drug 24 years later: “No adult or pediatric studies have demonstrated improved survival (after cardiac arrest) with use of epinephrine.” The same could be said about lidocaine and amiodarone, yet you can fail PALS if you don’t verbalize prompt administration of all three meds.


Despite our class’s professional bearing and reverence for all anatomically correct life forms, there were some amusing moments:

  • We were watching a video about the value of teamwork (also the value of having four nurses and a physician gowned up and waiting in the ED for an incoming cardiac arrest). As the EMS crew arrived with CPR in progress and prepared to slide their patient from the stretcher to the hospital gurney, the MD who was playing the stoic team leader told them, “Let’s wait until you get to 30 (compressions).” That doc should do a few ride-alongs. Even the actors portraying EMTs looked like they were thinking, Seriously?

  • I’ve heard EKGs described by novice caregivers as “camel humps,” “little fire hats,” and now, for the second time from a PALS instructor, “goats holding hands” (v-tach, of course). How precious. What’s next, “The Cat in the Hat Does an Amiodarone Drip”?

  • As we were practicing megacodes, our monitor suddenly sounded an alarm and displayed the message Shutting down now. Then there was a burning smell. We couldn’t recall any defibrillator-on-fire memory aids, so we improvised RA for run away.

  • Being a saver of lives, I was ordered to demonstrate endotracheal intubation on a decapitated polyurethane patient. I was struggling to visualize the cords—difficult on a free-floating head—when my instructor suggested I stop “trying to do it the right way” and just lean the blade against the teeth.

After my biennial bolus of PALS, I’m still not comfortable with incisors as fulcrums, but when the tones go out for “manikin down,” I’m your huckleberry.

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at


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