James C. Eisenach, M.D., Editor
ACLS Simulator, Version 3.11. By Howard A. Schwid and Daniel O'Donnell. Issaquah, Washington, Anesoft, 1997. Price:$69.00.
ACLS Teaching Series. By Bruce Argyle. Alpine, Utah, Mad Scientist Software, 1998. Price:$129.95 (Cardiac Arrest-Multimedia $89.95).
Let's face it, taking the Advanced Cardiac Life Support (ACLS) examination is intimidating. There are all of those branching decision tress to successfully traverse, while the eyes of your peers are focused on your every action. Oh, and don't forget to check the pulse when you finally get a rhythm back.
Wouldn't it be nice to practice megacodes in the security of your home or office? Now you can, with ACLS simulators on your personal computer. But which one is best for you? This review evaluates two popular packages: the ACLS Simulator by Anesoft and the ACLS Teaching Series by Mad Scientist Software.
The ACLS Simulator comes on a CD-ROM containing Macintosh- and Windows-compatible versions. The program can be run directly from the CD-ROM, but installation on the computer's hard drive may improve performance on some computers. The program has two modules: RHYTHM, used to practice electrocardiogram (ECG) rhythm recognition, and PULSE, used to practice the resuscitation of patients from cardiac arrest (i.e., ACLS megacode practice).
RHYTHM randomly presents a dynamic ECG tracing of one of 21 possible cardiac rhythms. The user identifies the rhythm and then checks to see whether the answer is correct; if the answer is not correct, a help feature points out the characteristics of the rhythm that are useful for correct identification. The strength of this approach is that it is fast, simple, and nonjudgmental, because the computer does not record the user's guess. However, this approach limits the ability of the program to automatically retest the user until all rhythms are recognized. It also makes the program inappropriate for classroom situations in which a teacher wants to track the student's progress.
PULSE begins by asking the user to select a case (such as “Case 3: Arrest in the Delivery Room”) from a list of 28. A brief history is presented and then a photo of the patient and two health-care workers appears, along with a dynamic ECG tracing. The user can examine the patient, order laboratory tests, direct airway support and chest compression, establish intravenous access, and administer medications and electrical counter-shock. Help is available, during and after treatment, in a number of different formats: the user can ask to see the appropriate ACLS guideline or a differential diagnosis, can refer to a drug tutorial, can ask what to do next, can review what he or she has done wrong, or can watch as an ACLS expert takes over care. The program indicates when patients either have been successfully resuscitated or are in a state from which they cannot be resuscitated (i.e., dead). Again, the approach is simple and nonjudgmental. The user directs resuscitation efforts using on-screen buttons and pull-down menus; no typing is necessary and no commands need to be memorized. The cases encompass a wide range of patients (including pediatric patients) and problems. However, the program is strictly limited to the immediate treatment of cardiac arrest and arrhythmia. For instance, only 18 intravenous drugs (predominantly cardiac medications) are available; other emergency medications, such as naloxone, cannot be administered. A minor limitation is that fluid boluses cannot be administered and there is no display of total fluids administered.
The ACLS teaching series from Mad Scientist Software comes on 3.5" diskettes and a multimedia CD-ROM. Our package included three modules: Code Team!, Version 6.1" (containing “Cardioquiz,”“EKG Teaching,” and “ACLS Protocols”), Cardiac Arrest!, version 5.31 (megacode simulator) and Cardiac Arrest! Multimedia Version (on two CD-ROM disks: adult and pediatric). Code Team! and the nonmultimedia Cardiac Arrest! are run from the hard drive and come in Macintosh and Windows configurations. Cardiac Arrest! Multimedia Version must be run from the CD-ROM and is only available in the Windows 95 version.
Code Team! is an ACLS preparation program that contains the sections “Cardioquiz,”“EKG Teaching,” and “ACLS Protocols.”“Cardioquiz” consists of 10 lessons discussing airway management, case management priorities, basic life support, intravenous techniques, and cardiac drugs. Lessons are formatted as sequential questions (the user chooses from four multiple-choice answers), each followed by a brief tutorial of the relevant concept. Feedback is immediate and the user's running score is tabulated. “EKG Teaching” teaches rhythm-strip interpretation. There are three lessons, discussing ECG parts and rhythms and pathology (e.g., electrolyte disturbances). Each lesson is followed by a quiz, in which a dynamic ECG tracing is displayed along with five possible answers. Depending on the answer chosen, the user is greeted with a quiet “nope, sorry” or an exuberant “all right!”“ACLS Protocols” allows the user to practice arrhythmia treatment in clinical situations. The user begins by selecting, from a list of 12, the cardiac rhythm that they want to practice treating. A simple drawing of a patient is displayed, along with a dynamic ECG tracing and vital signs. The user enters resuscitation orders by typing them; common orders (e.g., ventilate and administer epinephrine) can be selected by pressing on-screen buttons. The program requires strict adherence to ACLS protocols. It provides immediate feedback and, after several incorrect commands, a window pops up guiding the user to the next appropriate step. Help is available throughout the case in the form of drug information, ACLS protocols, and a brief textbook of cardiac resuscitation. At the conclusion of the scenario, the user's performance is reviewed and the steps that were not performed are shown. Each case is followed by a tutorial and quiz.
Cardiac Arrest! is a megacode practice program. The user selects 1 of 45 patients (including neonatal and pediatric patients) to resuscitate. Patients can be selected randomly or within a specified range of difficulty. It should be noted that patients behave differently each time they are selected. The user interface is similar to “ACLS Protocols,” but this program has much more breadth than does “ACLS Protocols.” The goal here is to resuscitate the patient by treating arrhythmias, blood gas abnormalities, hypothermia, hyperthermia, electrolyte abnormalities, and drug overdoses. In some situations, only endotracheal drugs may be used or an interosseous line may be needed. As in a real “code,” initial information may be vague, with statements such as, “A 4-yr-old girl ate a bottle of her grandfather's blood pressure medication and collapsed,” only to discover that the medication was potassium supplements. Feedback is not immediate; a help window only appears after several missteps. Help is available throughout the case via drug information, ACLS protocols, an abbreviated medical text book, normal values, and, of course, the patient's chart. As in “ACLS Protocols,” the user's performance is reviewed, and there is a tutorial and quiz at the conclusion of each scenario.
The multimedia version of Cardiac Arrest! adds realism to the program by showing slick video clips that provide some of the action, noises, and distractions of a real emergency room. In addition, the screen layout is better and the control buttons are bigger. The multimedia program is a lot of fun; it is really an interactive movie. In one opening scene, a van pulls up to the door of the emergency room with a portly patient slumped over in the passenger seat. The panicked driver says, “I was jogging with my boss and he just passed out!” Every command is acknowledged by the actors (there are six) and a wide array of video clips shows them intubating, defibrillating, and administering medications. Inappropriate dosages are sometimes questioned by the staff and an intrusive clerk occasionally interrupts with a statement such as, “The police just brought in your daughter and she looks drunk.” If you fail to perform a necessary step in a timely fashion, a professor who looks like Einstein makes suggestions in a stern but humorous way.
All of the Mad Scientist Software products reviewed herein allow you to administer fluid boluses and to use drugs such as naloxone. It takes a while to become adept at typing commands, but once you become familiar with Mad Scientist's nuances, it is very realistic and immerses you into the scenario. The score tracking makes it very useful in a teaching setting and the tutorials at the end of each case reemphasize areas of importance. One complaint about the multimedia version is the redundancy of some of the video clips. For example, when “OBSERVE” is typed, you have to wait each time for the completion of the video clip explaining that 3 s equals 1 min. This little annoyance aside, the Mad Scientist Teaching Series is useful and entertaining.
In summary, both products can help you successfully prepare for ACLS. The Anesoft program is easier to use, but the Mad Scientist programs are more comprehensive and a lot more fun.
Lawrence C. Walters, M.D.
Robert G. Loeb, M.D.
Department of Anesthesiology; University of Arizona; Tucson, Arizona
(Accepted for publication August 26, 1998.)