ACLS Scenario Practice

Ask anyone who has run a resuscitation that went badly what the problem was, and they will rarely say they forgot the algorithm. They will describe compressions that stopped for too long, two people doing the same job, a rhythm check that turned into a debate, or a reversible cause that nobody said out loud.

Which is the argument for scenario practice. Algorithm knowledge is necessary, cheap to acquire and quick to test. Team performance is the expensive part, it decays between courses, and it only improves by rehearsal with feedback.

If you want scenarios rather than a summary, run a resuscitation case in the app.

What the algorithm does not decide for you

Current guidelines are deliberately silent on several questions, because they depend on the patient and the setting. These are the ones worth drilling, because they are the ones that produce hesitation in real arrests.

• Which reversible cause you are actively pursuing. The list is memorable and reciting it is not the same as investigating it. A useful discipline is to name, at each rhythm check, the one or two causes you consider most likely in this patient and what you are doing to address them.
• Whether and when to seek expert help or an intervention beyond your resources. This is a judgement about the specific patient and what is available, and the answer differs enormously between an emergency department and a ship's medical centre.
• When to stop. Guidelines describe factors to weigh; they do not give a rule. Deciding this under pressure, in front of a team and often a family, is one of the hardest things in acute medicine and one of the least rehearsed.
• How to manage the team you actually have. Algorithms assume roles are filled. Practising a resuscitation with two people, or with people who have never worked together, is closer to most real situations than a fully staffed drill.
• What happens in the next hour. Post-resuscitation care, transfer decisions and the conversation with relatives all follow immediately and are almost never included in scenario practice.

A rehearsal structure that needs no equipment

Fifteen minutes, two or more people, a table. The absence of a manikin removes skill practice but leaves the decision and communication practice intact, which is the part that decays.

1. Two minutes — set the scene and assign roles out loud. Who is leading, who is on compressions, who is on airway, who is on drugs and access, who is recording. Naming the recorder matters: a resuscitation with no timekeeper drifts.
2. Eight minutes — run it in real time. One person calls the rhythm and the patient's responses. Do not skip the two-minute cycles by saying "two minutes later"; sit through at least two of them, because the discipline of not interrupting compressions is what you are training.
3. Two minutes — run the next hour. Either a return of circulation with a transfer decision, or a decision to stop with the conversation that follows. Do not end the scenario at the outcome.
4. Three minutes — debrief. Decisions and communication, not knowledge. Finish with one specific change for next time.

Rotating the leader every rehearsal matters more than running more scenarios. Most teams have one person who always leads, which means everyone else is practising following.

The things that actually go wrong

Four failure modes account for most poor performance, and each has a specific drill.

Interruptions to compressions. The most consistent predictor of poor quality. Drill it by having the recorder call out every pause and its length. Teams are usually shocked by the total, and the number drops immediately once it is measured.

Unclear task allocation. Two people reaching for the same thing, or a task nobody owns. Drill it with closed-loop communication: instructions are directed to a named person, and that person repeats the instruction back and confirms when it is done. It feels stilted for about four minutes and then becomes natural.

The leader with their hands busy. A team leader doing a procedure is not leading. Drill it by explicitly forbidding the leader from touching the patient in at least one rehearsal, and see what that changes.

Silence about the reversible cause. Everyone is thinking about it, nobody says it, and it gets addressed late or not at all. Drill it by requiring the leader to state their working hypothesis aloud at every rhythm check.

Rehearsing in a resource-limited setting

If you work somewhere without a full team, without a cardiac arrest trolley within thirty seconds, or without the option of expert help arriving, generic scenarios are of limited value. Build the constraints in.

Run the scenario with the number of people you would actually have at three in the morning. Use the equipment you actually hold, in the place it is actually stored, and time how long it takes to reach it. Include the communication that your setting requires — the call to a remote clinician, the message to the bridge or the control room, the conversation about whether transfer is even possible.

Two findings come out of this reliably. First, the physical layout of the space is a clinical variable, and rehearsal is how you discover that the trolley does not fit through the door. Second, the decision to stop arrives differently when there is nobody to escalate to, and it deserves to have been thought about in advance rather than for the first time during the event.

What this practice is and is not

Worth being explicit, because it is easy to blur. Scenario rehearsal maintains and improves performance between courses. It does not certify anything. Advanced life support certification comes from accredited provider courses run by recognised resuscitation councils, with assessed practical components, and nothing you read, watch or practise informally substitutes for that.

Nor does rehearsal replace the guidelines themselves. Recommendations are revised, and drug doses, energy levels and sequence details should always be taken from the current national guidance that applies where you work — not from a training scenario, a summary card or an article.

What rehearsal does supply is the thing courses cannot: repetition in your own environment, with your own team, on the decisions your setting actually forces on you. That is where the performance gap usually is.