In spite of the evidence to the contrary and a lack of rationality in the claim, we continue to be told that increasing the number of people with a title, such as paramedic, will result in better care.
Here is more evidence that dividing the skills among more people leads to less skilled care.
The authors begin by referring to other studies that demonstrate the high failure rate of doctors performing procedures on children.
How is that relevant to EMS? We have a low frequency of use of critical skills – and that is with our adult patients. With children, our absence of experience is even more of a problem. When we do use our infrequently used skills, we often use them inappropriately.,
Emergency physicians must be competent in the performance of critical procedures associated with pediatric resuscitation. It has traditionally been assumed that the clinical practice of pediatric emergency medicine is sufficient for the acquisition and maintenance of these skills. If the relative low acuity of the pediatric emergency medicine patient population provides inadequate opportunity, there is a risk that procedural skills will not be acquired by trainees or maintained by faculty. An accurate description of the frequency with which faculty and trainees perform critical procedures in a pediatric ED would allow for more informed discussion and targeted interventions to reduce this risk.
We need similar examinations of what we do in EMS.
We hypothesized that even in a high-volume pediatric ED, the overall frequency of critical procedures would be very low and the exposure of individual providers to critical procedures negligible.
Would that be any different from a busy EMS system with a lot of paramedics?
From April 1, 2009, through March 31, 2010, 3,067 evaluations were performed on medical and trauma patients in the resuscitation bays. Two hundred sixty-one critical procedures were performed during 194 evaluations, representing 6.3% of all resuscitation bay evaluations and 0.22% (2.2/1,000) of all ED patient evaluations during the study period.
That does not look bad.
147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions in a year.
Except – that is for the entire hospital.
When broken down by the doctor actually performing the procedure
Only 39% were able to try to perform any procedure during a year when there were 147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions.
Look at the range for all critical procedures combined –
0 to 6, with a median of 0.
The white clouds were most of the doctors. Zero critical procedures for the year.
How much experience do paramedics get when there are a lot of paramedics available to deprive them of experience?
Do we track this and post it for all to see?
What is the level of inexperience in an EMS system that has a paramedic in every seat of every piece of apparatus?
What kind of daily, or even weekly training is required to make up for this absence of experience?
Nearly two thirds of our faculty did not perform a single critical procedure during the 12-month study period.
 Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]
The chart is for all patients treated with needle decompression for suspected tension pneumothorax.
Many patients never had any kind of pneumothorax.
Did any patient have a tension pneumothorax?
We do not know.
 The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view.
Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS.
Ann Emerg Med. 2013 Mar;61(3):263-70. doi: 10.1016/j.annemergmed.2012.06.021. Epub 2012 Jul 27.
PMID: 22841174 [PubMed – indexed for MEDLINE]
 Quantification and perception of on-call podiatric surgical resident workload.
Meyr AJ, Gonzalez O, Mayer A.
J Foot Ankle Surg. 2011 Sep-Oct;50(5):535-6. doi: 10.1053/j.jfas.2011.04.035. Epub 2011 Jun 11.
PMID: 21652228 [PubMed – indexed for MEDLINE]
The results of these data suggest that all residents shared a similar workload during the study period without a clinically significant “black cloud” or “white cloud.” However, a difference was found in the perception of which resident was a “black cloud” or “white cloud.”
A reputation for difficult on-call experiences was strongly associated with few hours of sleep (r = -.77; 95% confidence interval, -0.49 to -0.91), but not with actual work load measured by the number of admissions, patients, deaths, or other variables. Sleep was the major predictor of reputation (multiple R2 = .567 using multiple linear regression analysis).
Some residents did have a black cloud; they slept less, perceived that they worked harder than average, and had a reputation for having difficult on-call experiences. Residents with a black cloud function differently from their colleagues; for example, some may be inefficient, while others may create extra work for themselves. Residency program directors must recognize these functional differences to effectively evaluate and counsel house officers.
Believing in black clouds, or other personifications of random occurrences is being fooled by randomness. Dr. Taleb does a good job of describing these errors of judgment.
Mittiga, M., Geis, G., Kerrey, B., & Rinderknecht, A. (2013). The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View Annals of Emergency Medicine, 61 (3), 263-270 DOI: 10.1016/j.annemergmed.2012.06.021
Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183
Tanz RR, & Charrow J (1993). Black clouds. Work load, sleep, and resident reputation. American journal of diseases of children (1960), 147 (5), 579-84 PMID: 8488808
Meyr, A., Gonzalez, O., & Mayer, A. (2011). Quantification and Perception of On-call Podiatric Surgical Resident Workload The Journal of Foot and Ankle Surgery, 50 (5), 535-536 DOI: 10.1053/j.jfas.2011.04.035