Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

National Registry Exam

There I am testing people for the NR (National Registry of EMTs) medic exam, saying to the examinee –

RM – It rubs the lotion on its skin. It does this whenever it is told.

Examinee – Lotion? We ain’t got no lotion. We don’t need no lotion. I don’t have to show you any stinking lotion.

RM – It rubs the lotion on its skin or else it gets the hose again.

Examinee – I see the tube going through the vocal cords.

I guess I was drifting off a bit. All this mindless repetition of the same thing, again and again and again.

The examinee removes the stylet from the tube, inflates the cuff on the tube, and attaches the bag.

When he squeezes the bag, his lie becomes apparent. The stomach/whoopee cushion inflates instead of the lungs. It is immediately obvious with this mannequin because there is no covering to the chest and abdomen. There is no real reason for confirmation of tube placement, because the mannequin makes it irrefutably clear where the tube is.

NR is not about reality. They are more interested in the equality of testing experience for the examinees than anything else. The only thing I am allowed to ask the examinee is “Is there anything else you would like to add?” And I must ask everyone that unless they obviously have passed. Maybe, even then. It has been a while and some of the NR silliness is less memorable than other NR silliness.

Since we are discussing reality, I never really recited the lines from The Silence of the Lambs. The examinee never really responded with any parody of the “badges” lines from The Treasure of the Sierra Madre.

NR insists that there not be any possibility of discrimination in its tests. Unfortunately discrimination is exactly what is needed. We need to discriminate between those who understand what they are doing and those who only memorize a routine and coincidentally place the tube in the correct hole.

We need to discriminate between those who are competent to begin work as medics and those who are not.

NR is all about the memorization of an entirely predictable testing station so that any idiot who can mouth the words and get the tube into the imitation trachea in the time allotted – well they pass.

If, as examiner, you have a question about the examinee’s technique, or knowledge, or why the examinee is doing something a certain way – you may not ask anything to clarify if the examinee has a clue. Even though that is supposed to be the whole reason you are there.

Catch-22 has nothing on NR testing.

The medic, because there is no reason to focus on those who do not pass. Well, the medic has learned to always say that he saw the tube go through the vocal cords.

What if the medic does not say this parrot phrase, but skillfully places the tube?

Automatic failure.

What if the medic cannot place the tube at all?

Automatic failure.

What if the medic says “I see the tube going through the vocal cords,” but the tube is in the wrong place?

You can’t get any extra points taken off for not telling the truth.

You need to learn to say I see the tube going through the vocal cords.”

No matter what!

You are taught that you have nothing to lose by telling a lie to please those who can punish you.

This could lead to serious problems.

You remember the article High-risk EMS procedure gets a low level of oversight[1] about esophageal intubations that were not recognized?


This is the way to train people to do that. Don’t think – jump to optimistic conclusions.

People were killed.

That is to be expected from this kind of thinking.

Surely, doctors know better than to go along with this.

Actually, doctors do the same thing when placed in a similar testing environment. ACLS (Advanced Cardiac Life Support) used to require that everyone intubate as part of the class.

Not everyone has intubation in their scope of practice.

True. Eventually that requirement was taken out of ACLS, but it is still there for physicians and medics. I used to have an easier time getting nurses, who had never before intubated anything, to intubate the mannequin than a lot of the doctors, but the one thing the doctors would consistently say is I see the tube going through the vocal cords.”


It is what they have been trained to say. It has become something they convince themselves that they really do see.

And they never went through the NR test.

No, but this is one of the big problems in intubation and airway education.

But, when the tube is in the trachea, that means that they saw it go through the vocal cords.

Maybe. All we know is that they say they saw the tube go through the vocal cords. They say the same thing when it doesn’t go through the cords, so why should we pay any attention to this statement at any time?

What you are stating is that when a medic or nurse or doctor says I saw the tube going through the vocal cords,” there is absolutely no reason to believe that person?

I couldn’t have said it better myself.

Then why focus on this?

Tradition – the enemy of progress and the antidote to thinking.

Why does NR try so hard to avoid discrimination?

They do not understand that patients’ lives are at stake. They think avoiding a law suit for “improper” examiner behavior is more important than keeping dangerous people from becoming medics.

You’re telling me that we are more concerned about the examinees than about endangering patients.

Exactly. There is money to be made convincing states to abandon their pathetic exams and try to slough off their responsibility to their citizens. NR is happy to make money on that and they will preach about how their ivory tower gurus can make this irresponsibility look good.

But this is nowhere near good.

That is correct.

When the medic has a real patient and is not protected from reality by the NR artificial test, the patient is in trouble?


Who protects the patient?

The medical director is supposed to by aggressively discriminating against those medics who do not know what they are doing, by continuing to look for signs of problems, by remediation, by continuing education, . . . . , and by termination when all else fails.

Many medical directors just look at the NR card and sign the medic’s license to kill.

I’m guessing that the NR will not be added to the list of organizations on your sidebar.

Not likely.

Pure evil, huh?

No, they do some good things, but the bad definitely outweighs the good.

This is one way to create your own Medic X.

My other posts on Medic X are:

OLMC (On Line Medical Command) Requirements Delenda Est

OLMC for President!

OLMC = The Used Car Dealers of EMS?

OLMC For Good Medics

Fun with explosives – NTG.

Other posts about medical oversight:

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

RSI, Intubation, Medical Direction, and Lawyers.

RSI, Risk Management, and Rocket Science


^ 1 RSI procedure gets low level of oversight in Texas
The Star-Telegram article is no longer maintained at their site, but EMS1.com has what I believe is the full article on their site. This was published in various abbreviated formats by various news organizations. The abbreviated articles usually were attributed to AP or some other news organization, rather than to Danny Robbins.
High-risk EMS procedure gets a low level of oversight at EMS1.com



  1. Ahhh, now I see why you dislike NR so much. I’d dislike it too if I had to practice idiocy at such a level to be a NR examiner, or to pass the NREMT exam.Granted, there is some level of idocy required in Louisiana, but nowhere near at the degree you describe.Not every state approaches NREMT testing in this way. Of course, that will inevitably lead to your questioning why NREMT allows such a wide disparity in testing practices…;)

  2. This is why I don’t stop until the equine skeleton is pulverized. :-)Maybe someday, I’ll learn to be concise.Of course with a national standardized certification, the idea of regional variations is silly. But what would EMS be without silliness?I have been told that things may have improved a little bit, but I am not a very trusting person. I have been in EMS too long. What is passed off as change is frequently just a new shine on the same old story.