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

- Rogue Medic

Raising the Standards for Rock Ridge EMS

Vince commented on the post “Rock Ridge Hospital and EMS.“:

“Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.”

Bad medic are only bad medics when they fail to have the integrity to realize “these are other people’s lives I am playing with and I better make sure I get my shit together.” A bad OLMC physician may allow medics to continue to deliver substandard care, an issue that needs redress to be sure, but he certainly did not force anyone to be a bad medic.

Medic X, who cannot imagine what a 52 card deck looks like, is responsible for his misbehavior.


The medical director is responsible for allowing this paragon of EMS to work in EMS.

Medic X is irresponsible and incompetent and reckless.


He cannot grant himself the authority to treat patients.

The medical director is supposed to protect the patients from Medic X.

Otherwise, what do we need the medical director for? Not much.

Personal Responsibility.

Exactly. Why excuse the medical director from personal responsibility?

This is why it is outrageous to me, in principle, to focus on ways to make bad medics ‘less dangerous’ by any means other than those discussed above (remediation, counseling et al)

When there is the possibility to improve the care delivered, we should look into that.

You know that I am not a fan of fancy gadgets. Waveform capnography is one gadget that is extremely useful, and improves the care delivered by competent medics. CPAP is a treatment that helps to avoid intubation. CPAP should be used, not because we are afraid of the medic missing the tube, but because CPAP is better for the patient.

I realize your motivation is patient care and, after all, that is what this is all about. I also concede that these are not mutually exclusive ideas.

But as I alluded to earlier, any tool/device etc. that makes it ‘appear’ easier and ‘more foolproof ‘ will likely have the unintended consequence of allowing an already sub-standard paramedic, to rely on them at the exclusion of his underdeveloped assessment skills and judgment.

I am just advocating eliminating the middleman 😉

I am also not a fan of middlemen.

The term foolproof is, at best, an exaggeration. Similar to unsinkable.

Snopes.com has a great page, Sinking the Unsinkable, on the use of the term unsinkable, its relation to the Titanic, and the arrogance of many involved. The current approach to physician oversight is often closer to the arrogance of pretending the Titanic was unsinkable, than it is to any real risk management.

We need to weed out the substandard medics, instead we find ways to accommodate them. That is not what I am trying to do. I am interested in better tools. Tools that will help competent medics provide better care.

Obviously, anything that would improve patient care and eliminate potentially fatal errors are something I think we are all on board with. I am not that arrogant. I just would put more of my ova into the standard raising basket.

Just how arrogant is to be determined. The ale in your most recent post appears to have been drained.

I am in favor of raising standards. We also need to police ourselves and insist that medical directors get rid of those who cannot be remediated.

Instead, we seem to try to defend the bad medics. Until they harm someone. Why shouldn’t we do something before they harm someone?

Just applying standards that relate to patient care would be much better than checking to make sure the prospective medic has a pulse and a license, which seems to be all too common in EMS. We also need to put an end to the distraction of the medics with unrelated tasks, such as janitorial work, landscaping, fire fighting, or whatever else is dreamed up to occupy medics’ time not actually on calls.

If you remember for many many years I have been of the opinion that the paramedic profession take similar steps that nursing did insofar as making itself a profession, i.e. with minimum education requirements. Not only would this serve as a first-line filter to keep out some of the knuckle-draggers with the “Your life is my hobby” attitude, it may make inroads in garnering much deserved respect from other professionals, in particular OLMC physicians, not to say anything about an increase in salary. Perhaps you can post on this idea….

I am not convinced that more school will make a big difference. Appearances may be changed, but look at how overeducated medical directors are. In many cases, these highly educated medical directors still do not get EMS. Otherwise, why would we have OLMC (On Line Medical Command) requirements? We used to have to call for permission to do everything, even to start an IV. As EMS becomes better understood, the need to have medics call for permission has been gradually going away, but there are still places that insist on it.


As long as there are OLMC requirements, the medical director can point to this fraud and claim that there is physician oversight.


There is no real physician oversight – the medical director has no idea what is going on with patient care.

Not many people understand medicine and fewer understand EMS. Few realize that OLMC requirements are just a substitute for real physician oversight. And a very dangerous substitute.

Real physician oversight is not cheap or easy. Many do not want to do all of that work. Many services do not want to pay what it would take.


If you aren’t going to provide real physician oversight, you need to limit care to BLS (Basic Life Support).

How many services will behave responsibly? Pay up for real physician oversight, get a medical director who understands EMS and oversight, or get out of the ALS (Advanced Life Support) business.

It doesn’t matter if you are the volunteers, fire fighters, private ambulance company, third service, National Registry, or anything else.

Do it the right way, or not at all.


  1. Come on, now!! We MUST cater to the idiots ruining our profession!! They have the RIGHT to be paramedics!!/sarcasm off.We may disagree about the C-collar, but at least we are passionate about ridding the EMS world of the idiots.

  2. cjh,Absolutely. If only there weren’t so many idiots in the EMS world. 🙂

  3. My point on raising education requirements does not necessarily mean we will get a better medic a priori, I think it will serve as a cursory filter to keep those who are not dedicated to being a professional, from “dabbling in the fine arts of paramedice”. Raising minimum requirements seemed to have helped out many a profession. I have no reason to believe any different in this case.You did notice I used those funny little squiggles around the term “foolproof” didn’t you ;)I agree that there are many a bad OLMC physicians with neither the experience or inclination to take an active role in the professional development of the medics working under them. And it has been my experience that many pay little if any attention to what actually happens in the back of the bus prior to arrival at the ED. But as I have said, increasing the the, percieved, and actual professionalism may work toward getting a bit more respect. Until that happens I don’t think much will change.

  4. Those who claim that the medical director has nothing to do with the quality of medic are as big a problem as the bad medics and they contribute to the abysmal quality in EMS in some places. It is strange, but this appears to be in places that have lax medical oversight, but that is probably just a coincidence.

  5. Lack of appropriate medical direction is only part of the problem. The chain of command has to take some measures as well. If they just allow bad medicine to happen over and over essentially rewarding bad medics for their behavior, change will never happen.OUr medical director is young and progressive and wants things to change in our department but he gets stone walled by a fire administration that is terrified of change. If he pushes too hard they will replace him with a yes man. Sad and dangerous.I agree that raising the education standard may not keep out all the idiots but it may keep out those who are not dedicated.

  6. I am not trying to lay all of the blame on the medical director, certainly the individual medics are responsible for their actions. The administration is another significant problem. Doctors need to do something to change the “We’ll just get another medical director,” approach of services that provide bad care.Medical directors can coordinate among themselves so they are not constantly having to appease the whiny administrator of the moment.Why do medical directors allow non-medical people to tell them how medical care should be delivered?Truly a Whiskey Tango Foxtrot situation.

  7. The answer is simply $$$This is the only sure-fire way a medically trained physician allows a mouth-breather (to steal my favorite descriptive) to dictate policy andf procedure.

  8. I can say that our MD has done good things for our department. But I also know that he pushes the limits as much as possible and when he pushes too far they threaten to replace him. Trust me the doctors who want his job right now I wouldn’t trust with my fish, so for now I will take the current problem.

  9. Glad to see that other health professions are also making sure the worst are well protected and promoted. I quit my admin job after they made me hire someone who (when she applied for the job) was in the psyche ward after O.Ding on drugs she stole from our department. No joke. It’s things like that that make me want to live in a straw bale house in the mountains and use gun powder to disinfect my wounds. 🙂

  10. vince,It isn’t always money. Some of these medical directors do it for free.You would think that there wouldn’t be much competition at that rate, but sometimes there is a lot of competition. Makes one wonder how they will pay off the school loans, but you wouldn’t know anything about that, would you?

  11. gertrude, That is a problem. The doctors don’t seem to know what is in their own interest, but are shocked and awed by the lights and sirens.Makes it difficult to get rid of dangerous doctors.

  12. ABB,There is something to be said for the independent life, but a lot of the problem children just need adult supervision. Part of what I am trying to do is encourage the medical directors to take their jobs more seriously and crack down on, or eliminate, the bad medics.