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

- Rogue Medic

National Registry of EMTs – Is it really that bad?

In the comments to Zero Tolerance III – Star of Life Law second comment, was a comment by Greg Friese,

Rogue medic, eliminating the NREMT (NR, or National Registry of EMTs) is a bold and radical suggestion. How can we assure some minimal knowledge and competency across all providers in all areas?

The way you write that, one might think that the NR had some way to assure some minimal knowledge and competency across all providers in all areas. The NR does not assure any level of competence. The NR claims to, but the NR fails.

Wouldn’t it be nice, if they did assure some level of competence? Wouldn’t it be even better, if it were actually a useful level of competence?

JCAHO (TJC, The Joint Commission, or the Joint Commission for Accrediting Healthcare Organizations) is just as dangerous to patients in the hospital. They are both about enforcing checklists rather than improving patient care. There are good uses of checklists. CRM (Crew Resource Management training) is something we need. CRM does not seem to be encouraged by JCAHO or NR, but JCAHO and NR love their irrelevant check off sheets.

If your instructors know enough to teach EMS well, they should know enough to evaluate the knowledge of candidates for a license/certification. The NR has become so focused on the avoidance of the appearance of discrimination, that they have made even the appearance of the actual evaluation of competence secondary to the avoidance of discrimination. The NR seems to be headed toward the complete automation of their testing system.

If your instructors do not know enough to assess the the knowledge of medic candidates, the NR check off sheets do not make up for that deficiency.

The NR focus is on several prepared scenarios and a bunch of stations. stations with scripts. Scripts just to avoid any appearance of variation. Do your patients present this way? Mine sure don’t.

NR Medic – I’m calling to notify that we will be arriving with a number 5 in seven minutes. No, wait. Make that a number 7 in five minutes.

Incomprehensible doctor noises on the other end of the line.

Yes. I gave him the drug in the spray bottle. No. I’m too busy filling out check off boxes to look at the patient.

More doctor noises, but noticeably cranky.

You’re the doctor. You figure out what’s wrong with him.

Really high pitched doctor noises, like nails on a blackboard.

Well, he’d better still be alive. He hasn’t signed the billing sheet, yet.

Having a limited number of medical conditions to deal with is great. These order off the menu numbers make patient care so much easier. We don’t have to mess around with any of that thinking stuff. Thinking makes my head hurt. Some of those numbers can be kind of difficult to tell apart.

Ooops. gotta go. There’s a number 3 five blocks from here. Or is that a number 5 three blocks from here. Whatever! We just give them medicine off the menu. It isn’t as if there are real differences – yellow box, silver box, blue box. What difference does a color make?

I am so glad I don’t get paid to think. Being indiscriminate is the best part of the job. Well, that’s out motto, but I don’t know what it means.

This is all about preventing the possibility of having a human make a decision. How can you create a system to evaluate human decision making, but act as if human decision making is the enemy? You can’t, but that is the goal of the NR. Will they ever recognize the futility of this behavior? Who cares? They are making money off of it. That is what matters.

Teaching students to be good medics will almost always make them highly likely to pass the exam.

I agree. A good medic should pass the exam, but I have failed an excellent medic for a simple oversight, just because I was not allowed to ask what he meant. The NR rules are more important than the outcome.

The more important question is, does the NR test weed out the dangerous medics?

Absolutely not.

True, some dangerous prospective medics will fail, but passing does not correlate with competence. What independent evidence do we have that passing this test is something that correlates with the ability to work with minimal supervision and full standing orders.

Why full standing orders?

Because anything less is an indication of incompetence. If the medics are not capable of working without that mother-may-I phone call, they are not competent. Go to the best systems in the country. You will find that they have the fewest requirements to call for permission.

If OLMC (On Line Medical Command) permission requirements were correlated with quality, you would find exactly the opposite. OLMC requirements encourage incompetence – not in the medics, but in the medical director. The medical director has OLMC requirements, because of a lack of understanding of EMS oversight. The lack of understanding of EMS oversight leads to dangerous medics – unless the medics are motivated to police themselves. Of course, this attempt at responsibility by the medics can be discouraged by the medical director or management.

Teaching students how to be good test takers will increase the odds of them passing significantly.

Yes, but what does that have to do with competence?

You are starting by assuming that the NR test actually has something to do with competence. It does not. Then you are claiming that you have to teach the student how to take the test.

The result is that too much time is spent on training the medic students how to take the medic test, rather than training the medic students how to be medics. In other words, how to use critical judgment.

What are the most important skills that a medic should have?

1. Assessment.

If you do not know how to assess patients, how do you know what to treat? How do you know what protocol to apply?

2. Critical judgment.

Critical judgment helps in knowing where to go with an assessment. You won’t assess every patient the same way, but you do need to know what questions to ask and what places to look.

Having initially assessed the patient, you need to be able to decide what to do with the information you have obtained. NR does nothing to evaluate critical judgment.

But what about the critical/not critical decision in the patient assessment station?

Trust me, the patient is critical. I don’t even need to be there to know that. Or have they changed something?

NR encourages the cookbook approach to EMS, by their devotion to check off evaluations, rather than an interactive assessment of ability. If medic evaluators cannot be trusted to use judgment in assessing medic candidates, then they should not be trusted to treat patients.

NR behaves as if the use of medic judgment is the worst thing that could ever happen. This is the antithesis of good EMS. Any system that takes this approach should limit itself to BLS (Basic Life Support). There is no reason to have a Procrustean EMS system.

Procrustes is from Greek myth. He had an iron bed into which he required every passerby to lie down. If the traveler was too tall, he would cut the legs down to fit the bed. If they were too short, he would stretch them on the rack until they fit the bed. Similarly, we end up harming the patients to make their assessments fit the protocols we have. Rigid protocols are not good for patients.

Instructors can do both things without teaching to the test.

There are people who need assistance with test taking skills, but why divert the whole class from paramedic education to teach basic test taking methods? Because the ritual is more important than the result.

One example of this ritual over result fascination is the intubation station. If you do not state that you see the vocal cords, do you pass intubation? It does not matter if you can place the tube in the mannequin better than the instructor, you do not pass unless you chant the chant.

What if you don’t see the tube go through the cords?

That does not matter. That is not one of the check off boxes. You really shouldn’t bring reality into this.

What about the written test?

How does asking trick questions with just a single best answer have anything to do with good EMS? How many patient care situations have just a single best answer? Almost none. Those that do are not the ones being asked on the multiple guess exam.

This multiple choice, trick question, setting requires a bunch of test preparation. This is poor testing, so we have to spend time making up for the horrible test design. I know they have a bunch of people with all sorts of classroom degrees to validate these farcical tests, but that does not seem to help them to screen out dangerous medics. They validated their test. Why doesn’t this validated test weed out the ones who do not understand?

Whenever I hear validated, I think of Inigo Montoya saying, You keep using that word. I do not think it means what you think it means. How do we end up with so many EMS invalids with such a well validated exam?

We will be talking with a NREMT rep on an upcoming episode of http://www.emseducast.com. We are working on using ustream.com to allow live listening and chatting.

I like the idea of the NR.

The execution leaves a lot to be desired. Sometimes I think that execution of those in the NR might be the solution. Just one, or two, ought to do the trick. How slow to catch on can they be?

EMS is not a computer simulation. Their validated Ivory Tower models do not apply. The ambulances are not all little boxes made of ticky tacky.

The patients are not little boxes. The patients are what EMS is all about – not the little boxes on the multiple choice test or the evaluation sheets.

As I stated, I like the idea of the NR. The problem is that the idea and reality are miles apart.

Having the ability to move, almost as if we were professionals, is a good idea. I have been a medic in several states. Getting reciprocity for each move was different. NR could assist those of us who do not manage to stay in one place. NR can have a lot of input on the way EMS is run.

NR could also facilitate reciprocity for out of state paramedic disaster assistance. The way it is now, paramedics are not really more useful than basic EMTs, once they have crossed a political boundary. Unless the receiving state has the capability to grant emergency authorization to medics in disaster situations. Many states do not have this ability. Reciprocity might take months, which is OK if the disaster is nice and patient. Even FEMA can get its act together faster than that.

From what I see, NR has a big effect on the way things are run. People look for a quick and cheap way to hand a medic card to people, but to avoid responsibility for giving medic cards to people who aren’t even good basic EMTs. NR provides that excuse.

The idiot passed NR. How bad can he be?

Sometimes the answer is very bad.

Why should a paramedic test be quick or easy or cheap?

We end up with a similar approach to medical oversight. Quick and easy and cheap.

Why should we be paying discount rates for medical directors? We have medical directors who authorize medics to treat patients, but never meet the medic. I have worked for some of them. This is the NR approach applied to medical direction.

EMS should be limited to BLS, except where there is a well compensated, well educated, aggressive medical director. A medical director who understands EMS. A medical director with appropriate support personnel depending on the size of the organization.

Medical directors who practice absentee medical direction should be locked up. There is no reason to allow patients to be subjected to that kind of abuse. BLS is safer than bad ALS (Advanced Life Support).