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

- Rogue Medic

You can judge a book by its cover? – JEMS.com

In JEMS there is an article by the editor, A.J. Heightman, with the title You can judge a book by its cover.

There are several problems with this article. Here is a picture that is displayed right next to the title.

If I were to judge JEMS and LA County Fire by this cover image, I could conclude that airway management is not understood by either of them.

The hand over the face is probably to satisfy privacy requirements, but why is the NPA (NasoPharyngeal Airway) being inserted from down around the patient’s chin? Probably because this makes for a better picture, rather than as an example of the technique used by these medics. Of course, if we were to judge a book by its cover this cover picture would be inexcusable.

Picture Credit

Maybe that is not a strong enough hint.

Even better, a real person, awake, and with access to all sorts of weapons. How would you insert the NPA in that person?

Picture Credit

No dragging it along the chin in that photo.

For more on the NPA, read Steve Whitehead’s post at The EMT Spot.[1] There is still a lot to write on this subject.

The title of the post is more of a problem. He wants to judge competence by appearances. As much as I criticize the National Registry of EMTs for their inadequate testing, they do not appear to pretend that showing up in a dress uniform, nice and neat, is any kind of indication of competence.

What impressed me about the L.A. County Station 7 crews was that they cleaned and organized everything, from the tubes in their medical kits to the rims of their wheels.

Silly me. I thought that tubes should be left in their original packaging, not taken out and cleaned every shift, or is it every day (if they do not work 24s), with different crews having different responsibilities, or is it only scheduled on certain days on a rotating schedule?

A crew showing up in a nice clean ambulance and wearing neat, clean uniforms means that the crew has clean uniforms and a clean ambulance and has not yet done anything to alter that. It does not mean anything more than that.

I know too many people who spend much of their time on appearances, but ignore skills, understanding, and other things that make a difference in outcome – if the patient requires any real medical care from competent EMS personnel.

Look at the debates over intubation. Plenty of people argue that they should be allowed to intubate because it would be an insult to take intubation away from them. all they care about is appearance.

If we wish to be allowed to intubate, we should work very hard to maintain and improve our skills – and we should keep our tubes in their original packages.

I don’t know if the tubes described being cleaned include endotracheal tubes, but I do know some people who do open at least one endotracheal tube package at the beginning of a shift. They think it saves time. It probably does, but the amount of time is insignificant and using non-sterile tubes increases the chances of an infection that will make a good outcome less likely.

Another point on judging a book by its cover.

The lubricated nasopharyngeal airway did the trick, and the crews then bagged and supported his airway en route to the hospital. At Cedars-Sinai Medical Center, a team of residents and attending ED physicians intubated the patient in a cleaner, more sterile environment.

Some may argue that the patient should have been intubated on scene. That transporting the patient with only BLS airway management looks bad – makes it look like they can’t intubate. I disagree.

I am not one to encourage judging a book by its cover jumping to conclusions based on superficial, and often inaccurate, information.

We need to improve our assessments – not encourage LGFD[2] thinking.

We need to pay more attention to substance and stop worrying about appearances.

A.J. Heightman and I may disagree on many things, but I do not doubt his integrity. I wrote Reducing Interruptions – How To Send The Wrong Message back in January. This was also about a photograph providing the wrong initial impression. A.J. Heightman, or someone pretending to be A.J. Heightman, responded taking responsibility for the choice of photo. I started my post with –

JEMS has a good article, and it is on an important topic, but whoever decided to use the picture (above) that accompanies the article needs to cut back on the use of the crack pipe, just a little bit, or maybe just cut back while at work.

This is from the response –

From A.J. Heightman, Editor-in-Chief of JEMS
I don’t smoke crack but I allowed the photo

The decision was made to continue CPR and transport him to the hospital. Right or wrong – I chose to allow the photo because it showed the awkward angle everyone tries to do CPR at on current-day max height stretcher position. We sholud have captioned it differently.

It is nice to see someone take responsibility for his actions, rather than blaming a subordinate. Too many times we see subordinates sacrificed on the altar of maintaining appearances.

Is the photo a major problem. No, but it does create a bad impression, especially without a caption to clarify things.


[1] The Art of The Nasopharyngeal Airway
The EMT Spot
by Steve Whitehead

[2] Looks Good From Doorway
Society for Hilariously Inappropriate Treatment a motto.
Another motto is We don’t just talk S#!+, we are S#!+.



  1. […] is what Happy Medic wrote in the comments to You can judge a book by its cover? – JEMS.com. Great article as always Rogue, but I wanted to stop in and remind folks that we DO judge books by […]