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

- Rogue Medic

Gaming the National Registry Exam – Part III

mpatk wrote the following in response to Gaming the National Registry Exam – Part II

At the risk of butting into a private argument…

Private? On the internet? Are you trying to turn my smiley face into a giggle face?

Rogue,

Obviously you don’t need to have a “smiling face” on your blog posts; a dose of harsh reality is necessary sometimes. However, there is a line between being brutally honest and being deliberately ( and maybe gratuitously) insulting.

Chy obviously thinks you crossed it here.

Charles Grodin had a particular dislike for people like Chy. He was at a dinner party and one of the hoi polloi looked at him and said, It Would Be So Nice If You Weren’t Here. They seem to feel that they can say anything they want, as long as they give it the appearance of being polite, but don’t suggest that they are less than perfect.

Should we defend a lottery system that helps to authorize clueless people to use dangerous treatments on defenseless patients? The testing system is supposed to be an important part of protecting patients. The idea of using a lottery to assess competence is absurd.

The smart EMS agencies insist on months of internship before allowing medics to work without restrictions. They know that the test does not work.

Am I supposed to be polite to people who are only fooling us with the appearance of screening out the incompetent, but are defending this dangerous system?

I could have a nice job as a supervisor, or manager, somewhere if I were to play nice and keep my mouth shut about the obvious idiocy that we see on a regular basis. I do not regret that, because I would hate myself for not telling the truth.

How much silence over how much harmful treatment, is necessary to go along to get along in EMS?

It is unfortunate that you intubated the patient’s esophagus, but you did a nice job of taping the tube in place and and you were getting every bit of oxygen out of that bag.

Two positives for each negative.

I am more interested in how I am going to break the news to the family of the executed patient. I will definitely use the word dead and I will repeat it, so that the family understands dead. No amount of sugar coating is not going to change the outcome and bring their child back.

The disgustingly civil people will be the ones demanding that we fire the medic who put the tube in the esophagus, because they are all about appearances, and the presence of that person invites scrutiny – as it should. Scrutiny is important.

They do not want scrutiny. They want to create the fraudulent appearance of perfection.

 

It will never happen again.

 

We fired the person who showed us that there is a problem.

 

No. We need to try to remediate the medic and to try to learn what contributed to the mistake, because systemic flaws are a large part of these errors. The people who claim that we should put all of the blame on the medic are accomplices in the killing of patients. They are helping to cover up the problems. They are worse than the medic who intubated the esophagus, because they guarantee that it will happen again.

We need to examine our mistakes, so that we learn from our mistakes, so that we make fewer mistakes.

Sometimes, I am impolite to someone who does not deserve it. When that is the case, I do apologize.

On the other hand, this is EMS. It is time for people to pull up their big girl panties and worry about what is important – our patients and the people who take care of them – not some people creating a test that does not do what they claim it can do. Not some concern troll.

Why doesn’t EMS get respect?

Because we listen to people like that.

Because we are more worried about appearances, than about reality.

Our problem is not that we are not polite enough.

 

Our problem is –

 

We have too many clueless people

 

AND we are comfortable with that.

 

We are not just comfortable with this cluelessness, but we defend the system that creates this dangerous problem.

No. The problem is definitely not just the lottery test.

If we want to make things better for our patients, we must stop worrying about appearances.

Too Old To Work, Too Young To Retire has a post on a similar topic – It’s Not The Crime, It’s The Cover Up.

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Comments

  1. How about the medics who make a mistake and piss off the almighty fire chief or ER nurse? They then get lambasted by the supervisor/boss/director/medical director/etc. all because they pissed someone off? But the medic who seriously FUBARS a patient is ok because they didn’t mean to hurt the patient? And while the incompetent one is allowed to continue practicing inappropriate medicine unfettered the competent medic is somehow the object of scrutiny? I’ve seen this in multiple places and it seems the common denominator is the competent medic questions things and the incompetent one doesn’t and is just a good little German. Seriously?!?!?

  2. Rogue,

    Wow.

    Before I address specifics, let me ask one question of you: Do you believe that intelligent, well-meaning people can disagree? Or if there is a disagreement, that one of the people arguing MUST be either stupid or evil?

    To clarify my previous remarks, I am not talking about the faux politeness that some think excuses any insult. I’m talking about the difference between discussing a problem and simply calling people names. On one side of the line I mentioned is remarks like, “That idea/practice is terribly wrong and harms patients.” On the other side is remarks like, “You’re a #$$%# idiot who should just shut up before you kill more people.”

    The disgustingly civil people will be the ones demanding that we fire the medic who put the tube in the esophagus, because they are all about appearances, and the presence of that person invites scrutiny – as it should. Scrutiny is important.

    So you’re arguing that the medic bears NO responsibility for his actions? Perhaps the medic is a victim of The System just like the unfortunate patient? Yes, we need to examine the system to determine if there is a wide-spread problem (i.e. lots of medics tubing the esophagus); but claiming that we should “just remediate the medic” is just as wrong as assigning all the blame to him.**

    Personally, I don’t think the National Registry system itself is the problem; how it is IMPLEMENTED is the problem. In my state, you have to pass a minimum of 500 hrs of field internship under a preceptor medic, and 200+ hours of clinical internship in various hospital departments (over 1/2 in the ED). If you don’t pass that, you don’t even get to take the NR exams. No, 500 hrs is not a lot (works out to probably 3 months of normal shifts); but it’s not trivial. How is it the NR’s fault if “too many clueless people” manage to get past that screening process? National Registry isn’t supposed to assess for critical thinking and understanding; that’s the role of the internship required prior to the NR exam. The NR exam is simply to ensure that all the topics have been covered by the paramedic school. It is intended as a check on the SCHOOLS not the medics.

    If you want National Registry to actually work the way it was designed, then your critique should be aimed at the “schools” that create unsafe medics. Blame the “factory schools” that crank our a new class every couple of months. Blame the “preceptors” who don’t care how good their intern is as long as they get the preceptor bonus on their paycheck. Blame the “preceptors” who are more interested in having a submissive little creature that does everything s/he’s told rather than a student who asks questions and thinks for themselves. Most of all, arrange that NR (or someone else) can ELIMINATE these things; which create the unsafe medics you accuse NR of permitting.

    ** = to clarify, the problem is not an esophageal tube; the problem is not recognizing the esophageal tube. I’m sure you know that, Rogue; but wanted to make it clear that I did as well.

    • mpatk,

      Rogue,

      Wow.

      Before I address specifics, let me ask one question of you: Do you believe that intelligent, well-meaning people can disagree? Or if there is a disagreement, that one of the people arguing MUST be either stupid or evil?

      I don’t see any connection between what you wrote and what I wrote. Please, provide some examples, or any example.

      To clarify my previous remarks, I am not talking about the faux politeness that some think excuses any insult. I’m talking about the difference between discussing a problem and simply calling people names. On one side of the line I mentioned is remarks like, “That idea/practice is terribly wrong and harms patients.” On the other side is remarks like, “You’re a #$$%# idiot who should just shut up before you kill more people.”

      Have I told anyone to shut up?

      The disgustingly civil people will be the ones demanding that we fire the medic who put the tube in the esophagus, because they are all about appearances, and the presence of that person invites scrutiny – as it should. Scrutiny is important.

      So you’re arguing that the medic bears NO responsibility for his actions?

      How do you come up with that?

      I never wrote that the medic bears no responsibility. I wrote that we should attempt to remediate the medic, rather than reflexively firing the medic.

      Perhaps the medic is a victim of The System just like the unfortunate patient? Yes, we need to examine the system to determine if there is a wide-spread problem (i.e. lots of medics tubing the esophagus); but claiming that we should “just remediate the medic” is just as wrong as assigning all the blame to him.**

      “just remediate the medic”?

      I did not write that.

      Why are you making up quotes? Is your criticism not able to work when you stick to what I actually wrote?

      Why would anyone wait until there are lots of medics with unrecognized esophageal intubations?

      Harm to patients should be caught early, as when studies consistently showing harm from epinephrine in cardiac arrest should cause us to reassess the lack of benefit of this treatment.

      Personally, I don’t think the National Registry system itself is the problem; how it is IMPLEMENTED is the problem.

      The NR is only part of the problem. I do not give the NR credit for everything wrong with EMS.

      In my state, you have to pass a minimum of 500 hrs of field internship under a preceptor medic, and 200+ hours of clinical internship in various hospital departments (over 1/2 in the ED). If you don’t pass that, you don’t even get to take the NR exams. No, 500 hrs is not a lot (works out to probably 3 months of normal shifts); but it’s not trivial. How is it the NR’s fault if “too many clueless people” manage to get past that screening process? National Registry isn’t supposed to assess for critical thinking and understanding; that’s the role of the internship required prior to the NR exam. The NR exam is simply to ensure that all the topics have been covered by the paramedic school. It is intended as a check on the SCHOOLS not the medics.

      Then the schools should pay for the test.

      If you want National Registry to actually work the way it was designed,

      I do not want the rubber stamp to act as a rubber stamp. I do not want the lottery to act as a lottery.

      then your critique should be aimed at the “schools” that create unsafe medics. Blame the “factory schools” that crank our a new class every couple of months. Blame the “preceptors” who don’t care how good their intern is as long as they get the preceptor bonus on their paycheck. Blame the “preceptors” who are more interested in having a submissive little creature that does everything s/he’s told rather than a student who asks questions and thinks for themselves. Most of all, arrange that NR (or someone else) can ELIMINATE these things; which create the unsafe medics you accuse NR of permitting.

      First, you complain that I am too critical, then you complain that I am not critical enough.

      I criticize everyone for their contributions.

      Where have I stated that the NR deserves all of the credit for incompetent EMS?

      ** = to clarify, the problem is not an esophageal tube; the problem is not recognizing the esophageal tube. I’m sure you know that, Rogue; but wanted to make it clear that I did as well.

      OK.

      .

      • Rogue,

        “just remediate the medic”?

        I did not write that.

        Why are you making up quotes? Is your criticism not able to work when you stick to what I actually wrote?

        You did not write that, for which I apologize. The quotes were an error on my part, and I should have made it clear that was how I interpreted your remarks and not what you said. It’s actually a relief to be wrong about that.

        I did say that I’ve been known to cross the line between brutal honesty and gratuitously insulting myself without realizing it. :-/

        Why would anyone wait until there are lots of medics with unrecognized esophageal intubations?

        Harm to patients should be caught early, as when studies consistently showing harm from epinephrine in cardiac arrest should cause us to reassess the lack of benefit of this treatment.

        Two or three medics making an error indicates some poor medics got through the screening (since all the other medics are performing properly). More and more medics making the same error points to a systemic problem, either in training or in practice/protocol. Yes, we should eliminate potentially lethal problems quickly; but we shouldn’t institute systemic changes on the basis of two or three data points; that’s what I meant by “lots of medics”.

        As for the National Registry, yes it would be nice if they were utilized properly and the schools paid for the oversight…and it would be nice if the states (and counties/cities for that matter) could agree to a single scope of practice for paramedics… and if there weren’t unscrupulous people running “certification factories” and raking in the money to churn out potentially dangerous medics.

        I’m confused about one point. Are you calling for the elimination of NREMT? Or changing it to do a better job of screening medics? Why the hell do we need to screen the medics further than the internships (clinical and field) when no test will ever do a better job of evaluating a medic than observing them in the field with real patients?

        One final point: NR isn’t a rubber stamp and it isn’t a lottery. A rubber stamp approves almost everyone put forward, and NR certainly doesn’t do that. And just because the NR exams don’t measure the criteria you want doesn’t make them random like a lottery.

        • mpatk,

          Rogue,

          “just remediate the medic”?

          I did not write that.

          Why are you making up quotes? Is your criticism not able to work when you stick to what I actually wrote?

          You did not write that, for which I apologize. The quotes were an error on my part, and I should have made it clear that was how I interpreted your remarks and not what you said. It’s actually a relief to be wrong about that.

          Thank you.

          I did say that I’ve been known to cross the line between brutal honesty and gratuitously insulting myself without realizing it. :-/

          Anybody who claims that they do otherwise is probably a mute.

          Why would anyone wait until there are lots of medics with unrecognized esophageal intubations?

          Harm to patients should be caught early, as when studies consistently showing harm from epinephrine in cardiac arrest should cause us to reassess the lack of benefit of this treatment.

          Two or three medics making an error indicates some poor medics got through the screening (since all the other medics are performing properly). More and more medics making the same error points to a systemic problem, either in training or in practice/protocol. Yes, we should eliminate potentially lethal problems quickly; but we shouldn’t institute systemic changes on the basis of two or three data points; that’s what I meant by “lots of medics”.

          I did not suggest systemic changes, but an examination of the system.

          How would we know if there is a problem with the way the medics, or a significant subset of the medics, intubate/confirm placement if we do not aggressively examine each of these low frequency events?

          Even in the worst systems, unrecognized esophageal intubations probably only make up a small percent of patients. If we were using a trauma triage method that consistently missed several percent of critical trauma patients, we would be frantically searching for a solution.

          With unrecognized esophageal intubation, we insist that there is no pattern, even though the systems with the worst intubation success seem to also have the highest rates of unrecognized esophageal intubation.

          Both can be systemic failures. Not examining the possible problem, but putting all of the blame on the individual medic, does nothing to solve any systemic problem. This only acts to protect any systemic problem from scrutiny.

          As for the National Registry, yes it would be nice if they were utilized properly and the schools paid for the oversight…and it would be nice if the states (and counties/cities for that matter) could agree to a single scope of practice for paramedics… and if there weren’t unscrupulous people running “certification factories” and raking in the money to churn out potentially dangerous medics.

          I’m confused about one point. Are you calling for the elimination of NREMT? Or changing it to do a better job of screening medics? Why the hell do we need to screen the medics further than the internships (clinical and field) when no test will ever do a better job of evaluating a medic than observing them in the field with real patients?

          The NR test is just another merit badge test.

          The NR test cannot demonstrate that it does not fail good medics and that does not pass bad medics. We don’t even know the rate for these categories.

          We do know that in their quest to avoid the possibility of any appearance of individual discrimination, they have come up with a system that discriminates in favor of those who are good at multiple choice tests and simple structured scenarios. Unfortunately, these are not skills that are important in EMS, except in passing the NR test.

          One final point: NR isn’t a rubber stamp and it isn’t a lottery. A rubber stamp approves almost everyone put forward, and NR certainly doesn’t do that. And just because the NR exams don’t measure the criteria you want doesn’t make them random like a lottery.

          You stated – The NR exam is simply to ensure that all the topics have been covered by the paramedic school. It is intended as a check on the SCHOOLS not the medics.

          If that is the case, then the NR is a rubber stamp for the schools. All the schools need to do is spend more time teaching test-taking strategy, rather than teaching understanding of patient care, so that their pass rate is high enough to get the rubber stamp.

          We need to spend more time teaching students how to be competent medics. We do not need excuses for teaching irrelevant material in medic class.

          .

      • Oh, and as for the thinking that anyone who disagrees with you is either stupid or evil? I think Dr. Grauer said it best in one of his comments:

        With all due respect to you Rogue Medic – I sincerely think your views would be more likely to receive wider acceptance (even if there wasn’t necessarily agreement) – IF you stopped accusing your readers of “Killing Patients Just to Get a Temporary Pulse with Epinephrine”.

        emphasis is mine, not Dr. Grauer’s You’ve even admitted that the study does not prove that Epi is harmful (exact quote:”I never stated that this is proof of harm.”); yet you persist with accusing anyone who disagrees with you of “killing patients”.

        • mpatk,

          All of the evidence supports the conclusion that giving epinephrine results in more dead patients than not giving epinephrine.

          If we are giving something that causes a net loss of life, we are killing patients with epinephrine.

          Please provide some evidence that epinephrine is improving survival.

          Anything?

          I have only accused one individual of killing patients with epinephrine. That was in response to a baseless assertion that epinephrine results in more patients walking out of the hospital.

          If epinephrine improved survival, we would be able to find some evidence.

          Provide some evidence to support your claim that, you persist with accusing anyone who disagrees with you of “killing patients”.

          anyone?

          .