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

- Rogue Medic

Low quality is identified by inability to use critical thinking

The title is a variation on a sentence written by David Givot.

You will notice that the “substandard” providers in your area are chiefly characterized by their inability to “handle” some situations through critical thinking.[1]


Do some of the people you work with seem to treat a lot more unstable patients than most?

Do some of the people you work with seem to need to use a lot more life saving treatments (intubation, needle decompression, crichothyrotomy, cardiversion, et cetera) than most?

Are they dealing with more unstable patients, or are they just over-reacting?

Needle decompression may be an excellent way to identify some of those who have the patient assessment skills that are deadly substandard.

Click on the image to make it larger.[2]

The chart is for all patients treated with needle decompression for suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Did any patient have a tension pneumothorax?

We do not know.

Are we providing this kind of oversight on EMS needle decompressions anywhere?

26% of patients did not have any pneumothorax at any time – not even after a paramedic stuck them with a large needle that is supposed to cause a pneumothorax.

This should have caused us to reassess our needle decompression assessment and treatment, but has anything changed?

Do any of our needle decompression patients have tension pneumothorax?

Do we care?

Back to the article –

In far too many cases, training programs offer the minimum legal subject matter required for accreditation as a training facility, usually little more than glancing over some EMS statutes and local rules.

“Don’t mess up, or you will get sued” seems to be the extent of the preparation new providers (who grow to be old providers) ever get with respect to protecting themselves legally.[1]


In the study, 26% of paramedics messed up in a very big way.

Did any of them get sued?

Did any of them receive any remediation?

Did the EMS service do anything to try to cut down on inappropriate needle decompressions?

In each case, a paramedic stabbed the patient in the chest.

How many of the rest of the patients only had a pneumorax because a paramedic stabbed the patient in the chest?

How representative is this study?

We don’t know.

We used to pretend that paramedics are great at intubation, but then we studied paramedic success rates and realized that only some rare paramedics seem to be good at intubation.

If we do not measure what we do, we do not know how bad we are.

If we do not measure what we do, how can we improve?

Our patients deserve excellent care, but we don’t even know what we are doing.


[1] If providers save lives, then the law saves providers
Providers who combine solid skills with knowledge and understanding of how law applies will be both good and safe
The Legal Guardian
by David Givot
August 13, 2012

[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010



  1. A few years ago a monitor/defibrillator sales rep was riding with us. He told me about how hard it was to sell montiors with the new data collection capabilities to some agencies because, in his words, they don’t want to know how bad they are at resuscitation. It’s time for people who have a clue to make more noise about this.

    • Terrible, but true. Rather than critically evaluating performance and using that data to improve future performance, the entire CQI/QA/CEd process in EMS seems to be directed at berating a provider for sub-100% performance, rather than using that information to improve in future similar situations.

      In turn, CQI has become nothing more than a back and forth vicious cycle of counter-productivity. This leads to not patient-centered care improvements, but documentation-centered care. The way we collect and analyze data and review performance demands serious overhaul.

      Focus should be placed on reinforcing positive performance rather than constant negative feedback.