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

- Rogue Medic

Do the wrong standards improve EMS



This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, and I discuss what we need to do to move EMS forward as a profession.

National Curriculum, EMS Titles and Hurdles
 

Is this the way your medical director, chief, CEO, ALS coordinator treats you?
 


Image credit.

We do seem to agree that our standards are too low, but we do not agree on what we should do to raise our standards and what are our obstacles to better standards.

We spend a lot of time worrying about the amount of classroom hours to complete each part of a merit badge, rather than how we should assess competence.

We avoid discretion as if it were evil, but we are exercising discretion every time we make any decision.

Every time we drive, we decide when and how hard to press on the throttle, when and how hard to press on the brake pedal, when and how much to turn the wheel, when and for how long to indicate a turn. Rather than assess competence behind the wheel, many organizations just require an EVOC (Emergency Vehicle Operator Course) completion cared.

As with all of the other merit badges that organizations require as an alternative to assessing competence themselves, the quality of these courses varies tremendously. It is like calling medical command for orders – more depends on who answers the phone than on anything else, but we pretend that this is some objective protection for patients.

We tell ourselves what we want to hear.

How much of what is taught in a merit badge course is based on the course materials and how much is based on the instructors opinions?

How much of what is in the course materials is based on good evidence?

We have a bunch of people trying to keep the standards low. Those who think that every seat should be filled with a medics will not have an easy time filling all of those seats with people wearing paramedic medic badge patches if the standards are high.

If being a paramedic is a participation award, will the patients really want the proud owner of a participation prize to be caring for them, or will patients want someone who is being held to standards that matter? Will patients want a paramedic who is treating the serious patients, rather than driving half of the serious patients to the hospital?

If medical directors, chiefs, CEOs, ALS coordinators, and others oppose improvements in standards, we need to ridicule them.

Medical directors who keep standards low do not deserve respect.

Chiefs who keep standards low do not deserve respect.

CEOs who keep standards low do not deserve respect.

ALS coordinators who keep standards low do not deserve respect.

If we are concerned about our image, we need to stop cooperating with the clowns running the circus.

Just because someone has a title does not mean they deserve respect. Leaders need to demonstrate that they deserve respect.

Those who don’t deserve respect should not be defended by us.

Go listen to the podcast.

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Comments

  1. Not too long ago a crew brought a MVC pt with a motorcycle helmet (full face) still on to the ER, saying it was causing too much manipulation of the spine to remove it. The QA/QI department of this service made the medic retake the two day ITLS saying he was in direct violation of ITLS standards and subsequently our protocol. Sure, ITLS states remove a helmet. No consideration was given to his argument of he was doing more damage by attempting to remove a helmet.
    It’s as you say, we set standards by an 8 hour course and not good judgement skills. EMS is a unique profession in which there are no blanket standards, and card courses do not allow for those pts falling outside the categories taught.
    So we’re to reward those following the card course teachings like blind sheep, but punish those who act as a pt advocate.

    • TexasMedicJMB,

      Not too long ago a crew brought a MVC pt with a motorcycle helmet (full face) still on to the ER, saying it was causing too much manipulation of the spine to remove it. The QA/QI department of this service made the medic retake the two day ITLS saying he was in direct violation of ITLS standards and subsequently our protocol. Sure, ITLS states remove a helmet. No consideration was given to his argument of he was doing more damage by attempting to remove a helmet.

      I have never taken ITLS and I am not feeling as if I have missed anything.

      My understanding of helmet removal (motorcycle, football, tin foil hat, . . . ) has been that if the patient is adequately managing his own airway and removal requires manipulation, leave the helmet on.

      The whole idea behinf spinal immobilization is supposed to be avoiding manipulation of the spine – not intentionally causing manipulation of the spine.

      The merit badge police are the enemies of critical judgment.

      It’s as you say, we set standards by an 8 hour course and not good judgement skills. EMS is a unique profession in which there are no blanket standards, and card courses do not allow for those pts falling outside the categories taught.

      Benign neglect is often the best treatment, but nobody wants to put that on any protocol, not even as continuing to not intervene as long as there is no apparent need to intervene.

      So we’re to reward those following the card course teachings like blind sheep, but punish those who act as a pt advocate.

      By preventing people from thinking, we are supposed to be preventing the mistakes that come from human error, but the decision to prevent thinking is a much bigger error on the part of the humans setting up the system.

      When oversight is about punishing difference, it ignores (and harms) the patients who do not easily fit the protocols and it encourages mediocrity.

      A great short story on the concept taken to its extremes is Harrison Bergeron by Kurt Vonnegut.

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