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

- Rogue Medic

Should Merit Badge Organizations Define Standards of Care?


The AHA (American Heart Association), NREMT (National Registry of EMTs), ACS (American College of Surgeons – PHTLS – PreHospital Trauma Life Support), and other organizations end up making standard of care decisions based on superstition.

We need to stop acting as if these organizations are creating good patient care.

They are improving, but they are so busy defending their ancient dogmas that they delay improvements in patient care.

Our patients are their guinea pigs, but we refuse to learn from their failures.

I want to know the real risks and benefits of this treatment.

For example –

AHA guidelines.

Ventilations have never been demonstrated to improve survival to discharge, but we are afraid of removing them because we don’t really understand what we are doing and finding out is even more scary than ignorance.[1]

Drugs have never been demonstrated to improve survival to discharge, but we are afraid of removing them because we don’t really understand what we are doing and finding out is even more scary than ignorance.[2]

NREMT guidelines.

Objective examination has never been demonstrated to be better than subjective examination by competent examiners. We are more afraid of people passing their friends and failing their enemies, or getting money to pass people (redundant, since the whole testing process requires a payment), than we are of incompetence.[3]

Objectivity does not mean competence.

Subjectivity does not mean corruption.

We need to be smart enough to assess competence.

Instead we hide behind a test that is focused on memorization and not understanding.

ACS – PHTLS guidelines.

We still pretend that EMS spinal immobilization is not harmful.[4]

We have evidence of many kinds of harm from EMS spinal immobilization.[5],[6],[7]

We have only a weak hypothesis of how EMS spinal immobilization might protect the spine of a patient if that patient has an unstable spinal fracture that might get worse during transport.

The evidence shows that this hypothesis is at best misguided.

Manipulating people into EMS spinal immobilization is manipulation of the spine.

We can pretend that it is not, but we can also pretend that we have magical powers. Wishing does not make it so.

We need continuing education that is continual, not sitting in a classroom for 4, or 8, or 16 hours every two years.

We need to keep improving our care of patients, not excuses for the bad care that is in the guidelines.

When will we find time?

At the beginning of every shift, we can work on something.

Intubation practice should be done on a mannequin at a minimum every week. High-quality practice – even if it is on Fred The Head.

The same for medical and trauma megacodes.

We need to demand evidence that the recommendations of these organizations include evidence of improved outcomes that matter.

Any standard of care that does not have evidence of survival benefit needs to have an expiration date.

If nobody can show that it works, then it is just an opinion.

Our patients deserve better than to be treated based on dangerous opinions based on wishful thinking.


[1] Nothing

No evidence of improved survival with a thinking brain.

[2] Nothing

No evidence of improved survival with a thinking brain.

[3] Nothing

No evidence of competence at assessment of competence.

[4] Nothing

No evidence of any decrease in disability, although there is evidence of an increase in disability with spinal immobilization. See below.

[5] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.


Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.


This paper was cited by the ACS as a justification for spinal immobilization for blunt trauma.

[6] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).


[7] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed – indexed for MEDLINE]

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.


[8] Cervical spine motion during extrication.
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
J Emerg Med. 2013 Jan;44(1):122-7. doi: 10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15.
PMID: 23079144 [PubMed – in process]

The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.


There is a detailed evaluation of this paper by Dr. Brooks Walsh at Mill Hill Ave Command.

In order to protect the c-spine, should we stop helping?



  1. I just recently went through the tedious dental extraction known as ACLS renewal. Questions of the lack of evidence supporting many of the recommendations aside, there was another thing that really bothered me about the process …

    The distressingly low standard that participants are held to.

    Can’t recognize basic dysrhythmias? No problem, just keep guessing til you get it right. After all, we already have your card printed.

    And we are trusting these same people with patients’ lives.


  1. […] Click here for the link to Tim’s post on Merit badges and standard of care. […]

  2. […] This part of the podcast was part of a discussion of what I wrote about in Should Merit Badge Organizations Define Standards of Care? […]