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

- Rogue Medic

Too Many Medics?

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In some of the posts on the recent intubation study,[1] this question keeps coming up: What is the right number of paramedics to provide the best care to patients?

There was an article that covered this.[2] Here is the chart from the article.


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The study examined cardiac-arrest survival in five
unnamed cities. The findings include:

City with best outcome City with worst outcome
Cases of sudden cardiac arrest per paramedic each year 4.7 1.6
Length of time paramedics arrive after first responders 4 minutes 1 minute
Survival rate 27% 4%

Source: Researchers at Ohio State University in Columbus


This does not mean that medics should not be sent at all. Rather, it strongly suggests, that in our desire for a quick ALS response for cardiac arrest, we may be making things, not just a little bit worse, but a lot worse.

These numbers agree with what I have been stating about ALS getting in the way of BLS during cardiac arrest treatments (CPR). The numbers do not prove what I have been stating, but they seem to be giving a very strong hint.

The places with fast ALS responses are able to respond quickly because they have a lot more medics. In other words, they have dramatically reduced the amount of experience per medic.


To make everybody feel good, even though it appears to be killing people.

Almost a 7 times higher survival rate in the cities with fewer medics.

Feel good?

More medics means that more people are medics, and can feel good about being medics.

More medics means that more people are having medics respond to treat them, and can feel good about receiving care from medics.

This is just to make people feel good. Then, why not make everyone a medic? The response time would be immediate, unless maybe you fall in the woods, and there is nobody else there to hear you fall. In which case the philosophical question is, If a patient falls in the woods and there is nobody there to call 911, is there a response time? Not, Does the patient make a sound? And, since the patient is a medic, there is already a medic on scene, so there is no worry about response time.

Do the response time rules state that the responding medic has to be alive?

Probably not.

We could have all of the patients in nursing homes become paramedics. Talk about cross-training leading to improved response times!

Too many medics = too many failed resuscitations.

Too much of a good thing can be a bad thing.


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not

^ 2 Fewer paramedics means more lives saved
Updated 5/21/2006 8:58 PM ET
USA Today
By Robert Davis

The chart is from this article.


Fla. EMS director pulls certification of 25 paramedics

It seems that there is a bit of a squabble going on down in Florida.

Twenty-five North Naples firefighters are no longer allowed to work as paramedics because they haven’t met training requirements set by Collier County Medical Director Dr. Bob Tober.

North Naples Fire Chief Orly Stolts said the move puts good medics out of commission and endangers residents.[1]

A fire chief opposed to training? WTF?

Oh, it’s EMS training that he is opposed to. That explains it. The chief thought that he would be able to force the medical director to sign off on the ex-medics, just because the chief was going to huff and puff and sputter and grimace and cry like a little baby.

“What he’s done is minimized the fire department’s ability to save lives,” Stolts said of Tober. “We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene. That puts our guys in a pretty hard spot.”[1]

Well, he is the chief. He should know.

He is a fire chief. His highest ranking medical person is telling him just the opposite of what he wants to hear. He just really, really, really doesn’t want to hear this.

“We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene.”

If he truly believes that, then maybe he should have acted as a Chief and made sure that his people had the required training. This is all the fault of Chief Numbskull.

This is a wonderful example of a blithering idiot.

Stolts said arranging to have his firefighters pulled from an engine once a month causes significant scheduling and overtime difficulties.[1]

In other words, Chief Stolts is completely responsible for this. He chose not to follow the medical training rules. I wonder if he does that with fire training rules.

Maybe he is cross-trained and incompetent at both fire and EMS.

Maybe. We know he has one area of incompetence fully covered.


^ 1 Fla. EMS director pulls certification of 25 paramedics
By Ryan Mills
The Naples Daily News
August 26, 2009


Another One Walks Away

Dr. Bryan Bledsoe[1] wrote an article for JEMS magazine called Another One Walks Away.[2] Copying the title was not imaginative, but I suspect that will be the least of the complaints about this post. This is an article that has generated a lot of comments at JEMS.com.
The article is about a medic, who left the profession club. EMS might be a bit better off if it weren’t viewed as just a simple task of transporting people, following protocols, and maintaining, or almost maintaining, low standards. 
If that were the case:
Maybe EMS would not be put in the hands of people who have a full time job in another field, but since they live in a rural environment feel they are qualified to provide medical care – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who are trained to fight fires, but due to the flashing lights and the woo woos feel they are qualified to provide medical care – As long as we keep the medical standards LOW.
Maybe it would not be put in the hands of nurses, but since they have a college degree feel they understand EMS better than those in EMS – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who are trained to be police, but since the state wants to maintain a monopoly on HEMS, feel that having a medic take a year off from EMS to work as a state trooper makes the medic better qualified to provide medical care than ground EMS providers – As long as we keep the medical standards LOW.
Maybe medical oversight would not be put in the hands of people who do not pay attention to what the medics actually do, but since they require a phone call for permission to do anything dangerous, they feel they are qualified to provide medical oversight – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who think that the purpose of a uniform is to blind you with a bunch of flare or some other appearance fetish, but since they have no clue about medical care, they think the uniform is important – As long as we keep the medical standards LOW.

Maybe EMS would not be put in the hands of people who are more concerned about the availabilty of ambulances, than the care provided by those in the ambulances – As long as we keep the medical standards LOW.

Maybe EMS research would not be put in the hands of people who think that the way to control for a variable is to make the same mistake as many times as possible – As long as we keep the medical standards LOW.
If I have missed anybody, I apologize, but I am working with low standards, here.
I do not mean to include all volunteer departments, all fire departments, all nurses, all police, all medical directors, all Liberace wanna be’s, all EMS researchers, . . . in my criticism. Part of the problem is that there are few who provide excellent EMS. Cross-training convinces people that EMS only requires part time attention.
I know people who provide excellent medical care and also do a good job in another field. Emergency services attracts the ADD personality. Some are good at several skills. Some are only good at making messes. Most are somewhere in between. Being an adult means having to make choices. Do I want to be a fire fighter, police officer, doctor, nurse, paramedic, . . . As a grown up, I need to choose.
Why should we eliminate people from a field, because the do not have a desire, or the aptitude, to be cross-trained in an unrelated field as a requirement of the job? Is our quality problem that everyone is too good? Absolutely not. We need to trying to recruit the best at EMS – not EMS and whatever the town council has chosen from a grab bag of jobs they, in their ignorance, think are related.
Cross-training only encourages the bean counters to devalue everyone. Look at triage nurses. They are required to provide all sorts of social screening and are having more added to their job requirements.[3] This is idiotic, but that’s what you get when you convince people that cross-training is a good idea. 
When we get serious about eliminating the lowest common denominators, we will need to eliminate this trend toward cross-training. In order to accept cross-trained providers, you have to accept that the LCD (Lowest Common Denominator) will drop even lower. Training people in unrelated fields will never result in higher standards in either field.
If there is a fire, I want those responding to be fire fighters – not paramedics cross-trained as fire fighters.
If I need the police, I want those responding to be police officers – not paramedics cross-trained as police officers.
If I need to be triaged in the ED, I want to be triaged by a nurse – not a social worker cross-trained as a nurse.
Maybe what we need is for anyone in EMS, who can get a real job (that includes fire fighter), to get one. Maybe we should leave EMS to those with only the ability to understand Would you like fries with that? 
On the other hand, maybe a job in EMS is one of the safest if there is a recession. It might even be better than having a real job.
^ 2 Another One Walks Away

By Dr. Bryan Bledsoe

^ 3 Here is the post I wrote about proposed changes in the duties of triage nurses.

If it’s not one thing, it’s your mother.

Ambulance Driver has another excellent piece on the EMS/Fire Department relationship over at EMS1.com.

Marriage Counseling Part II: The Dysfunctional Fire/EMS Relationship

For the few of you who might not already read everything he writes, this puts things in a different light that may help some to understand some of the problems of dual role/cross-trained people. Read it.

I have written a bunch on the subject and I know that people do care about it. Leave him a comment, so that the people at EMS1.com know that people care enough about the subject to express their views on the subject.

Part III next month?


More Medics Means More Medical Misadventure – more commentary

This is another post that is a reply to Anonymous 30 year FF/Medic in the Southwest US. First, to clarify one important point.

I do not dislike fire fighters.

I do not disapprove of fire fighters.

We each could argue that the other group has dumber people forever. We all have our examples of evolutionary misconduct. There are plenty of single role medics, who would mess up an order for beer if they were tending bar. Keeping fire and EMS separate will not eliminate that, but I think that it will be a big step toward decreasing that. A step toward directing people to their aptitudes, if any.

There is little about being a good fire fighter that will help you be a good medic. There is little about being a good medic that will help you be a good fire fighter. Discipline and intelligence will help with both, but they are not exclusive to either job. They are not enough of a similarity to justify cross-training.

I do not like treating fire fighters any more than I like treating police or EMS. Everybody should be able to come home from their jobs safe.

Every day.

I think that being trained to do your job to the best of your ability is going to make it more likely that this happens. The bad guy goes to jail or the morgue and the police officer goes home without injuries. The fire is controlled quickly and put completely out and the fire fighter goes home without injuries. The patient is treated well, has the best chance of a good outcome and the medic/EMT goes home without injuries.

Anyway, I do not think that anyone commenting on these posts has been suggesting that this is the good guys vs. the bad guys.

Anonymous said…

“‘Subclavian lines? Why? Water saves lives in fires, but rarely in a patient’s veins. You put the wet stuff IN the red stuff.'”

“You lost me on this one.
A trauma pt needs some kind of blood pressure to make it to surgery. The IV is may not be first on the list of things important, but is is on the list.”

I think that Dr. Mattox has made some very good points about the need to control the bleeding before adding fluid, even if the fluid being added is blood. There is too much attention to treating the blood pressure at the expense of survival. The research is not at all clear on what is best. I prefer to avoid treatment, rather than follow what was expert opinion long ago when trauma research was more of a concept than a reality. I will write a bunch of posts about that, but not this week.

How much BP they need is something EMS does not seem to agree on. Systolic BP of 50? 60? 70? 80? 90? 100? The number may not be one number for all patients, but I think that the higher end numbers are a bad idea, similar to withholding appropriate pain medicine out of inappropriate fear of respiratory depression.

“If the limbs are busted up, burned or missing and there isn’t a peripheral IV site handy, central lines work just dandy.”

I’ve never started anything more central than EJs on a patient. I have seen doctors take forever to start subclavians. One took almost an hour. In a moving ambulance, this might have been abandoned earlier, or the decision to stay and play might have been made. Staying and playing is already a big problem. Part of the quality issue.

IO’s with a pressure infuser just don’t give decent volume in my experience.”

I do not think that the volume is as important as we have been led to believe.

“Don’t ‘stay and play’ but enroute to 1 of our 5 trauma centers get done what needs to be done. Even with 5 centers, I’ve had transport times over 40 min.
Urban sprawl at its best.”

This is true.

“‘If I want to be a helicopter pilot and want to be a flight nurse, should cross-train everyone so that I can have my dream job?'”

“Get your nursing license and your pilots license. Why would you train everyone?
Your employer doesn’t have anything to do with it unless you want them to pay for it. Once you have the license you want, get the job you want. :)”

This was a reference to your desire to be both fire fighter and medic. Your desire fits the framework of your employer, but there is nothing really connecting the two jobs. I think that my example just demonstrates that there are many ways of cross-training. Expecting people to do perform different jobs, by combining the job description, is not a good idea.

The response to the person who wants to be a fire fighter and a medic should be the same as the response to the person who wants to be a pilot and a flight nurse/flight medic – “Once you have the license you want, get the job you want. 🙂

“‘If you take a utility truck to EMS calls and rendezvous with the fire apparatus at the fire and have automatic dispatch of medics to all working fires, the result should be better.'”

“We do have automatic dispatch of medics. They’re on every engine.
I shudder at the thought of meeting the fire truck on the scene of a working fire.
If the truck gets there first and the homeowner sees nothing being done because there is no crew, now what?
If the crew gets there first, nothing is getting done because they don’t have any fire fighting equipment.
I wouldn’t want to have to explain that one to the news crews or defend the video that will show up on YouTube.”

You make an excellent point. Although, I expect that there are several crews responding and do not know how common the YouTube experience might be. This would probably generate an auto-lynch response from the public.

“Witness noted: ‘The medics aren’t terrible as a whole, but there are several merchant medics of death who continue to practice their deadly art.'”

“There are some turds floating in every punch bowl. (why I drink beer) If you see a turd, make whoever is in charge of EMS or training do their job and cleanse their mortal souls.
We have had guys given the choice of dropping their patch or going through another medic training course from day one to graduation.”

You have beer in your fire house? Now that is a persuasive argument! 🙂

One of my goals in writing this blog is to try to persuade people to do something about the bad medics. They are dangerous, do not ignore them. I think that the person most responsible for eliminating them is the medical director. An absentee medical director is worse than no medical director.

What are you guys seeing in the new hires quality wise?”

I don’t think that they are that much worse than they were years ago, but everybody seems to tolerate a lot more misbehavior than years ago. There is a bit of a problem with kid gloves preventing quality improvement.

A disturbing trend I see is a lot of youngsters (say 19-24) haven’t had a real job yet. They’ve been in school, lived with Mom & Dad and now they get hired here.
Some take to hard work and long hours like a duck to water because they have been blessed with parents that showed them what a work ethic was.
A small but very visible minority have the attitude of “hey, I’d rather be…you know…like, at the lake on my boat.”
By all means, take your boat to the lake. Maybe it will sink and backflush the gene pool of your DNA!

I agree. I had worked in various construction jobs for over a decade before EMS. Part of it is the schools and preceptors not pulling the plug earlier. If they aren’t getting it, get a tutor, repeat the class, or move on to some other career path. Too many people view a good outcome grade-wise as a right or something they deserve for just showing up.

Everyone seems to be afraid of discrimination, but that is what school is supposed to teach us to do. To discriminate between things on a logical basis. That definition of discriminate seems to have been replaced by the fear of someone not being treated as the “beautiful or unique snowflake” we would like to be. Empathy and compassion are important as a medic, but we should not encourage students to use others’ empathy and compassion as a tool to coerce them into giving an undeserved passing grade. Choosing appearance over substance is a bad choice.

The educational system has been moving this way in leaps and bounds. Somebody needs to pull on their leash, good and hard.

I think that one of the differences between fire and EMS is the type of person who excels at the job. In my opinion, good medics tend to be comfortable doing their own thing and not worrying about the protocols, or some other rules. Their job is to take care of the patient. While good fire fighters need to work as a team. You need to know that the fire fighter is going to be where assigned, not going off and trying something else or backing out of the fire without notifying anyone or just not remaining in contact on a scene with limited visibility.

These goals are divergent. Some people are able to adapt to both roles well, but that is not normal.

A medic who is primarily worried about matching the patient with the closest protocol, so that they have some rules to follow, is not a good medic. A fire fighter who needs to do things his own way is not a good fire fighter.


More Medics Means More Medical Misadventure – commentary

30 year FF/Medic in the Southwest US wrote a comment that I could not easily answer with just a comment. Here is the original comment broken up by my responses.

Sorry, kind of late to this party.
No wonder AmbulanceDriver links you. He seems to dislike fire medics also.

I do not think that Ambulance Driver dislikes fire fighters, but he can speak for himself.

I do not dislike fire fighters. I would like to see administrations find sensible ways to meet staffing needs. This FF/EMT-P idea is bad fire fighting and bad medicine. Having fire fighters make medical decisions is as bad as having medics make fire fighting decisions. Having EMS run by FD and having FD run by EMS. Both are bad ideas.

I think fire fighters should fight fires and paramedics should provide medical care. It seems that most of the fire fighters I know do not want to have anything to do with EMS. They want to fight fires. In the midatlantic states fire departments have to require minimum amounts of time working as a fire fighter, before they can be released form that obligation and be just fire fighters.

Do you want someone taking care of patients who does not want to be taking care of patients? Yes, It does happen with burn out and everyone has bad days, but this is intentionally recruiting from those who have to be forced to sign a contract just to have the chance to fight fires later on.

Are either of these jobs so simple that we want to force people, with no interest in the job, to be the ones who are responsible for life and death decisions?

“The silliness of sending a fire engine to a medical emergency deserves a post on cluelessness all to itself.”

OK, how about 515 sq miles to cover and no one to do it?
When you have the 10th largest city in the country land wise, and someone codes or yet another 2 yr old drowns, I don’t have a problem getting on my fire engine and having an *average* response time of 5 min.
Why would you??
They’re in the neighborhood. Why not utilize them?

Having a person become a medic, because the person is already in the neighborhood performing another job, is a bad staffing decision. Hire the right number of medics for the EMS workload. Hire the right number of fire fighters for the fire fighting workload. Don’t complain if some of them are not busy.

The comment you quoted was about the waste of sending an engine just to transport personnel. Why do you need to send the big truck out on a shoe run? Why not get a utility vehicle and leave a driver at the station to rendez vous with the rest of the crew at the scene of a fire – if a fire call comes in?

Why put all of that wear and tear on such an expensive piece of apparatus?

Engines sure don’t maneuver better than much smaller trucks. They do not decelerate as well, when required to. They do not accelerate back up to speed well, either. In some places they avoid this problem by just blowing through the lights without slowing.

There was an accident in Baltimore, in December 2007, that demonstrated this problem.

“Fire department policy requires a truck operator to stop before proceeding through a red light. But in this case, the truck was going 47 mph at the time of the crash.

“The fire truck was third in a line of four emergency vehicles and reached the intersection eight seconds after an ambulance had safely gone through it, officials said.”

That all of the fire apparatus sped through the red light tells you that this is not an unusual occurrence. This appears to be the common practice. This is one of the problems of driving a truck that is so difficult to slow down and to speed up. They were responding to a report of smoke, so this is not an EMS call, but would they have responded any differently if it were an EMS call. We are supposed to be protecting the public, not endangering them.

And this article does not describe an isolated incident.

I just don’t understand the fire bashing. I get along great with the private ambulance company medics that I run in with.
I run in with them because we’re closer to some of their calls and we don’t stop at some line on a map if someone needs help.

As medics we all have to wade through the same blood and puke and put up with the same nurses and docs don’t we? So why the attitude?

How do medics benefit from being fire fighters, other than through the stronger union representation? How do fire fighters benefit from being medics other than a bit of perceived job security?

We shouldn’t cross-train people in unrelated fields. These two jobs are not complementary. Being a good fire fighter does not help you to be a better medic and being a good medic does not help you to be a better fire fighter.

I am not trying to bash fire fighters.

If my home is on fire, I want fire fighters to respond to put it out. I do not want somebody cross-trained in other unrelated jobs. My life, my child’s life, my neighbors’ lives may be on the line.

If there is a medical emergency affecting me, my child, or anyone else I care about, I want a medic to respond to provide medical care. I do not want somebody cross-trained in other unrelated jobs. My life, my child’s life, the lives of the people I care about may be on the line.

Cross-training is a way for taxing entities to save money. It is similar to Walmart putting pressure on suppliers to produce products more cheaply. Eventually the production will be so cheap that it is not worth the cost savings.

The problem is requiring that people be trained for roles that are not compatible. Fighting fire and providing medical care are not connected, except by the lights and sirens.

“The large number of medics needed to meet the “everyone is a medic” staffing criteria, seems to encourage those, who should be providing oversight, to overlook patient care instead of overseeing patient care.”

If I’m reading this right, that is a problem with the training program and the preceptors. Or there is someone who should be doing quality control that isn’t. Either way, I don’t see it as the medics fault. They need someone with experience to tell/show them the way it should be done.
The bad medic is a symptom of the disease the higher ups have.

30 yrs and counting

In that part of my post you have understood the point I was trying to make.

The cost of providing well trained medics with aggressive medical oversight is more expensive than many wish to consider. ALS on the cheap is a bad idea, but that is the motivation behind cross-training. There are some people who will do well when cross-trained, but I do not believe that this is true of most people. You will end up with many who may be good at one job, but are dangerous at the other.

Do you want to go into a fire with someone who is a bad fire fighter, but the bosses need that person’s medic skills?

Do you want to be cared for by someone who is a bad medic, but the bosses need that person’s fire fighting skills?

If the person is not going to operate in the other role, what is the point of being cross-trained in the other role?

This is not a match made in heaven, except for some who may be very good at both jobs. This is calling out for an annulment, so that the various emergency services can specialize in what they are supposed to be doing.

Administrations pitting fire fighters and medics against each other is just a way to take attention off of the real problem. Doing the job right costs money and requires a focus on the job – not a focus on a couple of different jobs, or a few different jobs.


Drinking Problem? Try SBI.

In I’LL Give You A Comment, White Coat Rants writes about a new counterproductive, and probably lethal, policy.

Well, if you have a drinking problem, or if you have a family member who has a drinking problem, or if you make money treating people who have drinking problems, then the latest JCAHO mandate to impair ED (Emergency Department) treatment is your kind of drug. Of course, that is assuming that the SBI (Screening and Brief Intervention)[1] becomes a mandate. Screen everyone for alcohol abuse, then provide a 15 minute intervention to stop the problem drinking. Ooops, most of them call this SBIRT, the RT for Referral to Treatment. That is where the counselors will make their money. Then there are the rest of the JCAHO screenings. Then you may receive a medical assessment for the emergency that resulted in your trip to the ED.

Looking at the web site for this, it seems to be guaranteed. I counted about a dozen people posting opposing views on this topic. Some of them were only “not completely thrilled.” They only seem to be concerned about where their money will come from. If they get their cut, that only leaves about half a dozen opposing voices. One is clearly a crackpot, linking this to a rebirth of Nazi style government, but the rest stay on topic. In favor of this are about 200 posts. Reading them is like reading the positive comments about Big Brother from the government officials in 1984,[2] so maybe the crackpot isn’t so crazy. How can so many be oblivious to the harm?

The trauma personnel in favor of this mandate deal with a situation that is different from what the ED faces. You are not presented with a triage nurse asking all of these screening questions and then performing a brief intervention before you are seen. Trauma centers tend to be much better at keeping social workers on staff (available to trauma), so they can respond with the rest of the trauma team and ask the screening barrage after the patient has been stabilized.

JCAHO (the Joint Commission for Accrediting Health Care Organization) was their old name, but they are trying for a new and improved image. Never a good sign in health care. Now they call themselves TJC (The Joint Commission). What were they thinking? Hmmm. That’s not right. What were they smoking?

Inevitably, with a bunch of bloggers who have a sense of humor, some refer to them as the Medical Marijuana Advocates. [3]

If you are unfamiliar with the topic, the Medical Marijuana Advocates are the people who the hospital calls in for prearranged inspections, so for that one week where everyone is doing everything by the book, it is because these runaways from the circus are coming to visit. They make all sorts of silly rules, as you can see from these links.[4], [5], [6]

They act as if the ED is Lake Woebegone, where all of the children are above average and giving them more and more divergent responsibilities will actually not cause competency to decrease. As if there are no lowest common denominators, who will no longer be up to that minimum standard. Now they will be more dangerous.

“Oh no! It’s Nurse X. Why do we have to work with Nurse X, nobody is worse at patient care than Nurse X.”

“Hush, Nurse X always completes the SBI thoroughly and gets such good evaluations from the patients. We are all about the Press Ganey scores, not patient care. So what if we lose a few patients, dead people don’t fill out evaluations.”

My opinion ofcross-training[7], [8], [9], [10], [11] has not changed. This is not different from the requirement that paramedics become cross-trained to satisfy somebody’s misunderstanding of medicine. The only positive I see here is that it may help others to see the problems with EMS cross-training.

Eventually, you will arrive at the ED and be asked such a ridiculous number of questions before you are treated, that most people will look for genuine alternatives. Someplace to go for real emergency care, not an emergent screening for all sorts of chronic social problems. The purpose of the ED is to keep you from immediate death or disability. Screening for smoking in the home, domestic violence, TB, suicidal ideation, alcohol consumption, . . . is not necessarily wrong. When the screening and brief intervention distract the nurse from focusing on the life and limb threats, then screening is bad. When this encourages the hiring of nurses and doctors, who are incapable of recognizing a life or limb threat, then it is very bad.

But this is just one more question, how bad can that be?

It is not one more question – it is a 15 minute intervention.

An extra quarter of an hour out of the treatment of each patient. Where are the ED nurses to find the time? If the hospitals hire more staff for this, you know that they will be the first to go when the next “belt tightening” happens.

The addiction community is lining up at the feeding trough to stuff themselves on the bacchanalia that they see as their reward for being ignored for so long. As long as nobody questions where the money or the time is supposed to come from, nobody seems to care. I see the dilution of skill, in order to include this new skill for doctors and nurses, as a bigger problem.

This is coming from you. From your wallet and from your quality of life – assuming it doesn’t kill you.

The ED cannot turn anyone away, so every “deserving” social program shall be foisted upon the ED. Eventually, the ED may have nothing to do with emergency medicine. The ED is being made to atone for the guilt of everyone else.

The ED has become the Lady MacBeth of medicine. Lady MacBeth was guilty in the death of the king. The ED has many faults, but it does not have that kind of blood on its hands – yet.

This stain will not go away.

This stain will make a mockery of emergency medicine.

No. I do not think that I am exaggerating.

Another view of the same situation is presented in the book The Victim by Saul Bellow.[12] Guilt vs. entitlement. How much do we let our guilt, or our neighbors’ guilt cause us to harm ourselves and to encourage the guilt tripper in his dissolution?

Responsibility has become a foreign concept.

No individual responsibility is to be allowed in America.

^ 1 The Joint Commission
Standards Development & Research

^ 2 From The Literature Network

^ 5 From MDOD

^ 6 From MDOD

^ 7

^ 8

^ 9

^ 10

^ 11


Raising the Standards for Rock Ridge EMS

Vince commented on the post “Rock Ridge Hospital and EMS.“:

“Bad medics come from medical directors allowing them to treat patients without requiring that they demonstrate competence. Maintaining competence is ignored, too.”

Bad medic are only bad medics when they fail to have the integrity to realize “these are other people’s lives I am playing with and I better make sure I get my shit together.” A bad OLMC physician may allow medics to continue to deliver substandard care, an issue that needs redress to be sure, but he certainly did not force anyone to be a bad medic.

Medic X, who cannot imagine what a 52 card deck looks like, is responsible for his misbehavior.


The medical director is responsible for allowing this paragon of EMS to work in EMS.

Medic X is irresponsible and incompetent and reckless.


He cannot grant himself the authority to treat patients.

The medical director is supposed to protect the patients from Medic X.

Otherwise, what do we need the medical director for? Not much.

Personal Responsibility.

Exactly. Why excuse the medical director from personal responsibility?

This is why it is outrageous to me, in principle, to focus on ways to make bad medics ‘less dangerous’ by any means other than those discussed above (remediation, counseling et al)

When there is the possibility to improve the care delivered, we should look into that.

You know that I am not a fan of fancy gadgets. Waveform capnography is one gadget that is extremely useful, and improves the care delivered by competent medics. CPAP is a treatment that helps to avoid intubation. CPAP should be used, not because we are afraid of the medic missing the tube, but because CPAP is better for the patient.

I realize your motivation is patient care and, after all, that is what this is all about. I also concede that these are not mutually exclusive ideas.

But as I alluded to earlier, any tool/device etc. that makes it ‘appear’ easier and ‘more foolproof ‘ will likely have the unintended consequence of allowing an already sub-standard paramedic, to rely on them at the exclusion of his underdeveloped assessment skills and judgment.

I am just advocating eliminating the middleman 😉

I am also not a fan of middlemen.

The term foolproof is, at best, an exaggeration. Similar to unsinkable.

Snopes.com has a great page, Sinking the Unsinkable, on the use of the term unsinkable, its relation to the Titanic, and the arrogance of many involved. The current approach to physician oversight is often closer to the arrogance of pretending the Titanic was unsinkable, than it is to any real risk management.

We need to weed out the substandard medics, instead we find ways to accommodate them. That is not what I am trying to do. I am interested in better tools. Tools that will help competent medics provide better care.

Obviously, anything that would improve patient care and eliminate potentially fatal errors are something I think we are all on board with. I am not that arrogant. I just would put more of my ova into the standard raising basket.

Just how arrogant is to be determined. The ale in your most recent post appears to have been drained.

I am in favor of raising standards. We also need to police ourselves and insist that medical directors get rid of those who cannot be remediated.

Instead, we seem to try to defend the bad medics. Until they harm someone. Why shouldn’t we do something before they harm someone?

Just applying standards that relate to patient care would be much better than checking to make sure the prospective medic has a pulse and a license, which seems to be all too common in EMS. We also need to put an end to the distraction of the medics with unrelated tasks, such as janitorial work, landscaping, fire fighting, or whatever else is dreamed up to occupy medics’ time not actually on calls.

If you remember for many many years I have been of the opinion that the paramedic profession take similar steps that nursing did insofar as making itself a profession, i.e. with minimum education requirements. Not only would this serve as a first-line filter to keep out some of the knuckle-draggers with the “Your life is my hobby” attitude, it may make inroads in garnering much deserved respect from other professionals, in particular OLMC physicians, not to say anything about an increase in salary. Perhaps you can post on this idea….

I am not convinced that more school will make a big difference. Appearances may be changed, but look at how overeducated medical directors are. In many cases, these highly educated medical directors still do not get EMS. Otherwise, why would we have OLMC (On Line Medical Command) requirements? We used to have to call for permission to do everything, even to start an IV. As EMS becomes better understood, the need to have medics call for permission has been gradually going away, but there are still places that insist on it.


As long as there are OLMC requirements, the medical director can point to this fraud and claim that there is physician oversight.


There is no real physician oversight – the medical director has no idea what is going on with patient care.

Not many people understand medicine and fewer understand EMS. Few realize that OLMC requirements are just a substitute for real physician oversight. And a very dangerous substitute.

Real physician oversight is not cheap or easy. Many do not want to do all of that work. Many services do not want to pay what it would take.


If you aren’t going to provide real physician oversight, you need to limit care to BLS (Basic Life Support).

How many services will behave responsibly? Pay up for real physician oversight, get a medical director who understands EMS and oversight, or get out of the ALS (Advanced Life Support) business.

It doesn’t matter if you are the volunteers, fire fighters, private ambulance company, third service, National Registry, or anything else.

Do it the right way, or not at all.