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

- Rogue Medic

When Is It Enough EMS Training? – EMS Office Hours

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, John Broyles, and I discuss how we are perceived outside of EMS.

When Is It Enough EMS Training?

Why do some EMS organizations just throw new medics to the wolves?

Why do the rest of us encourage this?

Image credit.
We discussed the topic of EMS organizations putting fresh, inexperienced medics out on the street as an example of the organization that try to do everything on the cheap ignoring one important liability that they create.

They whine, We could be sued! for so many less dangerous practices and especially for things that would be good for patients. When it comes to inexperience, all these EMS-on-the-cheap organizations seem to see is lower payrolls.

This is one thing they should be sued for, but lawyers don’t seems to pay attention to the experience of the medics who screw up or to the organizational responsibility for that.

The suggestion is made that there isn’t any money to sue for, as if EMS organizations are not required to carry adequate insurance to cover the damages they may cause. Of course there is money there for legal settlements.

Unfortunately, the topic is diverted into unrelated territory. When companies are sued for malpractice, the lawyers should spend time establishing for the jury the education, or lack of education of the paramedic, as well as the experience, or lack of experience of the paramedic.

For some reason the discussion switched to medics giving testimony in murder trials, where the medic is only there to confirm facts that are not even disputed.

What does the jury think about the experience of the medic in those cases?

Who cares. That has nothing to do with putting inexperienced medics on the street.

Does the lawyer spend time explaining the experience of the medic in those cases?

Of course not. That has nothing to do with putting inexperienced medics on the street.

If a malpractice suit is brought against a company for putting an inexperienced and dangerous medic on the street, the plaintiff’s lawyer should be explaining just how inexperienced the medic is, while the defense lawyer should be making the opposite case. The amount of time spent on this could be extensive. What matters is the way the lawyers are presenting their cases. If experience is relevant to the case, why wouldn’t a lawyer spend hours, days, or even weeks on the topic?

Being a good medic is about making decisions and learning from our mistakes.

A brand new medic has probably not made enough mistakes to learn to be a good medic.

An experienced medic may have made a lot of mistakes, but may not have learned anything from those mistakes.

There is an old saying about the tremendous difference between a 20 year medic having 20 years of experience and a 20 year medic having a year of experience 20 times over (or 6 months of experience 40 times over, or 3 months of experience 80 times over, or . . . ).

We pay attention to standardized tests, rather than assessing the ability to learn and assimilate new knowledge and new experiences. We pay attention to things that do not make a difference in patient outcomes.

We need to change what we pay attention to. How many of our employers track skills and post them publicly?

How good are the medics at intubation?

Is this a secret?

Is it unknown?

If it is not known, that is a sign of organizational incompetence.

We encourage organizational incompetence.


EMS Rapid Fire Show – September Edition

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, John Broyles, and I discuss what is important in EMS.

EMS Rapid Fire Show | September Edition

Does it matter if I am called an ambulance driver?

Why do we spend more time worrying about what we are called than we do about the quality of our patient care?

If I want to be seen as a professional, should I spend my time improving my abilities or should I spend my time telling people I deserve respect?

When someone refers to us as ambulance drivers, we get comments as if it is the most important thing in EMS.

When the topic of poor intubation quality comes up, we ambulance drivers seem to want to deny that there is any problem.

If we cannot look down at nurses for not being permitted to intubate, although we seem to be surprised when we learn that some nurses are permitted to intubate, our image will be crushed?

When someone in EMS does something that receives negative media coverage, we come out of the woodwork to condemn those actions, no matter how ignorant we are of what actually happened.

We go to conventions and prance around in dress uniforms, as if that is some kind of indicator of competence.

How many of us post our intubation success rates?

How many of us post our resuscitation rates – not ROSC (Return Of Spontaneous Circulation), but leaving the hospital to go home to continue a meaningful life?

If I resuscitate only 10% of my cardiac arrests, does it matter if I get pulses back on 20%, 40%, 60%, 80%, or even 100% of those patients?

We worry about appearances at the expense of patients.

Does a snappy Cap’n Crunch suit improve resuscitation?


John Broyles mentions responding in a bath robe and slippers, rather than getting all dressed up for the sick patient brought to his barracks. Which is more important, the patient or our attire?

We spend more time criticizing the attire of other ambulance drivers, than working on the quality of our own care.

Maybe we should learn what is good patient care, rather than pretend we are fashion critics.

It may be that we have more skill at fashion criticism, than at EMS, but how would anyone know?

Regardless of what people call me, I do drive ambulances.

Go listen to the podcast.


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.


EMS Zebra Hunting, Doing What’s Right or What’s Expected


This week on EMS Office Hours, Jim Hoffman, Josh Knapp, and I mostly discuss whether needle decompression for tension pneumothorax[1] is overused and what the indications are for this poorly understood skill.

EMS Zebra Hunting Or Doing What’s Right?

Is needle decompression of tension pneumothorax overused?

Are we too aggressive with the harpoon?

Didn’t this get Ahab into trouble?

Image credit.

Is it safer to use something that is too short to be called a harpoon?


A short needle does not work.

If you use a short needle, it is because it doesn’t matter if the patient has a tension pneumothorax, because the needle will not reach the pleural space.

If the needle will not reach the pleural space, there is no possible benefit.

OK, there is one possible benefit – if the patient responds to the painful stimulus of being stabbed in the chest, that is a potential benefit, but I don’t have a protocol to stab a patient in the chest to encourage breathing.

Image credit.

Many public agencies have lauded TCCC initiatives, citing anecdotal reports where TCCC interventions have prevented combat deaths.6,7 No study has rigorously analyzed battlefield application of both these devices to determine if they are being used appropriately in the field.[2]

We ought to find out, but a bigger study will be needed. Still, this is a good beginning – at least we are examining treatments.

Health care interventions are appropriate if performed properly for accepted indications. Conversely, inappropriate care occurs when an intervention is misused (improperly performed), overused (performed for an improper indication), or underused (not performed despite proper indications).8 [2]

If ND (Needle Decompression) is being done for no benefit, should we continue to use it?

If ND is being done with poor technique, and therefore not providing the intended benefit, should we continue to use it the same way?

If ND is being overused, and causing more harm than benefit, should we continue to use it the same way?

Underuse criteria
Seven (two coalition military, five Afghan army) soldiers presented with vital signs absent. One was from blunt trauma, three were from penetrating thoracic injury, and three were from blast injuries. None received NDs in the field.

Misuse criteria
Seven NDs were performed on five soldiers for appropriate indications. All of these were Afghan army soldiers. All seven decompressions were performed at least 2cm medial to the midclavicular line. No major complications resulting from the NDs were identified.

Overuse criteria
One Afghan soldier fell from standing during a unit physical fitness session. He reported unilateral chest pain but was otherwise stable. He was needle-decompressed twice in the field. Apparently, no “gush of air” was detected after each procedure was performed, so each needle was removed and the puncture sites were covered with sterile dressings.
Fortunately, a chest radiograph at hospital revealed no pneumothorax, despite the initial fall and subsequent attempts at ND.

If I am going to use ND, then the patient should not be awake enough to feel it, or comfortable enough to care about being stabbed in the chest.

But is the way that we are currently using needle decompression safe and efficacious?

Despite widespread use of TCCC in combat care, very little has been reported on how TCCC interventions are actually being applied on the battlefield. This is particularly important as these skills have potential complications, and are being taught to many soldiers with nonmedical back-grounds before overseas deployments.1,2 [2]

Since we are stabbing the chest near the heart, we should not consider this to be a treatment to take lightly.

We were unable to determine if NDs actually saved lives or if failure to perform NDs (despite appropriate indications) resulted in preventable deaths. Most of these patients suffered severe multisystem injuries.[2]

Likewise, patients who presented with vital signs absent also had either accompanying severe brain injury, exsanguinating hemorrhage, or both, which might have accounted for their death, despite the lack of ND.[2]

So, we cannot tell, from this study, if there is more benefit or more harm, or if there is abny benefit or any harm.

Those who has the needle decompression might not have needed it and those who did not have needle decompression might have needed it.

All NDs were performed at least 2 cm medial to the midclavicular line, and well within the cardiac box.16 This error in technique risks inadvertent injury to the heart or great vessels,17[2]

Image credit. Location B is Bad.

Location A is good.

We tend to think of the clavicle as extending along line B in the image above. If we think that way, we end up putting the needle in between the sternum and the nipple. That is a mistake.

Line A is the actual position of the clavicle. We should not be placing the needle medial to the nipple. If we can’t follow that direction, we should place the needle in the side.

Go listen to the podcast.


[1] Tension pneumothorax

[2] An evaluation of tactical combat casualty care interventions in a combat environment.
Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC.
J Spec Oper Med. 2009 Winter;9(1):65-8.
PMID: 19813350 [PubMed]

Free Full Text Download in PDF format from Journal of Special Operations Medicine

Tien HC, Jung V, Rizoli SB, Acharya SV, & MacDonald JC (2009). An evaluation of tactical combat casualty care interventions in a combat environment. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 9 (1), 65-8 PMID: 19813350


Does Rural EMS Have A Patient Care Advantage?

We have a large group of people this week on EMS Office Hours. Jim Hoffman, Josh Knapp, David Aber, David Blevins, Rommie Duckworth, and I discuss differences between rural and urban EMS.

Does Rural EMS Have A Patient Care Advantage?

Does the transport time affect what we do and where?


How often does the transport time affect what is done on scene?

Do we not treat CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure) aggressively on scene, because we are going to wait until we are in the ambulance to do what needs to be done?

CPAP (Continuous Positive Airway Pressure)?

Are we going to first carry a patient downstairs in a stair chair from the Little House on the Prairie and wait until we are in the ambulance to begin to treat with CPAP?

I hope not.

High-dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries)?

Are we going to first carry a patient downstairs in a stair chair from the Little House on the Prairie and wait until we are in the ambulance to begin to treat with high-dose NTG?

I hope not.

These are the two most effective treatments for CHF/ADHF.

Is one of these treatments better than the other?

Only one study seems to have looked at that and it used Bi-PAP (Bi-level Positive Airway Pressure), rather than CPAP and ISDN (IsoSorbide DiNitrate) rather than NTG. The conclusion was that high-dose ISDN is safer and better than Bi-PAP.[1]

Does that mean that we should not use Bi-PAP, or that we should not use CPAP?


What it does mean is that we need to stop coming up with excuses to avoid using high-dose NTG.

CPAP has been demonstrated to be safe, even if not demonstrating significant improvement in outcomes.[2]

Other studies have shown CPAP to improve outcomes.[3],[4],[5]

Since we can make a significant difference in the outcome by starting treatment early, why would we wait until we get the patient in the ambulance?

I know you can’t breathe, but we have a long ride, so you will have to wait until we are in the ambulance for me to start treating you.

I don’t think so.

I do not want to carry a CHF/ADHF patient in a stair chair until after I have started treatment.

Image credit.

One of the first things I do is to sit the patient upright. If the patient is comfortable laying down, that is a strong hint that the patient does not have CHF/ADHF. Then there is the anxiety produced by being carried on something that does not feel sturdy and worrying about being dropped. That has the wrong effect on blood pressure.

Is it any better if I am placing the patient on a stretcher and wheeling the patient to the ambulance without treatment, or maybe with just an oxygen mask on?

Making the patient worse is not good EMS care.

It does not matter if I am 5 minutes from the hospital or 5 hours from the hospital.

What about chest pain that appears cardiac?

Do we do the 12 lead in the ambulance, while we are rushing to the hospital, to find out which hospital we are going to? Maybe the closest hospital and the hospital with the cath lab are in the same direction, but maybe not.

Do we do the 12 lead in the ambulance, while we are rushing to the hospital, to find out what treatment we are giving? Oops, that is an RVI (Right Ventricular Infarction). We should have found out before giving NTG.

Do we start the IV (IntraVenous) line in the ambulance, while we are rushing to the hospital, before we can give NTG?

NTG is great for pain relief for many chest pain patients, but NTG has not been shown to improve outcomes for heart attack patients. NTG can be shown to affect the amount of ST elevation, but that has not been shown to improve outcomes for heart attack patients.

We give NTG to decrease the patient’s pain and we hope that there is some other benefit – even if that benefit does not improve outcomes. Pain relief should decrease catecholamine release by the body, which should help to keep from making things worse. Carrying the patient in a stair chair is probably going to increase catecholamine release, so I want to begin treatment before carrying the patient in a stair chair.

Is it any better if I am placing the patient on a stretcher and wheeling the patient to the ambulance without treatment, or maybe with just an oxygen mask on?

It does not matter how far I am from the hospital.

If I am on the hospital grounds, or if I am a couple of hours away, if I have a patient with severe pain from a broken leg, I want to minimize the pain and avoid patient movement (The patient thrashing around in pain could make things worse) before moving the patient.

There is also a discussion of whether we should have higher standards and more permissive protocols for rural EMS, since they will be doing much more with each patient.

Go listen to the podcast.


[1] High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema.
Sharon A, Shpirer I, Kaluski E, Moshkovitz Y, Milovanov O, Polak R, Blatt A, Simovitz A, Shaham O, Faigenberg Z, Metzger M, Stav D, Yogev R, Golik A, Krakover R, Vered Z, Cotter G.
J Am Coll Cardiol. 2000 Sep;36(3):832-7.
PMID: 10987607 [PubMed – indexed for MEDLINE]

Free Full Text and Free PDF Download from ScienceDirect

[2] Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study.
Frontin P, Bounes V, Houzé-Cerfon CH, Charpentier S, Houzé-Cerfon V, Ducassé JL.
Am J Emerg Med. 2011 Sep;29(7):775-81. Epub 2010 May 1.
PMID: 20825901 [PubMed – indexed for MEDLINE]

[3] Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema.
Park M, Sangean MC, Volpe Mde S, Feltrim MI, Nozawa E, Leite PF, Passos Amato MB, Lorenzi-Filho G.
Crit Care Med. 2004 Dec;32(12):2407-15.
PMID: 15599144 [PubMed – indexed for MEDLINE]

[4] Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis.
Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD.
Lancet. 2006 Apr 8;367(9517):1155-63. Review.
PMID: 16616558 [PubMed – indexed for MEDLINE]

[5] Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema–a systematic review and meta-analysis.
Winck JC, Azevedo LF, Costa-Pereira A, Antonelli M, Wyatt JC.
Crit Care. 2006;10(2):R69. Review.
PMID: 16646987 [PubMed – indexed for MEDLINE]

Free Full Text from BMC Critical Care


Interfacility Transport vs. 911 EMS

This week on EMS Office Hours, Jim Hoffman, Josh Knapp, Joe Paczkowski, and I discuss whether 911 medics are better, interfacility medics are better, or if it is more complicated than that.

Interfacility Transport vs. 911 EMS

However, Josh starts out by returning to an earlier discussion of education evaluation standards and whether a multiple choice exam is the best method of evaluating knowledge.

Anyone who understands education assessment should realize that this is not any kind of reasonable suggestion. Josh does agree with this, to some extent, but then he states.

It may not be the best way, but we don’t have another way.

The only reason we don’t have another way is that so many of us have gone along with the status quo.

I will continue to point out how ridiculously inappropriate it is to use a multiple choice test to evaluate knowledge.

Being able to select the right answer (from a tiny group of choices worded to be misleading) is not the way to find out what people understand.

The way we find out what people know is by asking open-ended questions – and waiting for the answer, then asking for more information – and waiting for the answer, then asking for more information – and waiting for the answer, then asking for more information – ad infinitum.

This is not anything new.

Socrates, if he existed, was doing this thousands of years ago. This applies to medicine as much as to philosophy.

How do we learn about the ways a person will respond to a mistake he makes, if we give him a mistake we thought up, rather than waiting for him to make a mistake himself – then asking questions about how he deals with that?

This is what we deal with in real patient care – basic EMT, medic, nurse, doctor, . . . everyone who provides patient care. We are human. We make mistakes. We have to be able to deal with those mistakes.

In the real world, we do not have a multiple choice selection of responses.

We have to figure out what to do based on our understanding.

We can write complex multiple choice questions, but multiple choice tests can be passed by people who are good at taking tests. These tests discriminate in favor of those who are skilled at taking tests, which is not important in patient care settings.

Pick one answer and remember your answer. This is a test. The answer is at the end of the earlier post on this.

The topic under discussion for the rest of the show is one that will never be solved, but it depends on the patient. Some 911 patients require excellent patient care. Some interfacility patients require excellent care. They are different, but not necessarily in a way that one is better than the other.

Go listen to the podcast.


Do EMS Exams Really Gauge Provider Competency?

Does an exam evaluate competence?

Absolutely not, but we spend this week’s podcast making excuses for using exams, especially the worst exams (multiple choice exams), to do create the illusion of evaluating competence.

Jim Hoffman, Josh Knapp, Bob Sullivan, and I discuss testing on EMS Office Hours.

Do EMS Exams Really Gauge Provider Competency?

Josh is attending the EMT-CC (EMT- Critical Care) course at UMBC (University of Maryland Baltimore County), so part of the discussion is why we need to have this as an add-on

The recent article by Kelly Grayson – Occupy EMS is discussed. That article will be my topic tomorrow.

We can come up with more complex multiple choice questions, but the problem is that a multiple choice test is the wrong way to evaluate understanding.

Multiple choice is about recognizing the answer that was written with the intention of being the correct answer. Other choices are written with the intent of misleading us so that we choose one of them, because of some similarity to the correct answer.

We cannot ask the person why he chose that answer, because one of the purposes of multiple choice questions is to prevent interaction between the person being tested and the examiner(s).

It is pointed out that not everything is gray, as if this is a justification for applying a black and white guess test to medicine, which is almost never black and white.

It is suggested that since doctors will take multiple choice tests as part of medical school, multiple choice tests are valid.

Doctors also complete years of residency after completing medical school. If the multiple choice exam were enough to evaluate competence, doctors would not need to continue to be supervised and evaluated during years of residency.

If a doctor fails to complete his residency successfully, can he claim that he has passed a multiple choice test and that the residency clearly is missing the competence that he demonstrated on the multiple choice test? 😳

What about nurses? They take a multiple guess test.

Nurses generally start in med/surg and only progress out as they demonstrate the interest in doing more, but nurses will be precepted in these more acute care settings.

It is also suggested that the hospital and ambulance time during paramedic school justifies using an irrelevant test, because this has already been evaluated.

If that is the case, we need to throw out the irrelevant test.

If the test is useless, no matter how much we think it is a part of a larger theme.

If the test does not do what it is supposed to do, it is useless.

Multiple choice requires that the one (as if there could be just one) correct answer be presented as one of three, or four, or five, or mix and match guesses. The correct answer is always among the guesses presented (even if the correct answer is none of the above).

Pick one answer and remember your answer. This is a test. The answer is at the end.

Is it improbable that anyone would be able to pass one of these multiple guess tests by guessing?

The evidence is abundant in the bad EMS providers that we see passing these tests.

Ask them some questions and they will demonstrate their lack of understanding of patient care.

Do this as they leave the test.

Do this a day later.

Do this a week later.

Do this a month later.

Do this a year later.

There will be a lot of people who passed the multiple guess test, but who are not able to demonstrate understanding of the medical topics that the multiple guess test claims to be evaluating.

We all know this, so why do we pretend otherwise?

We don’t know what else to do, because we believe in the test.

Does the test prevent dangerous people from becoming paramedics?

Of course not.

Does the test work?

Of course not.

The test is purely a ceremony of passage that should be viewed exclusively as the superstitious ritual that it is.

The answer to the multiple choice question above is at the end.

How many of you knew the answer?

How many of you were able to figure it out?

We can automatically rule out Eeeny, Meeny, and Miny, because they are not relevant to EMS.

Larry and Moe are critical to good patient care, but not the best choices.

Shemp came before Curly. Shemp came after Curly. A couple of good reasons for choosing Shemp, but –

It’s always Curly.

You can never go wrong with Curly.

There is no such thing as too much Curly.

This is EMS lore and will stand up to rigorous validation.

Ask a hundred EMS educators.

It’s Curly.

Ask anyone.

It’s Curly.

However, if the patient is not a Three Stooges fan, or if the patient is a Three Stooges fan, but one of those adherents of a deviant sect that does not acknowledge the greatness of Curly, then this information may not help the patient.

Validation of EMS exams has more to do with popular opinion, than with medical evidence. The lack of a well designed, randomized, placebo-controlled trial comparing Stooges is not a fatal flaw for this test question.

The odds of guessing the correct answer are one in seven. It would be impossible for a million monkeys taking this test to come up with the correct answers by chance, at least that makes sense if we do not understand coincidence and probability.

A 14% chance of coming up with the correct answer by chance, but I would be surprised if any group scored less than 90% correct on this question.


Image credit.

If the questions do not evaluate what they are supposed to evaluate, does the test matter?

Go listen to the podcast.


Protocol Deviation and Mother-May-I Silliness

In response to the conversation David Aber and I had at the end of last week’s episode of EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, David Aber and I discuss the problems with requiring permission to deviate from protocols that cannot possibly cover every patient. I was on a call for the first 45 minutes of the show, but I do get on the show at the end.

EMS Protocol Deviation

When is the right time to talk with a doctor for protocol deviation?

Is the protocol badly written?

Before the new protocol is finalized is the best time, but not all of us can attend protocol development meetings.

Next would be after the protocol is written, contacting the medical director(s) to change the protocol.

The best time to change a bad protocol is before the call, but that is not always possible.


Protocol deviations are NOT a bad thing.

The protocols are guidelines and cannot be intended to cover all patient care situations, except in systems where the medical director is discouraging competence.

Rigid protocols are part of the the same idea that is behind on line medical command permission requirements. Both encourage incompetence and discourage competence.

I know he’s incompetent, but he can’t do anything dangerous without calling, so the patients are safe.

I used to regularly hear variations on this from a county medical director as a justification for ignoring incompetence, but requiring rigid protocols and medical command permission for almost everything.

What kind of education is required to follow rigid protocols?

Very very little.

What kind of education is required to follow on line medical command permission requirements?

Very very little.

Skills training – IV training, minimal intubation training, an ability to ignore the harm we are causing, a ruthless devotion to the protocol, and not much else.



Really. There is no requirement for an understanding of assessment.

There is no need, since that would suggest that a paramedic is capable of understanding what to assess for without calling command or without reading it out of the protocol.

If a medic understands what to assess for, who knows what kind of things the medic might do next. Assessment involves thinking and we cannot have thinking.

Image credit.

This is what our EMS education is geared toward in too many places.

Doctors are encouraging bad EMS care because they do not trust EMS.

They don’t trust EMS for a variety of reasons, but a big one is the low quality of education.

Our education is based on handing down traditional treatments and only discarding treatments reluctantly, and only when told to by someone in a position of unquestioned authority.


We don’t know and we don’t care. It isn’t going to be on the test.

How do we know what works?


What is the quickest way to scare away medics, nurses, and doctors?

Start talking about research.

This is changing as more understanding of research is required in medical school, but even medical schools are ignoring research and adopting alternative medicine.[1]

What are two things NOT supported by research?

Rigid protocols.

Medical command permission requirements.

Where is the evidence to support these dangerous practices?

But that’s the way we’ve always done it.

Put that in a translator and out comes –

But we like being incompetent. You can’t expect us to change now.

What is required to get a medic card? A multiple choice written test and a highly structured practical exam. Does this have anything to do with ability to work independently?

We cannot even take the test without first completing a paramedic course, because if we were to allow untrained people to take the test, too many would pass.

A valid test does not need to limit candidates to only those who have taken a full course. If the candidates do not know what they are doing, they cannot pass a valid test.

Well, they sat through all of paramedic school, so how dangerous can they be?

How bad can we be?

Look at how bad we are at treating tension pneumothorax.[2]

Click on the image to make it larger.

How dangerous is that?

It depends on which side of the needle you are on.

We are sticking needles in the chests of patients who do not have any reason to be harpooned.

What kind of remediation was there? None was mentioned in the study.

How bad can we be?

Look at how bad we are at intubation.[3]

How dangerous is that?

It depends on which side of the endotracheal tube you are on.

Go listen to the podcast.


[1] Evil Spirits, Shock Trauma, Anecdotes, and Gullibility
Rogue Medic
Sun, 26 Sep 2010

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

[3] In Defense of Intubation Incompetence – Part II
Rogue Medic
Sun, 21 Aug 2011