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

- Rogue Medic

Protecting Systemic Incompetence – Part I


We demand the lowest standards, because we are willfully ignorant and we do not want to understand. The surprise is that so many of us survive our devotion to incompetence. The loudest voices tend to dominate the discussions and the loudest voices demand that their excuses for incompetence be accepted. The rest of us don’t oppose incompetence enough.

A nurse was told to give 2 mg Versed (the most common brand of midazolam in the US) for sedation for a scan, intended to give 1 mg Versed, but actually gave an unknown quantity of vecuronium (Norcuron is the most common brand in the US). The patient was observed to be unresponsive and pulseless by the techs in the scan. A code was called. The family learned the details from a newspaper article, not from the hospital.

A Tennessee nurse charged with reckless homicide after a medication error killed a patient pleaded not guilty on Wednesday in a Nashville courtroom packed with other nurses who came in scrubs to show their support.[1]


The nurse intended to give a medication that should be limited to patients who are monitored (ECG and waveform capnography), because different patients will respond in different ways. This is basic drug administration and deviation from that basic competence may even have been common in this Neuro ICU (Neurological Intensive Care Unit). We demand low standards, because we do not want to understand.

We don’t need to monitor for that, because that almost never happens.

Except these easily preventable errors do happen. And we lie about it. We help to cover it up, because we demand low standards, regardless of how many patients have to suffer for the benefit of our incompetence.

This is a common argument used by doctors, nurses, paramedics, . . . . It makes no sense, but we keep demonstrating that we don’t care.

The people in charge should act responsibly, but they delegate responsibility and we reward them.

Back to the hospital, Vanderbilt University Medical Center (VUMC) is a university medical center, so the standards should be high. VUMC was founded in 1874 and is ranked as one of the best hospitals in America.

There is a drug dispensing machine, from which less-than-killed nurses can obtain almost anything and administer almost anything, without understanding enough to recognize the problem. This is an administrative problem. This was designed by someone with no understanding of risk management.

The over-ride of the selection is not the problem, because emergencies happen and it is sometimes necessary to bypass normal procedures during an emergency. Ambulances are equipped with lights, sirens, and permission to violate certain traffic rules for this reason.

Some of the many blatant problems are:

* The failure of the nurse to have any understanding of the medication supposed to be given

* The failure of the nurse to recognize that the drug being given was not the drug ordered.

* The failure of the nurse to monitor the patient being given a drug for sedation.

* Most of all, the failure of the hospital – the nurses, the doctors, the administrators, to try to make sure that at least these minimum standards are in place.

* How often do nurses in the Neuro ICU give midazolam?

* Why is a nurse, who is clearly not familiar with midazolam, giving midazolam to any patient?

* How is a nurse, working unsupervised in a Neuro ICU not familiar with midazolam?

* What kind of qualifications are required for a nurse to give sedation without supervision?

* Since this nurse was orienting another nurse, what qualifies this nurse to orient anyone?

* Given the side effects of midazolam, why was midazolam ordered without monitoring?

* Given the side effects of midazolam, was it the most appropriate sedative for use in a setting where monitoring is going to be difficult?

* Was it the more rapid onset of sedation, in order to free up the PET scan more quickly and/or avoid having to reschedule the scan, that led to the choice of midazolam?

* How well do any of the doctors understand the pharmacology of midazolam if they are giving orders for a nurse to grab a dose, take it down to the scan, give the drug, and return to the unit, abandoning the monitoring of the patient to the techs in the PET scan?

* This is not a criticism of the techs in PET scan, but are techs authorized to manage sedated patients?

* Even though they will often scan sedated patients, are the techs required to demonstrate any competence at managing sedated patients?

The nurses being oriented apparently thought that it is customary to give sedation:

1. without even looking at the name of the medication

2. without confirming by looking at the name again, it before administration

3. without double checking with a nurse, or tech, that the label matches the name of the drug to be given

How many of the doctors, responsible for the care of ICU patients, would agree to be sedated, without being monitored, and to have their care handed off to PET scan technicians?

Why didn’t the doctors and nurses see this as a problem before it made the news?

If the problems were reported, nothing appears to have been done to address the problems beyond the usual – Nothing to see here. Move along. or That’s above your pay grade.

That is the primary point I am trying to make.

The problem is well above the pay grade of the nurse.

Here is the part that experienced nurses have jumped on immediately:

Why did the nurse think that midazolam needs to be reconstituted?

Vecuronium (most common brand name is Norcuron) is a non-depolarizing neuromuscular-blocker, which comes as a poweder, that needs to be reconstituted.

Image source

1. Read label instructions?

This nurse has repeatedly demonstrated a need to be supervised, but those responsible for that supervision have apparently ignored their responsibilities in a way that far exceeds any failures by this nurse.

Is it possible that this is a one time event and that the nurse has behaved in an exemplary manner at all times while around doctors and other nurses before this day? It is possible, but the number and severity of the failures on the part of the nurse strongly suggest a pattern of not understanding, not caring, or both. I suspect that any lack of caring is due to a lack of understanding, because I have not yet lost all hope in humanity.


[1] Nurse charged in fatal drug-swap error pleads not guilty
By Travis Loller
February 20, 2019
Associated Press


Does experience matter – Part II


In spite of the evidence to the contrary and a lack of rationality in the claim, we continue to be told that increasing the number of people with a title, such as paramedic, will result in better care.

Here is more evidence that dividing the skills among more people leads to less skilled care.

The authors begin by referring to other studies that demonstrate the high failure rate of doctors performing procedures on children.

How is that relevant to EMS? We have a low frequency of use of critical skills – and that is with our adult patients. With children, our absence of experience is even more of a problem. When we do use our infrequently used skills, we often use them inappropriately.[1],[2]

Emergency physicians must be competent in the performance of critical procedures associated with pediatric resuscitation. It has traditionally been assumed that the clinical practice of pediatric emergency medicine is sufficient for the acquisition and maintenance of these skills. If the relative low acuity of the pediatric emergency medicine patient population provides inadequate opportunity, there is a risk that procedural skills will not be acquired by trainees or maintained by faculty. An accurate description of the frequency with which faculty and trainees perform critical procedures in a pediatric ED would allow for more informed discussion and targeted interventions to reduce this risk.[3]


We need similar examinations of what we do in EMS.

We hypothesized that even in a high-volume pediatric ED, the overall frequency of critical procedures would be very low and the exposure of individual providers to critical procedures negligible.[3]


Would that be any different from a busy EMS system with a lot of paramedics?

From April 1, 2009, through March 31, 2010, 3,067 evaluations were performed on medical and trauma patients in the resuscitation bays. Two hundred sixty-one critical procedures were performed during 194 evaluations, representing 6.3% of all resuscitation bay evaluations and 0.22% (2.2/1,000) of all ED patient evaluations during the study period.[3]


Click on images to make them larger.

That does not look bad.

147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions in a year.

Except – that is for the entire hospital.

When broken down by the doctor actually performing the procedure


Only 39% were able to try to perform any procedure during a year when there were 147 intubations, 9 needle chest decompressions, and 6 synchronized cardioversions.

Look at the range for all critical procedures combined –

0 to 6, with a median of 0.

The white clouds were most of the doctors. Zero critical procedures for the year.

The busiest of the black clouds[4],[5],[6] were only averaging performing one critical procedure every two months.

How much experience do paramedics get when there are a lot of paramedics available to deprive them of experience?

Do we track this and post it for all to see?

What is the level of inexperience in an EMS system that has a paramedic in every seat of every piece of apparatus?

What kind of daily, or even weekly training is required to make up for this absence of experience?

Nearly two thirds of our faculty did not perform a single critical procedure during the 12-month study period.[3]


Does experience matter – Part I


[1] 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.

[2] Low quality is identified by inability to use critical thinking
Mon, 20 Aug 2012
Rogue Medic

Click on the image to make it larger.

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.

[3] The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view.
Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS.
Ann Emerg Med. 2013 Mar;61(3):263-70. doi: 10.1016/j.annemergmed.2012.06.021. Epub 2012 Jul 27.
PMID: 22841174 [PubMed – indexed for MEDLINE]

Free Full Text from Annals of Emergency Medicine.

[4] Quantification and perception of on-call podiatric surgical resident workload.
Meyr AJ, Gonzalez O, Mayer A.
J Foot Ankle Surg. 2011 Sep-Oct;50(5):535-6. doi: 10.1053/j.jfas.2011.04.035. Epub 2011 Jun 11.
PMID: 21652228 [PubMed – indexed for MEDLINE]

The results of these data suggest that all residents shared a similar workload during the study period without a clinically significant “black cloud” or “white cloud.” However, a difference was found in the perception of which resident was a “black cloud” or “white cloud.”

[5] Black clouds. Work load, sleep, and resident reputation.
Tanz RR, Charrow J.
Am J Dis Child. 1993 May;147(5):579-84.
PMID: 8488808 [PubMed – indexed for MEDLINE]

A reputation for difficult on-call experiences was strongly associated with few hours of sleep (r = -.77; 95% confidence interval, -0.49 to -0.91), but not with actual work load measured by the number of admissions, patients, deaths, or other variables. Sleep was the major predictor of reputation (multiple R2 = .567 using multiple linear regression analysis).

Some residents did have a black cloud; they slept less, perceived that they worked harder than average, and had a reputation for having difficult on-call experiences. Residents with a black cloud function differently from their colleagues; for example, some may be inefficient, while others may create extra work for themselves. Residency program directors must recognize these functional differences to effectively evaluate and counsel house officers.

[6] Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets
(Google eBook)
Nassim Nicholas Taleb
Random House Digital, Inc.,
Oct 14, 2008
316 pages
Google Books

Believing in black clouds, or other personifications of random occurrences is being fooled by randomness. Dr. Taleb does a good job of describing these errors of judgment.

Mittiga, M., Geis, G., Kerrey, B., & Rinderknecht, A. (2013). The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View Annals of Emergency Medicine, 61 (3), 263-270 DOI: 10.1016/j.annemergmed.2012.06.021

Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183

Tanz RR, & Charrow J (1993). Black clouds. Work load, sleep, and resident reputation. American journal of diseases of children (1960), 147 (5), 579-84 PMID: 8488808

Meyr, A., Gonzalez, O., & Mayer, A. (2011). Quantification and Perception of On-call Podiatric Surgical Resident Workload The Journal of Foot and Ankle Surgery, 50 (5), 535-536 DOI: 10.1053/j.jfas.2011.04.035


Cross-Training for More Diluted Skills

Image credit.
The ultimate in cross-training and fast.

There are many people who have wanted to be firefighters and paramedics since they were little kids. We should not ask them to grow up and make a choice. We should accommodate them and use that as an excuse to skimp on service.

Does cross-training as a firefighter improve the ability to provide medical care?


Does cross-training as a paramedic improve the ability to fight fires?


Does cross-training as a police officer improve the ability to fight fires?


Does cross-training as a firefighter improve the power of the IAFF (International Association of Fire Fighters)?


Does cross-training as a firefighter decrease the municipality budget for both services?


This is about money – not about quality.

4. Our staff is dual-trained, as both firefighters and paramedics. This creates a faster response time to both fire and EMS calls.[1]


Even the editorial does not attempt to push the fiction that this does anything positive for quality of care.

Fast care, not high-quality care.

5. There will always be a paramedic in-house on duty to answer questions, take blood pressures, and be available to assist the residents of Ashburnham.[1]


Are they going to pay a paramedic just to sit in the station and take blood pressures, or is that for the inevitable times when there are second calls, or when a paramedic is fighting fires and unavailable for medical calls?


8. TIME! Full-time paramedic coverage in town can make, and has made the difference between life and death. Early ALS intervention, a faster response time, and the personal touch of familiar faces from our own town can make a huge difference in the outcome of an emergency situation, not only medically but emotionally as well. It will take the nearest private ambulance service about 12-14 minutes just to reach the center of town.[1]


Fast care, not high-quality care.

Again – there is no mention of quality.

This is the big problem with diverting training to things that are not medical.

It is extremely difficult to produce high-quality paramedics.

Coming up with non-medical tasks for paramedics does nothing to improve the quality of care – it interferes with quality.

Medical skills, assessments, and treatments are constantly increasing. Time is needed to maintain the quality of new graduates, provide them with experience, and develop expertise over their years as paramedics.

Irrelevant job duties do not contribute to excellence, they distract from excellence.

While fire departments have been using cross-training as an excuse to take over ambulance services for a while, we are beginning to see police departments take over fire departments using the same excuses.

It is no surprise that the IAFF, and others who advocate for fire departments taking over ambulance services, are suddenly opposed when their people are the ones being taken over. I do not defend the police take-overs, but I do appreciate the irony and the exposure of their hypocrisy.

We do not require nurses to be cross-trained. We do not require doctors to be cross-trained.

We consider medicine to be too important to require nurses and doctors to be cross-trained.

When will we consider prehospital medicine to be too important to require paramedics to be cross-trained?


[1] Eight reasons to have 24/7 paramedic-firefighter coverage in Ashburnham
Sentinel & Enterprise
Posted: 04/22/2013 06:31:51 AM EDT

[2] Another Police and Fire Department Merger to Improve Law Enforcement and Fire Safety
Thu, 20 Dec 2012
Rogue Medic


Powerful Union Keeps Promoting the Myth that More Medics Mean Better Patient Care



A union is trying to keep staffing levels up for their higher paid members.


This has nothing to do with the union trying to protect patients. The opposite is true. This is about the union trying to protect jobs, regardless of the harm to patients.

Though DuRee predicted that the increase in the number of units carrying paramedics would reduce medical call response time overall by about 40 seconds, critics say that two paramedics back each other up and can execute interconnected procedures at the same time, such as intubating a patient while beginning intravenous therapy, or provide care that an EMT cannot.[1]


How many medics are needed on a call?

How much paramedic care needs to be performed at once?

How much experience is lost by having that experience divided among more patients?

Click on image to make it larger.

I have highlighted some of the factors. The service with the most cardiac arrest treatment experience per medic also had the highest rates of bystander CPR, and use of therapeutic hypothermia. The rate of VF (Ventricular Fibrillation) as the initial rhythm was not different.

Even though it took 1 12 times as long for the paramedics to get to the patient (probably due to having a lower concentration of paramedics), the outcomes were dramatically different.

2 12 times as likely to be discharged alive compared to one system with much less experienced medics.

4 12 times as likely to be discharged alive compared to the other system with much less experienced medics.


Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.


What about having more medics on the scene to treat a cardiac arrest?

Does more mean better?


When adjusted for variables previously correlated with cardiac arrest survival and referenced against crews with two paramedics, patients treated by crews with three paramedics (0.83, 95% confidence interval [CI] 0.70 to 0.97, p = 0.02) and crews with four or more paramedics (0.66, 95% CI0.52 to 0.83, p < 0.01) were associated with reduced survival to hospital discharge.[3]


Too bad they did not have a crew configuration of one paramedic with one basic EMT to compare with the outcomes for two paramedics, three paramedics, and more than 3 paramedics.

How much worse do we make things by adding paramedics, who have protocols focused on treatments that do not work?

Survival from cardiac arrest has increased as we have eliminated advanced procedures.

If more medics means more ALS procedures, that is just another reason to oppose having more paramedics on scene.

Pritchard turned around a comparison that has been used to promote the deployment model, saying that patients will get the same level of service for a stubbed toe as they would for a heart attack.

“That’s an inefficient use of resources,” Pritchard said.[1]


Is that as bad as sending more paramedics to calls that do not require, especially when more paramedics probably make things worse?

Has Pritchard ever been in favor of cutting union jobs to make the use of resources more efficient?

Picture credit.

The longer this union representative delays improvements in patient care, the more power he has.

More paramedics means less experienced paramedics.


[1] Los Angeles County may delay adoption of new Long Beach paramedic model
By Eric Bradley Staff Writer
Posted: 02/16/2013 04:34:35 PM PST
Updated: 02/17/2013 01:15:28 PM PST
Long Beach Press-Telegram

[2] Cardiac Arrest Survival Rates Depend on Paramedic Experience
Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121

Free Full Text Download in PDF format from Academic Emergency Medicine.

[3] The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival.
Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB.
Prehosp Emerg Care. 2010 Jan-Mar;14(1):71-7.
PMID: 19947870 [PubMed – indexed for MEDLINE]


Another Police and Fire Department Merger to Improve Law Enforcement and Fire Safety


Residents, police and firefighters filled the Bay City Commission meeting today. Justin Engel | MLive

As with the mergers of EMS and fire departments, the goal is to provide better service to the public.

To suggest anything else is cynical and offensive.

At least that is what fire fighters tell me when discussing fire departments taking over EMS.

In this case, the fire fighters clearly do not appreciate their contribution to improving the quality of emergency services.

Flashing lights = All hazards emergency response.

Perhaps this is not what the IAFF (International Association of Fire Fighters – the main fire fighters’ union) the had in mind when they began taking over EMS agencies.

The Bay City Commission on Monday, Dec. 3, approved a measure to put 12 Bay City police officers capable of fighting fires on the streets while laying off 14 firefighters by July.[1]


True commitment to the idea of All Hazards Response!

The IAFF should be ecstatic.

The proposal to merge the police and fire departments, city leaders say, will alleviate budget shortfalls by reducing the public safety budget by $1.8 million yearly beginning in 2017.[1]


We should expect to see more cases of this as cities try to save money.

At least the city is not trying to use the ridiculous IAFF excuse of improving care by cross training people in unrelated fields.

We pour water into hypotensive patients and we pour water on a fire. There is no difference.

If you don’t want to drink the All Hazards Kool-Aid, you will just need to find somewhere else to work.

The proposal to merge the police and fire departments, city leaders say, will alleviate budget shortfalls by reducing the public safety budget by $1.8 million yearly beginning in 2017.[1]


Will the IAFF acknowledge their double standard?

Or will they just view it as a numbers game and try to convert more EMS services to a decreased focus on patient care in order to add fire suppression services?

Kevin Kline, president of the Bay City police officers union, told the commission his membership “overwhelmingly” supported the merged department.

“We’re ready to serve the city as public safety officers,” Kline said. “We’re going to continue to give a high level of police and fire protection.”[1]


This is just a case of the IAFF message being used against the IAFF.

It is difficult to get a man to understand something, when his salary depends upon his not understanding it! – Upton Sinclair

Why do some people claim that their job is so easy that anyone can do it and another job at the same time?

It isn’t as if we are facing research demonstrating too much competence among paramedics.

As the medical knowledge required to be a paramedic increases, this will become harder to ignore.

Quality does not improve by adding irrelevant requirements.


[1] Bay City will merge police, fire departments; decision follows heated exchanges
By Justin Engel | jengel1@mlive.com
on December 03, 2012 at 10:07 PM,
updated December 04, 2012 at 10:01 AM


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.


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.


Does experience matter – Part I


In response to some of what I have recently written about the problems with too many medics, people have claimed that I don’t have any evidence to support my statements.[1],[2],[3]

This will cover just one of the many studies that demonstrate that less experience is bad for patients. For those who think that having all medic crews run all 911 calls, your problem will be burnout, since only a minority of patients are likely to benefit from any ALS (Advanced Life Support) providers. I will address that lack of critical judgment separately.

This is from a paper using video to review the quality of intubation with the documentation of the quality of intubation. It is not surprising that the actual quality was not as good as what was documented.

Humans are not good at memory. We document errors with a recall bias, but we pretend that this bias does not exist.

Figure 3.First-attempt success by physician type (nsubjects per type). “Attending” is comprised of both attending physicians from Pediatric Emergency Medicine and providers from Anesthesiology. First attempt success was 88% (6 of 7 subjects) for PEM attendings and 91% (10 of 11 subjects) for providers from Anesthesiology. Two study subjects, whose first attempts were performed by a neonatology fellow and an otolaryngology resident, respectively, are not included in this figure. 95% confidence intervals for the first attempt success of each physician type are indicated by the “error” lines: Attending (67%, 97%), PICU Fellow (40%, 89%), EM Resident (30%, 75%), PEM Fellow (25%, 64%), and Pediatric Resident (23%, 50%).[4]


The doctors at the top of the graph have the most experience. Those at the bottom have the least experience. If we want to determine the odds of successful intubation, we need to look at intubation experience.

Are we supposed to believe that experience has nothing to do with the success rates appearing in the graph?

A little detail about the actual experience of these doctors shows that they have about the same amount of experience as paramedics.

In trying to explain the difference between these results and the results from other studies of physician intubation and physician pediatric intubation, Dr. Green sees the primary point as the differences in the acuity of the patients and the differences in amount of experience available in a general ED as compared with a pediatric ED.

There are notable acuity differences between a general ED and a pediatric ED, with the latter demonstrating significantly fewer resuscitations and critical care procedures.8, 9 General emergency medicine residents perform an average of 146 intubations during their training,10 rendering them substantial comfort with the procedural sequence, equipment, anatomic features, techniques for endotracheal tube placement verification, and strategies for backup management.[5]


We don’t really want an inexperienced medic managing our child’s airway, but we demand less experienced medics. The fewer skills the medics perform, the less skilled they are.

The fewer procedures the doctors perform, the less skilled they are.

Pediatric emergency physicians, on the other hand, can learn and refine their ED intubation skills only on the rare children who require the procedure, and even at high-volume children’s hospital EDs, trainees are exposed to a low number of critically ill children.11 In a 2008 survey, pediatric emergency medicine fellows reported performing a median of 3.5 intubations per year, with some reporting that they performed zero.12 In a 2008 survey of pediatric ED directors, 62% reported that their volume of intubations was insufficient to maintain ongoing competency.13 [5]


The average number of intubations per medic per year was found to be 1 per year in Pennsylvania.[6] Pennsylvania does not require dual medics (some systems do use dual medics, but many do not). Pennsylvania also does not require responder-only paramedics on non-transport trucks as a way to dilute skill frequency even more. Some places are having not just 2, but half a dozen medics show up on calls.

This almost appears to be an attempt to prevent any medic from ever becoming experienced.


Some people pretend that being in the room while a patient is being intubated is the same as intubating the patient.

This study makes it clear that this is a lie. There are plenty of inexperienced doctors in the room, but they are still inexperienced.

This low-volume dilemma can be readily illustrated with data from the current article. The authors’ ED treated 90,000 children over the 12-month study period, during which there were 145 total intubations (of which 123 were rapid sequence).1 The program has 12 pediatric emergency medicine fellows, who performed just 21 of these intubations primarily. This averages to less than 2 intubations per fellow per year! During the fellows’ 3 years of training, they would average barely 5 total primary ED intubations.[5]


More than 1/4 of patients required 3 or more intubation attempts.

Skill dilution in action.

More medics equals more dilution of skills.

It is simple math. More medics available to perform the same number of skills means less experience.

How can any fellow become expert in such a setting? If techniques and strategies for managing difficult airways are not used frequently enough, they cannot be retained and effectively applied.[5]


Training and practice in difficult airway algorithms and rescue devices should be routine.[5]


Even if we do not have a medic in every seat, we should be regularly practicing airway management.

Before each shift, intubate Fred the Head 5 times in a row in less than 30 seconds each.

Before every shift.

That is silly of me. That is really only something that serious medics should do, not people who think that quantity is more important than quality.

When an airway must be secured, one must already know how to act, do it without hesitation, and have a well-thought-out backup plan should that first attempt fail. Action must be instinctive and reflexive but not mindless.[5]


Every week, we can practice a scenario of managing difficult airways.

Is this really too difficult?

Does a the tube automatically go in when enough paramedics are in the room?

Of course not.

Regardless, it suggests that a culture of command over airway management may not develop in locations with insufficient intubation volume.[5]


If we do not get enough tubes, we probably are not good at intubation.

The more medics the tubes are divided among, the worse we will be at intubation.


[1] Allentown EMS will remain an all-paramedic squad
Rogue Medic
Sun, 19 Aug 2012

[2] I ignore it when NJ calls me a Semi-Medic, but it hurts when you point it out
Rogue Medic
Fri, 10 Aug 2012

[3] Long Beach Fire Department considers single paramedic response system
Rogue Medic
Thu, 09 Aug 2012

[4] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.

[5] A is for airway: a pediatric emergency department challenge.
Green SM.
Ann Emerg Med. 2012 Sep;60(3):261-3. Epub 2012 Apr 19. No abstract available.
PMID: 22520991 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

[6] Procedural experience with out-of-hospital endotracheal intubation.
Wang HE, Kupas DF, Hostler D, Cooney R, Yealy DM, Lave JR.
Crit Care Med. 2005 Aug;33(8):1718-21.
PMID: 16096447 [PubMed – indexed for MEDLINE]

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653

Green SM (2012). A is for airway: a pediatric emergency department challenge. Annals of emergency medicine, 60 (3), 261-3 PMID: 22520991