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

- Rogue Medic

Is EMS a Trade or a Profession?


In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.[1]

trade vs profession 1

In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.[1]


Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.[1]


The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?


[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)


Should Merit Badge Organizations Define Standards of Care?


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

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

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

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

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

For example –

AHA guidelines.

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

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

NREMT guidelines.

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

Objectivity does not mean competence.

Subjectivity does not mean corruption.

We need to be smart enough to assess competence.

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

ACS – PHTLS guidelines.

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

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

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

The evidence shows that this hypothesis is at best misguided.

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

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

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

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

When will we find time?

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

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

The same for medical and trauma megacodes.

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

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

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

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


[1] Nothing

No evidence of improved survival with a thinking brain.

[2] Nothing

No evidence of improved survival with a thinking brain.

[3] Nothing

No evidence of competence at assessment of competence.

[4] Nothing

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

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

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


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


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

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

Free Full Text from Academic Emergency Medicine.

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


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

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

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


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

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

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


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

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


Skills Monkey or Skilled Medic?

What is a skills monkey?

A skills monkey is someone who has been trained to perform skills well enough to pass a simple choreographed test of that skill.

Medical skills monkeys are not limited to paramedics or EMT basics. Doctors, nurses, PAs (Physician Assistants), NPs (Nurse Practitioners), et cetera can all be skills monkeys.

What is most important in the use of medical skills is not the ability to do what we practiced on a mannequin, but the understanding to know when to treat the patient with that skill and when not to treat the patient.

Because it is the Standard Of Care! is not a competent reason to harm a patient with a skill. Every skill can harm patients.

Why are we using a particular treatment?

What are the possible benefits?

What are the possible adverse effects?

If we do not know of many more possible adverse effects of a treatment (than possible benefits), we probably do not know enough about the treatment to use the treatment safely.

How will we possibly know what to expect?

How will we know what to watch out for?

How will we know when to stop, when to increase, when to repeat, or when we have good evidence that what we were treating the patient for is not what is making the patient sick?

A skills monkey does not understand anything more than –

Α. Select a protocol.

Ω. Follow the protocol to the letter.

Skills monkeys tend to be literalists. Literalists generally cannot comprehend abstract thought and should probably not be allowed to make decisions. Skills monkeys tend to be only aping what they have seen others do. Their reasoning is – That’s what the protocol says to do.

Here are some examples from the skills monkey playbook –

Crackles = Lasix, even if the crackles are from pneumonia.

Fall = backboard, collar, and straps, even if the patient has contraindications to this treatment.

Pain management = transport to the hospital so that someone who has a clue can take care of this scary treatment.

It is better to do nothing than to do something that might be wrong.

If that is what we believe, we should not be making any decisions that affect patients. We can teach that kind of thinking in grade school.

You were expecting a monkey? This kind of thinking does not require the higher thinking skills of a primate.

Everything has the possibility of causing harm.

If we cannot handle that, we should not be permitted to hide behind protocols, or medical command permission requirements, or Standards Of Care.


Gaming the National Registry Exam – Part III

mpatk wrote the following in response to Gaming the National Registry Exam – Part II

At the risk of butting into a private argument…

Private? On the internet? Are you trying to turn my smiley face into a giggle face?


Obviously you don’t need to have a “smiling face” on your blog posts; a dose of harsh reality is necessary sometimes. However, there is a line between being brutally honest and being deliberately ( and maybe gratuitously) insulting.

Chy obviously thinks you crossed it here.

Charles Grodin had a particular dislike for people like Chy. He was at a dinner party and one of the hoi polloi looked at him and said, It Would Be So Nice If You Weren’t Here. They seem to feel that they can say anything they want, as long as they give it the appearance of being polite, but don’t suggest that they are less than perfect.

Should we defend a lottery system that helps to authorize clueless people to use dangerous treatments on defenseless patients? The testing system is supposed to be an important part of protecting patients. The idea of using a lottery to assess competence is absurd.

The smart EMS agencies insist on months of internship before allowing medics to work without restrictions. They know that the test does not work.

Am I supposed to be polite to people who are only fooling us with the appearance of screening out the incompetent, but are defending this dangerous system?

I could have a nice job as a supervisor, or manager, somewhere if I were to play nice and keep my mouth shut about the obvious idiocy that we see on a regular basis. I do not regret that, because I would hate myself for not telling the truth.

How much silence over how much harmful treatment, is necessary to go along to get along in EMS?

It is unfortunate that you intubated the patient’s esophagus, but you did a nice job of taping the tube in place and and you were getting every bit of oxygen out of that bag.

Two positives for each negative.

I am more interested in how I am going to break the news to the family of the executed patient. I will definitely use the word dead and I will repeat it, so that the family understands dead. No amount of sugar coating is not going to change the outcome and bring their child back.

The disgustingly civil people will be the ones demanding that we fire the medic who put the tube in the esophagus, because they are all about appearances, and the presence of that person invites scrutiny – as it should. Scrutiny is important.

They do not want scrutiny. They want to create the fraudulent appearance of perfection.


It will never happen again.


We fired the person who showed us that there is a problem.


No. We need to try to remediate the medic and to try to learn what contributed to the mistake, because systemic flaws are a large part of these errors. The people who claim that we should put all of the blame on the medic are accomplices in the killing of patients. They are helping to cover up the problems. They are worse than the medic who intubated the esophagus, because they guarantee that it will happen again.

We need to examine our mistakes, so that we learn from our mistakes, so that we make fewer mistakes.

Sometimes, I am impolite to someone who does not deserve it. When that is the case, I do apologize.

On the other hand, this is EMS. It is time for people to pull up their big girl panties and worry about what is important – our patients and the people who take care of them – not some people creating a test that does not do what they claim it can do. Not some concern troll.

Why doesn’t EMS get respect?

Because we listen to people like that.

Because we are more worried about appearances, than about reality.

Our problem is not that we are not polite enough.


Our problem is –


We have too many clueless people


AND we are comfortable with that.


We are not just comfortable with this cluelessness, but we defend the system that creates this dangerous problem.

No. The problem is definitely not just the lottery test.

If we want to make things better for our patients, we must stop worrying about appearances.

Too Old To Work, Too Young To Retire has a post on a similar topic – It’s Not The Crime, It’s The Cover Up.


Gaming the National Registry Exam – Part II

In the comments to Gaming the National Registry Exam – Part I, Chy Miller writes –

Certification and/or licensure (doctor, nurse, medic, etc.) testing never has validity in the viewfinder of those successful but is the cornerstone of public trust and the essential gate keeper of those who don’t possess your abilities. Change the public’s need for “something” that communicates trust as well as the lack of ability in people and you’ll change the need for “dogma deficiency detectors” forever.

I have no interest in changing the opinion of the public. I am interested in changing the opinion of the people who work in EMS and in emergency medicine – people who should know better.

Working on public opinion is just the tail trying to wag the dog.

Good luck! If that doesn’t work out for you, maybe you could build a new and improved NR model.

I would tear it down and start anew.


Assess understanding.


This is not easy or cheap, but it is much better than the NR lottery.

The problem is that we are too interested in avoiding the appearance of any possibility of an evaluator being in a position to make a subjective decision. This is ridiculous.

Discrimination is what they are supposed to do – based on the understanding of the candidate, not based on gender, race, religion, or anything else that is not related to the understanding of patient care.

We need instructors who understand the material they are supposedly teaching. If the instructors truly understand the material and they understand how to assess for understanding among the students, then what is required is to evaluate that understanding.

“Don’t be a cynic and disconsolate preacher. Don’t bewail and moan. Omit the negative propositions. Challenge us with incessant affirmatives. Don’t waste yourself in rejection, or bark against the bad, but chant the beauty of the good.” – Ralph Waldo Emerson

Don’t be a cynic like the people who claim that our instructors cannot be trusted to evaluate understanding?

Don’t be a cynic like the people who feel that the instructors should be hired, even though they believe that the instructors are not trustworthy?

Don’t be a cynic like the people who complain that our patients require the cheapest preparation possible?

Don’t be a cynic like the people who complain that evaluating understanding is just too expensive?

I have never been really good at going along to get along.

All that is necessary for the triumph of evil is that good men do nothing.[1]

If I do nothing, I do nothing to stop the use of this failed model for screening out the incompetent. I do not think that Ralph Waldo Emerson would encourage me to remain silent.

For example, in a speech at Harvard University, Ralph Waldo Emerson had this to say –

If the colleges were better, if they had any monopoly of it, nay, if they really had it, had the power of imparting valuable thought, creative principles, truths which become powers, thoughts which become talents, — if they could cause that a mind not profound should become profound, — we should all rush to their gates: instead of contriving inducements to draw students, you would need to set police at the gates to keep order in the in-rushing multitude.[2]

Hardly chanting the beauty of the good to his alma mater.

He continued with –

On the contrary, every generosity of thought is suspect and gets a bad name. And all the youth come out decrepit citizens; not a prophet, not a poet, not a daimon, but is gagged and stifled or driven away. All that is sought in the instruction is drill; tutors, not inspirers.[2]

Emerson was not averse to criticizing those he felt were not educating well.

Would Emerson be as critical of what I write?

Speak what you think now in hard words, and to-morrow speak what to-morrow thinks in hard words again, though it contradict every thing you said to-day.[3]

Emerson might notice that what I write is far from cynical. I notice that the comment did not include any claim that what I wrote is inaccurate, only that I did not put a smiling face on the first part of a multi-part article. On other subjects, I do Challenge us with incessant affirmatives. I avoid the hobgoblin of the incessant.

— `Ah, so you shall be sure to be misunderstood.’ —[3]

Then perhaps I should strengthen my criticism.

No, if I have nothing nice to say, I should remain silent./

Qui tacet consentire videtur[4]

I would not recommend baiting one’s breath, awaiting my silence.

If we cannot trust our instructors to competently assess understanding, then we need better instructors.

We definitely need better people to hire our instructors. If those doing the hiring think the instructors are inadequate, why are these bureaucrats hiring them to instruct?

Are those hiring the inadequate instructors the same bureaucrats enshrining our lethal treatments as Standards Of Care? Is this something that should not be addressed harshly?

I do not give consent.


[1] Edmund Burke
Quote page


All that is necessary for the triumph of evil is that good men do nothing.

This is probably the most quoted statement attributed to Burke, and an extraordinary number of variants of it exist, but all without any definite original source. These very extensively used remarks may be based on a paraphrase of some of Burke’s ideas, but he is not known to have ever declared them in so succinct a manner in any of his writings. They may have been adapted from these lines of Burke’s in his Thoughts on the Cause of Present Discontents (1770): “When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle.”

This purported quote bears a resemblance to the narrated theme of Sergei Bondarchuk‘s Soviet film adaptation of Leo Tolstoy‘s book “War and Peace”, in which the narrator declares “All that is necessary for evil to triumph is for good men to do nothing”, although since the original is in Russian various translations to English are possible.
More research done on this matter is available at these two links: Burkequote & Burkequote2 — as the information at these links indicate, there are many variants of this statement, probably because there is no clearly definitive original by Burke.

[2] The Celebration of Intellect
Ralph Waldo Emerson
Harvard University

[3] Self-Reliance
Ralph Waldo Emerson

[4] The Horror of Qui Tacet Consentire Videtur
Posted on October 2, 2008
by David W. Boles


Gaming the National Registry Exam – Part I

We generally have to take an exam created by the NR (National Registry of EMTs), or a similar test, in order to work in EMS at the EMT-Basic or EMT-Paramedic level. A lot of us worry about taking the test and wonder what we can do to prepare.

First – recognize that the exam is just a game.

Perhaps you think that the NR exam is not a game.

What is a game?

Playing a game is the voluntary attempt to overcome unnecessary obstacles.Bernard Suits.

Is there a better definition of what a game is? Feel free to provide a different definition of a game, but I will work with this definition.

Is the NR test voluntary?


Nobody has to work in EMS. The NR test is just what comes between us and the goal of working in EMS.

Are the obstacles (test questions and test stations) necessary?

Absolutely not. There are many ways of assessing understanding, and this methodology is not even good at assessing understanding. What this is best at assessing is the gaming ability of those being tested.

Is it necessary to ask about oxygen in half a dozen different ways, just to be able to confirm that the gamer has not escaped the oxygen is good – and more is better dogma?

This may be necessary to confirm adherence to the dogma, but it is not at all necessary to assess competence at patient care. Since dogmatic poisoning with oxygen harms patients, this is not only unnecessary, but it is counterproductive.

Understanding of what is good for the patient will probably interfere with an excellent score, but this is not about evaluating how well people provide patient care.

Hey, it’s better than nothing.

Why does anyone assume that the only other choice is nothing? Why would anyone think that the options do not fall into the category of something? But they do not think clearly, which is a big problem. Why are we going to people, who do not think clearly, for a way to assess the understanding of beginner EMS personnel?

Is the NR exam better than nothing?

Please provide some evidence that patients do better because of the dogma deficiency detector that is sold by the NR.


Failure Is an Option – Part II

Continuing what I wrote in Part I about the talk on education at TED Talks. Diana Laufenberg: How to learn? From mistakes. It is a 10 minute video, but the relevant part part I am interested in comes between the 6 minute and 7 minute points.

You have to be comfortable with this idea of allowing kids to fail as part of the learning process.

Don’t even suggest that EMS students should not be referred to as kids. The kids she is referring to are 11th grade students, old enough to fight and die for their country (although not old enough to buy alcohol), and not much younger than the typical EMS student.

Let’s look at some examples of our failures.

During transport, how many of us sit on the captain’s chair behind the patient, where we cannot see the patient?

How do we continue to assess our patient from there?

How do we recognize when something has changed?

Do we assume that nothing will change?

When we arrive at the hospital, how many of us disconnect the monitor/defibrillator and leave it in the ambulance?

Does a monitor/defibrillator only work in the ambulance?

Do we not bring the monitor/defibrillator in to the call for syncope patients, chest pain patients, or other ALS patients?

Do patients never have rhythm changes between the inside of the ambulance and the hospital bed?

How would we know if there is a rhythm change?

How would we shock V Fib without a monitor/defibrillator and without an AED?

If we do not need the monitor, then why did we attach the monitor to the patient at any point?

If we look at the patient’s rhythm, now, and see a sinus rhythm, what does that tell us about the rhythm before we looked at the rhythm?

When we leave the monitor in the ambulance, we are paramedics operating at a less than First Responder level.

This appears to be a form of patient abandonment.

We do not have to leave the patient to abandon our ability to care for our the patient.

We are called because something has gone wrong. Do we show up and choose a protocol and then never think about anything again?

This is failure.

We need to learn from these failures.

We need to learn to not defend failures.

We need to learn not to continually repeat failures.

We need to abandon the status quo and think about what is best for our patients.

If we just punish people for these behaviors, rather than educate them about why these behaviors are not good patient care, we can direct the Clipboard Nazis QA/QI/CYA people toward other things.

To be continued in Failure Is an Option – Part III.


Failure Is an Option – Part I

There is a great talk on education at TED Talks. Diana Laufenberg: How to learn? From mistakes. It is a 10 minute video, but the relevant part part I am interested in comes between the 6 minute and 7 minute points.

What do you do when the information is all around you?

We need to teach people to be able to figure out what is accurate, what is partially accurate, and what is completely wrong.

Here’s the thing you need to get comfortable with when you’ve given the tool to acquire information to students. You have to be comfortable with this idea of allowing kids to fail as part of the learning process.

Not just as a part of the educational process, but as a part of the QA/QI/CYA/medical oversight process.

EMS is medicine.

In medicine, mistakes are made frequently.

We can work to minimize the frequency of medical errors.

We can work to minimize the frequency of serious medical errors.

We will not eliminate medical errors by punishing people for errors.

We only end up with a much bigger, much more dangerous error.

We end up with the protocol monkey – the cluelessly fumbling protocol monkey, who is just trying to avoid doing something that will result in punishment.

What we want is someone providing patient care with the understanding that the patient is a real human being, deserving of care. This person delivering care needs to be capable of assessing patients who do not present as the protocol writers would like them too. Someone capable of deviating significantly from what is prescribed by an inflexible protocol.

Trying to fit all human beings patients into rigid protocols is a fool’s errand.

Giving a box of drugs to someone, who is incapable of assessing patients and adjusting treatments appropriately, is reckless and irresponsible.

Errors are a part of medicine.

EMS is medicine.

We will not improve EMS/medicine by punishing errors.

We need to learn how to learn from errors.

We need to teach students how to learn from errors.

We need to teach EMTs and paramedics how to learn from errors.

To be continued in Failure Is an Option – Part II and later continued in Failure Is an Option – Part III.