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

- Rogue Medic

National Registry of EMTs – Is it really that bad?

In the comments to Zero Tolerance III – Star of Life Law second comment, was a comment by Greg Friese,

Rogue medic, eliminating the NREMT (NR, or National Registry of EMTs) is a bold and radical suggestion. How can we assure some minimal knowledge and competency across all providers in all areas?

The way you write that, one might think that the NR had some way to assure some minimal knowledge and competency across all providers in all areas. The NR does not assure any level of competence. The NR claims to, but the NR fails.

Wouldn’t it be nice, if they did assure some level of competence? Wouldn’t it be even better, if it were actually a useful level of competence?

JCAHO (TJC, The Joint Commission, or the Joint Commission for Accrediting Healthcare Organizations) is just as dangerous to patients in the hospital. They are both about enforcing checklists rather than improving patient care. There are good uses of checklists. CRM (Crew Resource Management training) is something we need. CRM does not seem to be encouraged by JCAHO or NR, but JCAHO and NR love their irrelevant check off sheets.

If your instructors know enough to teach EMS well, they should know enough to evaluate the knowledge of candidates for a license/certification. The NR has become so focused on the avoidance of the appearance of discrimination, that they have made even the appearance of the actual evaluation of competence secondary to the avoidance of discrimination. The NR seems to be headed toward the complete automation of their testing system.

If your instructors do not know enough to assess the the knowledge of medic candidates, the NR check off sheets do not make up for that deficiency.

The NR focus is on several prepared scenarios and a bunch of stations. stations with scripts. Scripts just to avoid any appearance of variation. Do your patients present this way? Mine sure don’t.

NR Medic – I’m calling to notify that we will be arriving with a number 5 in seven minutes. No, wait. Make that a number 7 in five minutes.

Incomprehensible doctor noises on the other end of the line.

Yes. I gave him the drug in the spray bottle. No. I’m too busy filling out check off boxes to look at the patient.

More doctor noises, but noticeably cranky.

You’re the doctor. You figure out what’s wrong with him.

Really high pitched doctor noises, like nails on a blackboard.

Well, he’d better still be alive. He hasn’t signed the billing sheet, yet.

Having a limited number of medical conditions to deal with is great. These order off the menu numbers make patient care so much easier. We don’t have to mess around with any of that thinking stuff. Thinking makes my head hurt. Some of those numbers can be kind of difficult to tell apart.

Ooops. gotta go. There’s a number 3 five blocks from here. Or is that a number 5 three blocks from here. Whatever! We just give them medicine off the menu. It isn’t as if there are real differences – yellow box, silver box, blue box. What difference does a color make?

I am so glad I don’t get paid to think. Being indiscriminate is the best part of the job. Well, that’s out motto, but I don’t know what it means.

This is all about preventing the possibility of having a human make a decision. How can you create a system to evaluate human decision making, but act as if human decision making is the enemy? You can’t, but that is the goal of the NR. Will they ever recognize the futility of this behavior? Who cares? They are making money off of it. That is what matters.

Teaching students to be good medics will almost always make them highly likely to pass the exam.

I agree. A good medic should pass the exam, but I have failed an excellent medic for a simple oversight, just because I was not allowed to ask what he meant. The NR rules are more important than the outcome.

The more important question is, does the NR test weed out the dangerous medics?

Absolutely not.

True, some dangerous prospective medics will fail, but passing does not correlate with competence. What independent evidence do we have that passing this test is something that correlates with the ability to work with minimal supervision and full standing orders.

Why full standing orders?

Because anything less is an indication of incompetence. If the medics are not capable of working without that mother-may-I phone call, they are not competent. Go to the best systems in the country. You will find that they have the fewest requirements to call for permission.

If OLMC (On Line Medical Command) permission requirements were correlated with quality, you would find exactly the opposite. OLMC requirements encourage incompetence – not in the medics, but in the medical director. The medical director has OLMC requirements, because of a lack of understanding of EMS oversight. The lack of understanding of EMS oversight leads to dangerous medics – unless the medics are motivated to police themselves. Of course, this attempt at responsibility by the medics can be discouraged by the medical director or management.

Teaching students how to be good test takers will increase the odds of them passing significantly.

Yes, but what does that have to do with competence?

You are starting by assuming that the NR test actually has something to do with competence. It does not. Then you are claiming that you have to teach the student how to take the test.

The result is that too much time is spent on training the medic students how to take the medic test, rather than training the medic students how to be medics. In other words, how to use critical judgment.

What are the most important skills that a medic should have?

1. Assessment.

If you do not know how to assess patients, how do you know what to treat? How do you know what protocol to apply?

2. Critical judgment.

Critical judgment helps in knowing where to go with an assessment. You won’t assess every patient the same way, but you do need to know what questions to ask and what places to look.

Having initially assessed the patient, you need to be able to decide what to do with the information you have obtained. NR does nothing to evaluate critical judgment.

But what about the critical/not critical decision in the patient assessment station?

Trust me, the patient is critical. I don’t even need to be there to know that. Or have they changed something?

NR encourages the cookbook approach to EMS, by their devotion to check off evaluations, rather than an interactive assessment of ability. If medic evaluators cannot be trusted to use judgment in assessing medic candidates, then they should not be trusted to treat patients.

NR behaves as if the use of medic judgment is the worst thing that could ever happen. This is the antithesis of good EMS. Any system that takes this approach should limit itself to BLS (Basic Life Support). There is no reason to have a Procrustean EMS system.

Procrustes is from Greek myth. He had an iron bed into which he required every passerby to lie down. If the traveler was too tall, he would cut the legs down to fit the bed. If they were too short, he would stretch them on the rack until they fit the bed. Similarly, we end up harming the patients to make their assessments fit the protocols we have. Rigid protocols are not good for patients.

Instructors can do both things without teaching to the test.

There are people who need assistance with test taking skills, but why divert the whole class from paramedic education to teach basic test taking methods? Because the ritual is more important than the result.

One example of this ritual over result fascination is the intubation station. If you do not state that you see the vocal cords, do you pass intubation? It does not matter if you can place the tube in the mannequin better than the instructor, you do not pass unless you chant the chant.

What if you don’t see the tube go through the cords?

That does not matter. That is not one of the check off boxes. You really shouldn’t bring reality into this.

What about the written test?

How does asking trick questions with just a single best answer have anything to do with good EMS? How many patient care situations have just a single best answer? Almost none. Those that do are not the ones being asked on the multiple guess exam.

This multiple choice, trick question, setting requires a bunch of test preparation. This is poor testing, so we have to spend time making up for the horrible test design. I know they have a bunch of people with all sorts of classroom degrees to validate these farcical tests, but that does not seem to help them to screen out dangerous medics. They validated their test. Why doesn’t this validated test weed out the ones who do not understand?

Whenever I hear validated, I think of Inigo Montoya saying, You keep using that word. I do not think it means what you think it means. How do we end up with so many EMS invalids with such a well validated exam?

We will be talking with a NREMT rep on an upcoming episode of http://www.emseducast.com. We are working on using ustream.com to allow live listening and chatting.

I like the idea of the NR.

The execution leaves a lot to be desired. Sometimes I think that execution of those in the NR might be the solution. Just one, or two, ought to do the trick. How slow to catch on can they be?

EMS is not a computer simulation. Their validated Ivory Tower models do not apply. The ambulances are not all little boxes made of ticky tacky.

The patients are not little boxes. The patients are what EMS is all about – not the little boxes on the multiple choice test or the evaluation sheets.

As I stated, I like the idea of the NR. The problem is that the idea and reality are miles apart.

Having the ability to move, almost as if we were professionals, is a good idea. I have been a medic in several states. Getting reciprocity for each move was different. NR could assist those of us who do not manage to stay in one place. NR can have a lot of input on the way EMS is run.

NR could also facilitate reciprocity for out of state paramedic disaster assistance. The way it is now, paramedics are not really more useful than basic EMTs, once they have crossed a political boundary. Unless the receiving state has the capability to grant emergency authorization to medics in disaster situations. Many states do not have this ability. Reciprocity might take months, which is OK if the disaster is nice and patient. Even FEMA can get its act together faster than that.

From what I see, NR has a big effect on the way things are run. People look for a quick and cheap way to hand a medic card to people, but to avoid responsibility for giving medic cards to people who aren’t even good basic EMTs. NR provides that excuse.

The idiot passed NR. How bad can he be?

Sometimes the answer is very bad.

Why should a paramedic test be quick or easy or cheap?

We end up with a similar approach to medical oversight. Quick and easy and cheap.

Why should we be paying discount rates for medical directors? We have medical directors who authorize medics to treat patients, but never meet the medic. I have worked for some of them. This is the NR approach applied to medical direction.

EMS should be limited to BLS, except where there is a well compensated, well educated, aggressive medical director. A medical director who understands EMS. A medical director with appropriate support personnel depending on the size of the organization.

Medical directors who practice absentee medical direction should be locked up. There is no reason to allow patients to be subjected to that kind of abuse. BLS is safer than bad ALS (Advanced Life Support).

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How We Mess Up New Medics

In response to Bad Oversight – Part I, Mystery Medic wrote some interesting comments. These comments address a lot of the problems of EMS. My responses are in between his comments.

I love to throw in 2 cent when I can.

Nothing wrong with that. That is what we do. With my blog, I have probably exceeded my 2 cent quota.

1. Who says you always have to get to C in the ABC’s. If the A caused the C and you can’t correct A then who cares if you shock C.

It has been pretty clearly established that, in the case of cardiac arrest, unless you suspect airway obstruction as the cause, you start with C. It is one of the very few times that we change the order. Blood spurting from an artery is another reason to start with C. I can add oxygen, after the bleeding is controlled. I cannot add blood, after the airway is opened.

In this case, there was nothing about the patient to suggest that airway needed to be addressed first. After the tube was in, he still did not defibrillate. If the airway were obstructed, and could not be cleared, you would never move beyond A. In that case, you would be correct. Since he did get the tube/airway, that does not seem to apply, here.

2. No student that I know has ever graduated medic school with a grade of 100% at graduation.

Some do, but medic school is a different world from working as a real medic.

How many medics miss no questions on the written NREMT paramedic test?

I think that the NREMT-P test is one of the causes of incompetence in EMS. It is irrelevant to what a paramedic does. The main purpose of the NR seems to be to create the appearance of assessing students, but they avoid the substance.

I’m sure none. So if you graduated with a 92% like I did (I was number two)in my class that was 8% of my textbook that I didn’t learn. There are students that graduate with 80% so that’s 20% of the education they missed.

Remember, the written test has nothing to do with your knowledge of patient care. It is an assessment of your ability to answer often unrealistic multiple choice questions, in a classroom. A much better assessment of knowledge would be to have a version of oral boards. You are required to prove that you understand the material. Of course, that requires having knowledgeable people to ask the right questions and assess the answers correctly. People smart enough to shut up and listen to what the medic student is actually saying, and not read a bunch of what they expect into what the medic student is saying. NR would never accept that – there is the possibility of discrimination. Which clearly demonstrates their incompetence in assessment of ability. They are more worried about discrimination in testing, than about the quality of the medics they allow to treat patients. I have written about NR here and here.

Is that the teachers fault?

In the NR world of No Medic Left Behind, they might agree with you. Their answer might be that you cannot reach 100% for everybody. Their answer might be that you can only do so much. Their answers, while true, truly fail. The NR is all about teach to the test, but not teach the material so the students understand.

So when do you learn the rest? You get your certification, go to work, and hopefully your employeer will make up the remaining difference with a good mentor program and con-ed.

I believe that what makes the difference between a medic and a basic EMT is not any of the skills, but the ability to make the difficult decisions. Should I treat the patient now, and with this treatment, or should I wait. Continuing to assess is often a better choice, but we do not seem to place much value on not doing something. Better to do something – Better to appear to be in control – than to do what appears to be nothing.

Assessment is the one most important skill in EMS, but if you are not providing a treatment, you are seen as not doing anything. You are seen as not helping.

Assessment is a treatment.

Without assessment, all of the other skills are useless. If, for an imaginary example, I am able to intubate 100% of the patients on the first attempt and in less than 15 seconds. In this imaginary example, I am an airway tubing god. Yet, if I do not make good decisions about when to intubate patients, I will be making things worse for some patients. I will end up killing some patients. It is important to be able to intubate well, but it is much more important to be able to assess the need for intubation. Since things change, I need to be continually assessing the need for intubation. I need to be continually assessing for changes in the airway and breathing.

I need to be assessing the appropriateness of the patient’s airway. I need to be considering a bunch of other factors. Should I spend time, here, to intubate? Should I move the patient to the hallway, the ambulance, or the hospital for intubation? I am not an airway god. Nobody gets every tube, at least not if they have been around a while. Sometimes recognizing that the patient has an unstable airway, maintaining it the best that you can, and transporting to a more stable environment, is the right thing to do. Sometimes avoiding intubation, entirely, is the right thing to do. Sometimes RSI of a patient with a well controlled airway, is the right thing to do, because things change.

His system failed him and tossed him under the bus.

That does seem to be the EMS way. We eat our young. EMS isn’t really about the patients. It’s about the cuisine.

I also have a wee rant about assessment here.

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TOTWTYTR vs. Indoctrination in Iatrogenesis

Too Old To Work, Too Young to Retire has an excellent post about, well his title gives it away.

The One where he Rants about EMS Education

TOTWTYTR is right on target with this latest post. Mandatory reading for everyone involved in EMS.

In paramedic school, which is ALS (Advanced Life Support), the approach to airway management seems to be that medics will intubate the patient, so they do not need to be good at the BLS (Basic Life Support) aspects of airway management. The result is medics who do not understand the most essential part of airway management. There is nothing more important than competence in BLS airway management. Assessment is critical to competent BLS airway management, but there are plenty of medics who do not recognize esophageal tubes. Do they understand airway? Even a little bit? No.

Where is the assessment? Playing peek-a-boo with the life of the patient. Now it’s here! Now it’s not!

There should not be ALS without excellence in BLS. Teaching ALS without confirming and reinforcing excellence in BLS is bad instruction.

The medical directors for these schools should not allow this. The instructors should not, either. Nor should the students allow this.

Of course as you move from sentence to sentence, in the previous paragraph, the order of responsibility is dramatically decreasing. We should not expect the students to take responsibility for the curriculum. A bunch of people think that the medical director, the one who says that idiocy is permitted or that idiocy is not permitted, should not be held accountable for the results of his actions.

We allow medical directors to set up a system that proclaims:

Idiocy, Incompetence, and Iatrogenesis are permitted here.

Why?

If you look at what happens when these students have graduated and are developing as medics, the next big influence on the way they treat people is, surprise, surprise, the EMS medical director.

I believe that the difference between the ALS services that have excellent quality and the rest . . . .

What do you mean the rest?

There is no bronze medal in medical care, unless you believe in the government quality indicator rankings.

There are places that uniformly provide excellent care.

Excellent.

After excellent it is just a matter of naming the abuses the patient may suffer.

Statistically, many of these patients will arrive at the hospital unharmed, but there will be plenty who do not escape harm. So, what method of medical misadventure will they come up with this time?

I believe that the difference between the ALS services that have excellent quality and the rest lies in the involvement of the medical director.

An absentee medical director means that on a regular basis these are some of the medical misadventure menagerie that the medics will be inflicting on patients:

  • Unrecognized esophageal tubes,
  • Furosemide (Lasix) for pneumonia,
  • Delayed transport for IVs,
  • Patients treated according to the dispatch information instead of their actual medical condition,
  • Poor pain management,
  • Et cetera.
Absentee = Not being there.

  • Performing chart review is the same thing as not being there, because you aren’t.
  • OLMC (On Line Medical Command) requirements are the same as not being there, because you aren’t.
  • Having monthly/quarterly/yearly continuing education is the same as not being there, because you aren’t.
  • Telemetry (transmitting ECGs to be read by the doctor) is the same thing as not being there, because you aren’t.
  • Et cetera.
Being there to take report from medics at the hospital, showing up on calls, following up (with the patient and with hospital staff) on all unstable patients, . . . . are part of being there.

Do you know your medics?

Investing in some smart technology is a good thing (waveform capnography) when it is part of improving the abilities of the medics. Investing in telemetry is just a waste of money, an admission that you are trying to keep it stupid, and that you don’t know how to run ALS. Spending money on technology instead of a medical director, who WILL be there, is a waste of money.

Idiocy, Incompetence, and Iatrogenesis are permitted here.

Would you want this inscription on your certificate/diploma/degree?

Would you want this inscription on the side of your ambulance?

Would you want this inscription on your EMS patch?

The NR (National Registry of EMTs) should come up with a nice round patch EMT-P-III?

This is not the New York level of EMT-III (intermediate). It is quite a bit different.

Iatrogenesis = inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician.

Being There, the book or movie, is not the same as a medical director being there.

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Dispatch would have told us if it were something serious.

The 911 crew walk to the house with just a little “first in” bag.

Why?

It’s just a syncope call.

No monitor. No thinking. No understanding of patient care. No anticipation of what might be needed.

Why?

Because that is the way things are done in that area.

Tradition.

Certainly Deborah Peel can wait until they go back to the ambulance, get the stretcher, bring the stretcher to Deborah Peel. They were expecting Deborah Peel to walk. He’s not known for being that cooperative. Then they wheel Deborah Peel out to the ambulance, where the heart monitor is waiting, as yet unused.

Now that they are in the ambulance, the assessment and treatment can begin.

This is not much different from the medical command approach of “Just transport.”

Anything that happens outside of the Emergency Department doesn’t count.

Of course EMS has translated that to – Anything that happens outside of the ambulance doesn’t count.

The basic EMT is expecting that the medic will come up with a way to make Deborah Peel appear stable – stable enough to go to the hospital without any ALS (Advanced Life Support) care. In other words, the medic does not have to do anything, except drive.

So, they take a blood pressure, but there are problems obtaining the number. They can only get occasional beats. When you are letting the pressure out of the cuff quickly, there can be a bit of a “inaccuracy,” especially if the beats are not cooperating by being close together.

Well, they know that the number can’t be right because that would be really bad.

Why don’t we hook up the monitor? Oh, yeah, good idea. Then we can find out what his heart rate is. The monitor is the keeper of the heart rate on ALS calls, just as the pulse oximeter is the keeper of the heart rate on BLS (Basic Life Support) calls. For some reason the pulse oximeter malfunctioned on Deborah Peel, even though they spent a lot of time trying to troubleshoot it. The best they could get was a sat in the low 80s and a heart rate in the upper 20s.

Now, you are probably already experiencing more than a little frustration reading this. I was watching this as we were returning from the hospital to our station. We had heard the call dispatched and I asked my partner why the crew was coming out of the house with a syncope patient, but without the monitor. The response – “None of the medics do that. You and Jeff are the only ones who bring monitors in on this kind of call.”

Great Googly Moogly, I done died and went the wrong way.

As we are wandering over to lend a hand, which my partner says is a bad idea (not the first time I’ve heard that), we overhear the blood pressure confusion. They are hooking up the monitor and have a nice wide complex bradycardia* on the monitor. The medic automatically grabs the IV kit and tells his partner to get the atropine out.

Since I am just helping, I put an oxygen mask on Deborah Peel. I even turn the oxygen on. I ask about blood sugar and they actually did that inside. The blood sugar is in the normal range.

I suggest, in my helpfulness, that pacing might be a good idea, since Deborah Peel is clearly unstable. As in unconscious, hypotensive, and bradycardic. That atropine is not helpful for ventricular bradycardias. But, they don’t approach ACLS that way. Pacing is something they do not use. Why? I do not recall the response to that question, maybe I never got a response, maybe I was just doing a better job of keeping my mouth shut at that point – to avoid letting out the screaming that is going on in my mind.

The hospital is two minutes away, otherwise we would not have been driving by this call. Do they start driving? No, the EMT has to help the medic with the IV start, spike the bag, cut the tape, hand the tape to the medic, . . . .

The atropine does not make things worse. Then they drive lights and sirens to the hospital.

Everything is already done, as far as the protocol is concerned. Chart review on this should earn the medic brownie points for being so diligent in care. The medical director can rest easy. This officer is one of the good ones, making sure that the others are kept in line. Passing on the right way to take care of patients.

But the chart and reality do not have anything to do with each other. Do they?

For a different perspective, what if this had been something that fell into the significant trauma category?

Well, we would drive to the hospital and meet the helicopter there at the landing pad.

How far of a drive is it to the trauma center?

15 to 30 minutes.

So, to save a few minutes of drive time, you fly the patient?

We have to. We can’t deprive our service area of our excellent patient care. If we aren’t here, mutual aid from the next town over might have to come in and treat our patients.

This reasoning almost makes sense. These guys have seen the neighboring EMS and don’t trust those guys.

Those guys are dangerous!

Of course, the only difference between them is the uniforms. When not working their full time job as these guys, most of these guys work part time as those guys, many of those guys work part time as these guys, but some of those guys work part time as other those guys. This keeps the overtime down.

These guys and those guys probably even pass the National Registry of EMTs paramedic test without any problems.

If you don’t purchase the program on the way into the ball park, you aren’t going to know who the players are.

* Bradycardia means s l o w. In this case to the point of not circulating enough blood to the brain to remain conscious. Wide complex means that even the electricity in the heart is moving very slowly. The heart is slow and the electricity is not connecting efficiently. This may mean that the lower part of the heart is causing the heart to beat. Normally a group of heart cells in the top of the heart (the sinus node) are in charge of causing the heart to beat, if they fail, then farther down the conduction system, where the upper part and the lower part of the heart meet, there is a back up to the sinus node (the AV junction), but even that is not working for Deborah Peel.

Not really a big problem. He just needs a ________.

Even those of you not big on cardiology can probably figure out the word that goes in there. The word is pacemaker. Deborah Peel will receive one in the hospital.

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Helicopter EMS – The Starbucks Effect.

Safety über alles!

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More Medics Means More Medical Misadventure.

More does not mean better.

Sometimes more is better.

Sometimes more is just more.

Sometimes more is worse.

Of course, in a country with an obesity “epidemic,” how is it possible for people to understand that more of something might actually not be better?

True, medics aren’t calories,

The problems of the “more is better” fantasy are ones that I feel are obvious, but so many people do not. There are some medics who get the material. There are some medics who are slow learners. Then there are the medics who never get it; some medics who never put any effort into learning; some medics who never see the patients as human beings; some medics who only see a paycheck.

The more we increase the number of providers the smaller the percentage that come from the first two categories.

The more we increase the number of providers the larger the percentage that come from the scary, bottom of the barrel, “might be better to throw the shoe away than scrape these turds off the bottom of the shoe” category.

Cross-training is one of the best ways to increase the numbers in the “It’s just a job, they’re only taxi rides on the way to my paycheck,” category.

The large number of medics needed to meet the “everyone is a medic” staffing criteria, seems to encourage those, who should be providing oversight, to overlook patient care instead of overseeing patient care. What should have been an incident worthy of close examination, insteadbecomes just a comment in a file. Sometimes the comment goes in the file of the person pointing out the bad patient care. Perhaps a comment about being unmutual.

Nothing to see here. Move along. We determine what is good patient care and what needs to be reviewed by the medical director. If you don’t go along to get along, you will go away.

The medic passed the NR (National Registry of EMTs) medic exam. The medical director granted authorization to treat patients. Of course the medic is a good medic. Never mind that the medical director would not be capable of picking the medic out of any line up.

I have already described some of the problems with NR and with medical directors.

Imagine a medical emergency, where a fire engine is dispatched, a supervisor, and an ambulance. Not hard to imagine, since it happens many times every day in many places.

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

Now back to our imaginary, everyday occurrence. Four fire fighter/paramedics on the fire engine. What do you do with that many medics, when there is only one patient? You find something for them to do to keep out of the way, because there are too many medics there.

At least they can help move the patient out to the fire engine to take the patient to the hospital.

No. The fire engine is not designed to transport patients.

Then the supervisor medic shows up in the supervisor’s truck.

Finally we can transport.

Still no. The supervisor’s truck is also not designed to transport patients, but now we have another medic on scene.

That’s good.

Why?

Well, the supervisor should be more experienced than the other medics.

This is one of the roles of the supervisor, to provide the voice of experience.

Of course, one of the reasons the medics lack experience is that they have a lot of time standing around not obtaining experience – even though they may be credited with treating this patient.

“Can you hear what he is saying?

“No, I thought you could.”

“Did he say he has chest pain?”

“No, emphysema, I think.”

Don’t be silly, he said he is having a stroke. Just look at his face.”

“I thought he was doing a John Belushi impression.”

“Hey Lieutenant, what is going on?”

“There you are, Probie. He has some bleeding hemorrhoids. You need to hold direct pressure with this bandage.”

How are they obtaining experience at fighting fire or at treating patients?

Hold on. It gets better.

The ambulance arrives. 2 more paramedics.

How many medics do you need to treat one patient?

Just one. Kind of like the Texas Rangers – “One Riot, One Ranger.”

How many medics did we end up with on this call for one patient?

Seven.

Gosh, that is almost as scary as the movie Se7en.

At least this did not cover as many vices as the movie did.

So, do the medics all get in the ambulance and take the patient to the hospital?

No. The medics on the ambulance will transport the patient and the others go back to what they were doing before being sent to hover over the patient until the ambulance arrived.

Well, at least there are two medics getting experience on this call.

No. One of the medics is driving.

So, out of seven medics, only one really does any patient care and obtains experience?

Hold on. I exaggerate. One of the initially responding medics does some assessment and initial treatment, too.

Not a very good way to maintain any kind of skills, is it?

Actually, this kind of system should do a lot of simulation and mannequin work to make up for the lack of experience.

Is there any situation where it is beneficial to have so many medics?

Yes. When moving an extremely heavy patient. Even then, you probably have too many medics.

Does this make you a better medic?

No, but if you are able to provide enough simulation training to keep the level of experience up, it might not be too bad.

Do these services provide a lot simulation training?

I don’t know, but to think that this works, you have to be only simulating thinking, in my opinion.

So, what happens?

They run around a lot, because there are a lot of EMS calls. They don’t have much patient contact experience, because there are so many medics.

Then, this is really about how much you want “in name only” paramedics on scene?

In some cases, yes.

They have the call volume of a big city combined with the experience of a small town.

A “worst of both worlds” situation?

A lot of calls that will need experience, but so many medics that the experience is diluted the way homeopathic remedies are diluted – any possible effectiveness is gone, but the memory of they original chemical is supposed to remain, even though chemical don’t have memories.

What?

Some people believe that homeopathy makes sense, too.

But at least paramedic/fire fighters put out fires better than just fire fighters.

It is just as bad to cross-train fire fighters as it is to cross-train medics.

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Why am I so negative?

I am not negative about patient care, about EMS, or about education.

I am trying to make things better.

Should I take the attitude that “It’s just a job, why care about it?”

Should I not point out things that I see as dangerous?

“You go, Captain! We don’t need to worry about icebergs. We’re unsinkable!”

The captain is the medical director.

The medical director has the most control over the quality of care.

If these decisions are left up to someone else, the decisions will not be focused on medicine.

Medical care directed by non-medical personnel will not be good.

We need for medical directors to understand EMS. EMS treatment is significantly different from treatment in the hospital. Anyone who does not understand this should not be directing prehospital medical care.

It isn’t about looking good in fancy imitation police uniforms, but about providing appropriate care to the patient.

It isn’t about who has the biggest, or the loudest, or the fastest, or any of the other superlatives.

It is about providing competent patient care.

If you cannot provide a medical director, who understands EMS, who has the time to appropriately oversee medics, who is appropriately paid for the medical direction, then you cannot afford ALS (Advanced Life Support) and should limit care delivered to BLS (Basic Life Support).

Good BLS is not bad care.

Good BLS is essential to good ALS.

Not everyone needs a medic.

If your medics are not getting enough practice – assessments and skills performed – then they will get worse.

Simulation is a way to make up for lack of volume of assessment or skills, but requires a lot of medical director involvement to make sure that it is thorough and directed appropriately.

Medical directors need to solicit feedback from the hospitals about the care delivered by the medics. When the medic transports an intubated patient, was the tube properly placed? Was the patient’s airway traumatized by the intubation? Was capnography in place (waveform capnography should allow the printout of this information, but some people are too arrogant to use it)? Was the ventilation rate appropriate? Et cetera.

But, more importantly, was the airway managed appropriately?

If an endotracheal tube was used, was it necessary to intubate this patient?

If a tube was not successfully placed, even though intubation was indicated, was the airway managed appropriately with an alternative airway device, so that the patient was successfully ventilated?

Ventilation is the gold standard, not intubation, and not even oxygenation.

Focusing on oxygenation at the expense of ventilation is bad airway management.

Focusing on ventilation does not exclude oxygenation.

Was treatment appropriate for the condition of the patient?

Did the verbal report match the patient?

If not, why not?

Medical oversight by OLMC (On Line Medical Command) permission requirements is not oversight, but rationing.

Medical oversight by chart review is not oversight but ridiculous optimism that what you are reading is an objective presentation of the patient care delivered.

Medical oversight by the occasional continuing education course is not oversight, but providing continuing education. Continuing education is important and allows the medical director a forum to get to know the medics better, but it is not oversight.

I am negative toward things I see done badly in too many places.

Raising a child is not different.

When my child is behaving inappropriately, I should point this out to my child – unless the “dangerous” behavior has a minor downside. If the consequence is not very significant, then it may be appropriate to allow the child to learn from making the mistake.

This does not apply to patient care.

The downside is not minor.

With airway management, the consequences of bad patient care are significant.

Allowing people to learn from their mistakes does not seem to work well, even with the experience of significant consequences.

Does the criticism mean that I do not love my child?

Not at all.

If that were the case, I would always remain silent and ignore the risky behavior.

I am glad that my child is now a healthy, intelligent adult with good risk management skills and good money management skills.

If only people in EMS, including medical directors, were so easy to teach.

And I haven’t even mentioned bad instruction, evaluation, NR (National Registry of EMTs), bad research, ignoring good research, and a bunch of other stuff in this post. 🙂

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Who needs essential skills?

In her latest post, The downward spiral of the paramedic program…, Gertrude at Ridin’ the Bus writes about some of the problems with paramedic education and with paramedic students.

The primary problem –

What happened to teaching people that their assessment was the best and biggest tool in their bag of tricks?

A frequent topic of discussion in EMS is What is the most important skill?

Gertrude doesn’t even give us a chance to debate this. Not that it really makes for an interesting debate. This is right to the point.

Does any other skill matter, if you do not properly assess the patient?

If you do not perform a competent assessment, but are highly skilled at everything else, how do you know which of your excellent skills to use?

Well, paramedic students do not seem to understand this. They seem to be resistant to learning assessment. They seem to think that they can treat patients without knowing what they are treating.

The scary thing is that only a few people seem to see this as a problem. The medical directors allow these idiots to treat patients, they are the ones who seem to have the most authority to stop dangerous medics, but the medical directors claim it is not their responsibility.

The schools have the ability to stop these dangerous idiots from graduating, but are trying to avoid being sued for discrimination. Their discrimination is what is needed. A school that produces graduates indiscriminately is worse than worthless.

We are possibly on the verge of intelligent machines. In 1950 Alan Turing proposed what came to be known as the Turing Test. A test of whether a person, corresponding through a computer, is able to tell if a human is on the other end. If there is a computer on the other end and the human feels it is a human, the computer passes the test. There are problems with this, but the irony is that as computers are becoming better able to make intelligent decisions, humans are being discouraged from making intelligent decisions – because they might make a mistake.

The typical solution – preventing humans from making decisions – is the biggest mistake possible, but that is where EMS, and possibly all of medicine, seems to be headed.

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National Registry Exam, part 2

This post is actually about my first National Registry Exam experience. I am testing for NR (National Registry of EMTs) medic exam. I am evaluating the spinal immobilization station.

We are briefed by the representative from NR. Nobody may say anything to the examinee other than a greeting, what is written on the testing script, and “Is there anything else you would like to add.” The testing script is a description of the “patient” and the information needed to treat the patient. I may not give any feedback to the examinees to indicate if the examinee passed, came close, or bombed so badly that their school should be embarrassed. At my spinal immobilization station, I have two EMT students as “patients.” They are earning brownie points and a little money by helping out with the class.

The first few examinees are a bit of a learning experience for all of us. After each examinee, I ask the “patients” how they felt they were handled by the examinees and if they thought the examinee passed. At first they are unsure of the mandatory criteria, but quickly learn them by heart. We agree on all of the examinees – including the ones who didn’t hit any of the mandatory failure points, but are still scary as providers of patient care.

Then one of the examinees comes in, more confident than the rest. I do not know him. He breezes through everything smoothly and is an excellent example of the kind of medic I would want taking care of my family.

But, the last mandatory part of the exam is to reevaluate circulation, sensation, and movement after immobilizing the patient. He did this appropriately earlier (before moving the patient). For some reason, at the end of the immobilization (instead of rechecking circulation, sensation, and movement), he states “And I recheck DCAPBTLS.”

DCAPBTLS is “Deformity, Contusion, Abrasion, Puncture/Penetrating Injury, Burns, Tenderness, Laceration, and/or Swelling.” This is not a relevant reassessment of circulation, sensation, and movement. DCAPBTLS is a way of remembering things to cover in a trauma assessment.

I ask the only thing I am allowed to say to the examinee at this point. “Is there anything else you would like to add.” He thinks a bit and says “No.” We repeat this for a while until he insists that this is his final answer. I am nothing like Regis Philbin.

He leaves the room. I ask the, now able to recite the script in their sleep, “patients” if he ever stated that he would reassess the circulation, sensation, and movement. They both state that he did not. I talk with the representative from NR. He states that as long as he did not state the mandatory reassessment of circulation, sensation, and movement he has to be failed. The representative from NR states that I did the right thing, that this is what they want from their examiners. This is supposed to be praise, but feels as if I am being indoctrinated by a higher ranking cult member. I feel dirty.

A reasonable approach to examination would be to ask the examinee “What does DCAPBTLS mean?” It would be appropriate to ask a lot of questions of the examinees, but that introduces opportunity for thought.

Thought appears to be the enemy of NR.

Critical judgment is something that can lead to a bad decision, so it must be opposed.

Too bad we have patients who do not present in a scripted manner, where supplying the approved response automatically heals the patient.

Preventing examiners from thinking and using discretion eliminates the need to having any experience. As an examiner. As a provider. Anywhere in patient care.

Follow the protocol. Do not think.

Wait, how do we know which protocol to follow if we do not think?

There you go thinking again. Dispatch will tell you.

WTF?

That is the way some areas handle EMS. The medics hyperventilate, whine, and generally carry on like 2 year olds if they do not get a full report from dispatch – one as thorough as they are expected to give when transferring care in the ED. This is what we are training them to do – stop thinking.

The NRing of America is not isolated to EMS, but is dumbing us down to a dangerously incompetent level.

Don’t get sick.

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