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

- Rogue Medic

National Security Roulette Follow Up

Here is a response to my post National Security Roulette, which was an expanded comment to a post by Too Old To Work, Too Young To Retire called Airport Security Again. The TSA (Transportation Security Administration) has a lot of problems and I chose to address some of the other problems, aside from profiling, or the lack of it. Hmm, not the lack of it, but the clumsy attempts to be doing everything possible to avoid the appearance of it – profiling, that is.

TOTWTYTR said…

A friend of mine recently returned from a week long trip to Israel. The short story is that airline security, by necessity, is much more serious a matter in Israel than it is in the US.

Not only is the questioning more intense and appropriate, but they actually *gasp* profile. Quite successfully to as it happens.

Profiling is another tool that can be used. As with any tool it can be misused. If we alienate Muslims, or Arabs, or any other group of which a small number are a threat, by using just that identity as our profile, we lose resources and gain nothing significant. The resources we lose are those in the community who are opposed to what the terrorists are doing. Even if they agree with the political aims of the terrorists, they may be completely opposed to the methods. What we gain is the appearance of safety, but not the substance.

We need counter-terrorist people from the communities that threaten us. One problem with indiscriminate profiling, other than the inherent oxymoron, is that it is just a stereotype that leads us to make mistakes that are easy to manipulate. Back in the days when drug smuggling on airlines was more common, one tactic was to have a very normal looking person carry on the drugs, with a very suspicious looking person a couple of people behind in line, the security person becomes so eager to get to the person who is the profile poster boy that he performs a more cursory than usual examination of all those between the him and the suspect.

We need to be thinking about the ways that we make security worse by profiling, but there is nothing inherently wrong with using a profile that is more specific than just Arab-looking or Muslim-looking. The FBI uses profiles to track down all sorts of criminals. The idea that this should be abandoned, just because of one of the parts of the profile is not politically correct, is a bad idea.

With the attacks on abortion clinics, the profile would have included all Christians. Many Christians oppose abortion and would support the aim of someone trying to limit abortions. Few Christians have supported the use of terrorism to achieve that goal. Muslims have expressed displeasure with the secular excesses of our society. The terrorists claim that this tolerance, which is essential to our Constitution, is what they seek to destroy with violence. Few Muslims have supported the use of terrorism to achieve that goal.

To limit the profile, of those attacking abortion clinics, to Christians would have been a mistake and probably would have alienated those most likely to be able to help in identifying the criminals. Christians have a similar history of killing people because of religion and they also have the history of being extremely peaceful. The same arguments of “religion of peace” and “look at this passage that demonstrates the inherent violent nature of the religion” could be used for Christians as well as Muslims.

The important point in profiling is to have people with both the capability to use critical judgment and the the permission to use critical judgment. This is not really any different from my approach to paramedics. The people who work for the TSA do not seem to have either. I’m sure there are screeners, who could be taught to use critical judgment and some who understand, but just are not permitted to use critical judgment. The approach of the TSA administration seems to be to discourage all possible critical judgment. This is not the way to security, no matter how prominently the word Security is placed in the organization’s name.

Paramedics have the same problem. Protocols written to prevent critical judgment, end up discouraging all judgment. A wise medical director will know what his/her medics are capable of, will educate them to use critical judgment, and will write protocols to encourage them to use critical judgment.

While I have been posting on less medical topics lately, the reason is to discuss problems with judgment. Bad science, bad oversight, and bad judgment in general. These are problems that have significant ramifications for all medical topics.

One of the things opposed by the terrorists is the open nature of our society. This is something protected by our Constitution. They have been somewhat successful in getting us to remodel our society in a way to limit freedom. The powers given to the government, in reaction to the terrorism, have made us less protected by our Constitution, in exchange for the appearance of safety. How much of that appearance is real? I don’t know, but too much of the method is in ways that strip America of the things that this country was created to exemplify.

One of my favorite quotes is from A Man for All Seasons. I hate to give a recommendation for a movie over a book, but I have not read the play. The acting is so good, that it probably only adds to the quality of the material. I think these quotes stand on their own, but I can provide more information if you disagree. This is from hundreds of years before our revolution, in the country America fought against for independence, a country not protected with something like America’s Bill of Rights.

William Roper: So, now you give the Devil the benefit of law!

Sir Thomas More: Yes! What would you do? Cut a great road through the law to get after the Devil?

William Roper: Yes, I’d cut down every law in England to do that!

Sir Thomas More: Oh? And when the last law was down, and the Devil turned ’round on you, where would you hide, Roper, the laws all being flat? This country is planted thick with laws, from coast to coast, Man’s laws, not God’s! And if you cut them down, and you’re just the man to do it, do you really think you could stand upright in the winds that would blow then? Yes, I’d give the Devil benefit of law, for my own safety’s sake!

And in another part, when he is having the law used against him:

Sir Thomas More: You threaten like a dockside bully.

Cromwell: How should I threaten?

Sir Thomas More: Like a minister of state. With justice.

Cromwell: Oh, justice is what you’re threatened with.

Sir Thomas More: Then I am not threatened.

We have to be careful what we give up to protect ourselves. We end up mocking those who fought and died for the freedoms we give up. Mocking those who continue to fight and die to protect and defend that Constitution. In order to protect us, it sometimes needs to protect those who would harm us.

To put this in the EMS perspective, we need to be looking to do what we can to protect and defend the well being of the patient. This is our entire reason for having EMS. Rules that defeat that purpose need to be opposed. Whether they come from doctors, lawyers, politicians, or medics. We need to stop putting the patient last, or so far down the list of priorities, that the patient might as well be last. Both directions lead to harm, but continually working to improve the care of patients is one that learns from its mistakes and improves.

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National Security Roulette

Another Normal Sinus Rhythm post. Read the rest, too. NSR Week 6.

In a recent post by Too Old To Work, Too Young To Retire, Airport Security Again, he comments about the arbitrary and unrestrained power trips taken by the people who never want to leave the airport. The TSA (Transportation Security Administration) have suddenly been taken from thoughtless and meaningless jobs, to the epitome of appearance over function jobs.

In his comments he states the following.

You have a point there, Rogue Medic. It’s the policies, especially the one that refuses to admit that some groups might, must might, present a higher threat than 89 year old ladies in wheelchairs.

Can’t say that though, because political correctness trumps actually making flying safer.

This is part of the problem with the TSA. They have a bunch of rules that revel in their arbitrariness. Their strict, unthinking obedience is something that should be criminalized. We are having the transportation system destroyed by people who are forbidden independent thought.

The PC (Politically Correct), better not offend anyone, approach is dangerous. We are so afraid that a person might think something that is mistaken that we discourage people from thinking, because “What if . . .?” What ifs happen. They cannot be prevented by prohibiting thinking. They are encouraged by prohibiting thinking.

What is the group that might be a bigger risk than the “89 year old ladies in wheelchairs?”

Yes, there is a group, but if you watch this you might doubt it.

Is there any particular reason for thinking that old ladies in wheel chairs are a threat?

No, but we have to make things random, we cannot select anyone based on judgment.

Judgment might be wrong. The only thing worse than an ineffective laughing stock of a government agency is allowing someone to make a decision without going through a bunch of committees. None of us is as dumb as all of us.

Of course, there is not much chance of a repeat of September 11, 2001, because the passengers would not cooperate. There might be some fools who believe that they might survive, if they cooperate. There may be a future in government service for people who think like this.

We need to have people anticipating the next move of terrorists, not defending against the last move. Idiocy is not to be encouraged, just for the peace of mind of the paranoid.

There is an amusing article about the silliness of TSA in Salon.com in the Ask the pilot category.

Propped up by a culture of fear, TSA has become a bureaucracy with too much power and little accountability. Where will the lunacy stop?

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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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