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

- Rogue Medic

EMS Needs to Be a Separate Medical Specialty – Now – Part I

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following the protocol orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic’s place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can’t imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this – from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts – here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8th Law – Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur – 10 Laws I’ve Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 – 1541, so this is not exactly new) wrote –

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population – a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.


Changing Standards in Education – from other things amanzi

I am often critical of the way EMS keeps trying to make it easier to keep up a steady flow of brand spanking new paramedics. Not because we produce a high quality product (new medics), but because the public is too ignorant to notice.

The main tool is the National Registry of EMTs exam, but other exams aren’t noticeably better. Dr. Bongi, from other things amanzi, has a post up at Better Health by the name of When Incompetence Kills.

Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea.

It becomes difficult to have half a dozen, or more, medics show up for every emergency call, when we have standards. Do we decide that one competent medic is enough, or do we hit them with a double dose of barber shop quartets – in the hope that all the patient really needs is a lot of company, and maybe a song?

Of course, we choose the high quantity, low quality route.

The image is from the Wikipedia Project Triangle article.

Now not all that long ago, to miss free air on an X-ray even as a student was a mistake that would fail you. These days you can easily get through medical school without worrying about trivialities like free air on X-rays. Also, to have perforated bowel causes intense almost unbearable pain. Even a street sweeper would be able to pick this up in the patient.

Seems as if EMS is not alone in the just push them out the door with a card kind of standards.

Yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days.

About 9 years ago, I stopped teaching paramedic school, because I could not continue to contribute to this farce. I was forbidden from doing anything outside of the limited classroom time. There were 2 people in the class holding everyone else back, but nothing was to be done about them, because they have not failed the ridiculously low criteria to remain in the course. It’s up to their preceptors to pass, or fail, them. According to the program director. I was forbidden from getting rid of the dangerous students future paramedics.

So not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do, because they didn’t know how to do it properly, caused further damage to the poor man.

One student was considered a troublemaker. One reason was that he would ask questions about things that would not be on the test. It was OK to have to essentailly repeat a lecture, because 2 people want to have paramedic cards, but don’t let on that they haven’t grasped the most basic points, the points from the first 5 minutes of the class. Everyone knows that the real evil is to ask a question about something that will not be on the test.

I cast my mind back to when I was still in academic circles. I remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared.

I guess I was just imagining things, because that would never happen in paramedic school. Dr. Bongi’s description is of medical school.

I myself was asked to examine a student in a practical exam. I failed her because she was simply a danger to any person unlucky enough to become her patient. And yet the powers that be had so changed the system from when I was a pregrad that she could not be failed and was released into the community.

When you cannot change the system from within, the only choice left is to leave or to force them to throw you out. I have taken advantage of both exit strategies.

We are killing them with kindness.

Killing the patients with kindness to the students. But the NR validates everything they do, and they are the experts. And you can’t go wrong buying a house when everyone else is, too. We’ll give you one mortgage on the house and another on the downpayment.

Don’t worry about the interest rate.

Debts like these never come due . . .

except in the real world.

The mortgage sellers and the NR don’t have to deal with their mistakes. They are making money selling their sub-prime product. The patients pay.

Dr. Bongi, you have my sympathies. It is too bad that more people do not understand.


Trauma Premier Live Commentary on EMS Garage and MedicCast

From JEMS News

Podcasters, Bloggers Set for Online Premiere Party of Trauma

From online discussion during the show to a post-show call-in chat for tonight’s premiere of Trauma. Join leading EMS Podcasters Jamie Davis, Chris Montera, Greg Friese and others in watching and discussing the premiere of the new NBC show Trauma. Browse to EMSGarage.com/live or http://mediccastlive.com at 9 p.m. EDT/ 8p.m. CST on Monday September 28, 2009 for live conversation and commentary.

Full story.


What Do You Think? Are You Going to Watch Trauma? Discuss Before, During and After …

I will be on the road, so I will not be watching this pean to the incompetent, but bipolar, narcissistic, schizophrenic, psychopath in all of us realistic, thoughtful, and respectful treatment of EMS. however, based on the trailer released earlier in the year, I wrote Trauma – New NBC Drama To Ridicule EMS.

Did it turn out to be everything I feared hoped it would be? Or do I owe somebody an apology?

I would rather apologize, than be right, but something tells me I will not be eating crow tonight, or for the duration of the series (at least as far as my comments on the quality of the series are concerned).


Too Many Medics?

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In some of the posts on the recent intubation study,[1] this question keeps coming up: What is the right number of paramedics to provide the best care to patients?

There was an article that covered this.[2] Here is the chart from the article.


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The study examined cardiac-arrest survival in five
unnamed cities. The findings include:

City with best outcome City with worst outcome
Cases of sudden cardiac arrest per paramedic each year 4.7 1.6
Length of time paramedics arrive after first responders 4 minutes 1 minute
Survival rate 27% 4%

Source: Researchers at Ohio State University in Columbus


This does not mean that medics should not be sent at all. Rather, it strongly suggests, that in our desire for a quick ALS response for cardiac arrest, we may be making things, not just a little bit worse, but a lot worse.

These numbers agree with what I have been stating about ALS getting in the way of BLS during cardiac arrest treatments (CPR). The numbers do not prove what I have been stating, but they seem to be giving a very strong hint.

The places with fast ALS responses are able to respond quickly because they have a lot more medics. In other words, they have dramatically reduced the amount of experience per medic.


To make everybody feel good, even though it appears to be killing people.

Almost a 7 times higher survival rate in the cities with fewer medics.

Feel good?

More medics means that more people are medics, and can feel good about being medics.

More medics means that more people are having medics respond to treat them, and can feel good about receiving care from medics.

This is just to make people feel good. Then, why not make everyone a medic? The response time would be immediate, unless maybe you fall in the woods, and there is nobody else there to hear you fall. In which case the philosophical question is, If a patient falls in the woods and there is nobody there to call 911, is there a response time? Not, Does the patient make a sound? And, since the patient is a medic, there is already a medic on scene, so there is no worry about response time.

Do the response time rules state that the responding medic has to be alive?

Probably not.

We could have all of the patients in nursing homes become paramedics. Talk about cross-training leading to improved response times!

Too many medics = too many failed resuscitations.

Too much of a good thing can be a bad thing.


^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not

^ 2 Fewer paramedics means more lives saved
Updated 5/21/2006 8:58 PM ET
USA Today
By Robert Davis

The chart is from this article.


Fla. EMS director pulls certification of 25 paramedics

It seems that there is a bit of a squabble going on down in Florida.

Twenty-five North Naples firefighters are no longer allowed to work as paramedics because they haven’t met training requirements set by Collier County Medical Director Dr. Bob Tober.

North Naples Fire Chief Orly Stolts said the move puts good medics out of commission and endangers residents.[1]

A fire chief opposed to training? WTF?

Oh, it’s EMS training that he is opposed to. That explains it. The chief thought that he would be able to force the medical director to sign off on the ex-medics, just because the chief was going to huff and puff and sputter and grimace and cry like a little baby.

“What he’s done is minimized the fire department’s ability to save lives,” Stolts said of Tober. “We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene. That puts our guys in a pretty hard spot.”[1]

Well, he is the chief. He should know.

He is a fire chief. His highest ranking medical person is telling him just the opposite of what he wants to hear. He just really, really, really doesn’t want to hear this.

“We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene.”

If he truly believes that, then maybe he should have acted as a Chief and made sure that his people had the required training. This is all the fault of Chief Numbskull.

This is a wonderful example of a blithering idiot.

Stolts said arranging to have his firefighters pulled from an engine once a month causes significant scheduling and overtime difficulties.[1]

In other words, Chief Stolts is completely responsible for this. He chose not to follow the medical training rules. I wonder if he does that with fire training rules.

Maybe he is cross-trained and incompetent at both fire and EMS.

Maybe. We know he has one area of incompetence fully covered.


^ 1 Fla. EMS director pulls certification of 25 paramedics
By Ryan Mills
The Naples Daily News
August 26, 2009


Trauma – New NBC Drama To Ridicule EMS

3 minutes and 43 seconds. No shortage of stupidity, misrepresentations, and bad examples to write about. As if we do not have enough problems in EMS, we have this onslaught of stupid.

They like helicopters. A lot. This is the same network that used helicopters to attack a doctor on ER. Twice. The same doctor. Perhaps if we were to look at helicopters as useful tools, when used appropriately, then EMS would be a lot better off. I don’t have a problem with helicopters, just with the misuse of helicopters. Maryland has been the poster child for misuse of HEMS (Helicopter EMS). Could be bad – better fly the patient. The Maryland You can’t be too careful attitude is dangerous, but it is the MIEMSS (Maryland Institute for Emergency Medical Services Systems) philosophy.

Medical helicopters in San Francisco? Really?

It has been a long time since I was in San Francisco, but I don’t remember any medical helicopters being used in the city. The city has no need for them. Manhattan, in New York city, is about the same size, but with a much larger population, but they do not need medical helicopters, either. What would be the point?

One line from the trailer is typical of how too many people view medical treatment – We are going to do everything we can!

Doing something just because you can do it. That is bad medicine. A much better line would be – We are only going to do what is appropriate, because medicine has limitations. I don’t expect to hear anything like that from this show. Dramas, such as Trauma, are a part of why people believe in homeopathy, naturopathy, and other alternative treatments that do not work. They believe that because they want it to work, it will work. Because they are special. But that is not the way that medicine works.

Yelling at dead people as a resuscitation technique? Of course. And it is effective, too. How silly of me to scoff at something that works on TV.

If you want to learn how to kill people, here is your interactive training. You see something dramatic and say, I’ve gotta do that!

The people who watch this, but do not use the opportunity to ridicule the show, may be the ones we need to worry about.

This is the Ghost of EMS Yet to Come. This is a warning of the way that EMS can be warped by those, who think that louder, faster, more intense, more hopeful, . . . is what makes a difference. Well they do make a difference, but they are all harmful. This show is medical toxic waste.

The most important part of EMS is calming everybody down.

How many people will decide on a job in EMS because of this show? These will be the wrong people for EMS. These will be people who think that they can make something work, just because they want it to work. These will be people who think that they can make something work, just because they want it to make them look good.

One small positive in the show. They do show people dealing with bad outcomes. This is something that might be presented well, but considering the rest of the show . . . .

There was a letter written to Resuscitation that described part of the problem with intubation instruction.

Many trainees reported limited supervision or hands-on training. Remarkably, however, when asked how they had therefore learned, after “trial and error”, a surprising number answered that television medical dramas had been an important influence. Almost all had seen intubation on television, and “ER” was by far the most common source.[1]

In examining the problem, they looked at how well ER portrayed positioning of the head for intubation.

We therefore assessed these three components in the 41 intubation attempts that occurred over the 42 episodes that comprised the latest two seasons of “ER”. Fourteen were excluded due to inadequate view, and 5 more involved cervical-spine precautions which precluded optimal positioning. Of the remaining 22, none (0/22) achieved more than one, let alone all three, components of optimal airway positioning.[1]

In other words, if you are trying to learn from a TV drama, I pity your patients.

You are looking at TV drama for examples of good patient care. You see that they have a bunch of people listed.

Michael Goto …. technical advisor: medical scenes / technical advisor:medical / … (101 episodes, 2003-2009)

Mel Herbert …. medical consultant (42 episodes, 2006-2009)

Greg Moran …. medical consultant (42 episodes, 2006-2009)

Jon W. Fong …. technical advisor (35 episodes, 2000-2009)

Armand Dorian …. technical advisor / medical technical advisor (13 episodes, 2007-2009)[2]

These are the medical consultants/advisors for the episodes studied. All except for Michael Goto are listed as doctors. This is what is written about how Michael Goto became a medical technical advisor on ER.

He was playing a video game online and “met” one of the “ER” property masters, who invited him onto the set. After being around for several days, he was hired as a technical assistant.[3]

He was probably just between shifts at his other job as emergency physician.

If that is what it takes to make medical decisions on ER, imagine what the qualifications are for Trauma.

He and another monkey were copulating with a football and “met” one of the “Trauma” property masters, who invited them onto the set. After being around for several days, they were hired as medical experts.

Horatio Alger would be proud.

I will use this show just as I did ER. As a tool for pointing out errors in patient care and skills performance. TV is great at providing us with object lessons. We need to be familiar enough with the backgrounds of our students to use media appropriately to educate. We need to counter the bad education of the TV drama.

Facial immersion in ice water is one of the AHA vagal maneuvers that used to be listed in the guidelines. ER could not pass up the opportunity to use it. They actually used facial immersion in ice water appropriately, but it is a hard procedure to justify. I don’t know if they used the digital circumferential sweep of the anus on ER, but that is another vagal maneuver from ACLS.


^ 1 Positioning prior to endotracheal intubation on a television medical drama: Perhaps life mimics art.
Brindley PG, Needham C.
Resuscitation. 2009 May;80(5):604. Epub 2009 Mar 18. No abstract available.
PMID: 19297069 [PubMed – in process]

^ 2 ER
Combined details

^ 3 Michael Goto


Anti-Science and Killing and EMS

Rogue Medic,

Why do you keep writing about homeopathy and vaccines and other stuff that doesn’t have anything to do with EMS?

Anti-Science is Anti-EMS. Here is one example of how anti-science kills.[1] This was not some serious medical condition that is a mystery to conventional medicine. The medical condition was – eczema.

How does eczema, a skin condition, become so bad that it leads to septicemia. Septicemia is a serious medical condition, but not one that is a mystery to conventional medicine. Eczema should not progress to septicemia in an otherwise healthy child. This was an otherwise healthy child.

On the few occasions that they did follow conventional medical advice, Gloria would improve, but they would soon revert to homeopathic remedies and she would continue to deteriorate.[2]

So they did get conventional medical treatment for their daughter. This is the fault of conventional medicine.

They only took her to a real doctor to get her well enough, so that they could go back to treating her with their anti-science treatment.

Hmm. The parents use conventional medicine and the daughter gets better. Since there is no cure for eczema, it is a chronic condition, the parents go back to the homeopathy to manage the eczema and she gets worse. The parents again use conventional medicine and the daughter again gets better. Since there is still no cure for eczema, the parents go back to the homeopathy to manage the eczema and she gets worse.

Lather, rinse, repeat. Just as it says to do on the label for the eczema/dandruff shampoo.

Lather the health out of their daughter.

Rinse the homeopathy away, temporarily.

Now that she is healthy again, lather the health back out of her.

Well, her father is a doctor. I’m sure he knows what he is doing.

He is a doctor of homeopathy.

Becoming a doctor requires a lot of time studying science.

There is no science in homeopathy.

A doctorate in homeopathy is an oxymoron. This is the equivalent of President Clinton having a doctorate in Celibacy. This is nothing but delusional thinking.

The parents, who each had university degrees and postgraduate qualifications, instead sought help from other homeopaths and natural medicine practitioners,[3]

I suppose they are the equivalent of Jenny Killer McCarthy, just with more classroom time.

This just is further proof that it is not the amount of the education, but the quality of the education. If you attend classes and pay your tuition, some schools will give you a degree, because they would feel guilty if they didn’t. When the degree is in homeopathy, there is no quality to assess.

Practical examsDude, you are like totally succussing[4] too hard, Dude.

Knowledge base (like cures like[5]) – I need a beer to cure my hangover, Dude. Hair of the dog is the only thing that works.

If they were to use homeopathy to try to send someone to the moon, they could instantly claim success. All they have to do is just dilute the trip to the point where the person never even has to leave Earth. The inverse of Zeno’s dichotomy paradox.[6] Homeopathy is amazing. Nothing is Everything. The illogic is perfect.

Late addition 5/05/09 19:49 – from The Macho Response[7] – Health service warns against homeopathic whooping cough remedy.[8] A dead baby. Apparently this is due to choosing homeopathic vaccination over a real vaccination.

How does this relate to EMS?

Original cartoon

Recently I wrote about the Trendelenburg Position,[9] which is an EMS treatment with as much scientific basis as homeopathy. In spite of the lack of evidence to support this as a real medical treatment, there are people who insist that it works because they just know it works. To suggest otherwise would be to suggest that they have been wasting their time, or even worse, harming patients. Rather than deal with this rationally, they take an extra-strong dose of Cognitive DissonanceTM. No homeopathic doses, when it comes to fooling yourself and harming your patients.

You’ve just got to believe in it. Because if you know what you are doing, you can’t continue this patient abuse.

But we can’t just do nothing.

You aren’t doing nothing, just because you are not providing a treatment, that might be harmless, but also might be harmful. One thing the treatment is not – helpful, at least not helpful to the patient. It is helpful to the continuing cognitive dissonance of the paramedic.

Assessment is a treatment. Assessment is essential.

Transport is a treatment. In these cases, transport is also essential.

Doing something, just for the sake of doing something, is horrible patient care.

Doing something, just for the sake of doing something, is patient abuse.

But if the patient dies, I need to feel like I did something. I can’t just stand there and not do something.

What if doing something is what is killing the patient?

Updated 9/14/2012 at 01:15 for formatting and links.


[1] Homeopathy Kills a Child
Respectful Insolence

[2] Dead baby’s parents ignored advice: QC
Harriet Alexander Court Reporter
May 5, 2009
The Sydney Morning Herald

[3] Dead baby’s parents ignored advice: QC
Same article as above.

[4] Dilution and succussion

[5] Law of similars

[6] Zeno’s dichotomy paradox

[7] Homeopathy Does It Again: Baby Dead At 4 Weeks Old – Much Too Young To “Believe”
The Macho Response

[8] Health service warns against homeopathic whooping cough remedy
ABC News (The Australian Broadcasting Corporation)
March 19, 2009

[9] Springtime for Witchcraft in Wake County
Rogue Medic
Tue, 28 Apr 2009

TM Cognitive Dissonance
How to harm people with a clear conscience. Fool yourself.