“No evidence of mistakes” is not the same as “evidence of no mistakes.” [1]

Bad paramedics are conspired against by others; they are a victim of circumstances beyond their control and are almost always wrongly persecuted by the QA department. Bad paramedics never make mistakes

A needle decompression is attempted and the paramedic fails to recognize there is a pacemaker in place and cannot get the needle in to the plural space.

A patient with a cervical spine injury has a femur fracture go undetected by a paramedic because it does not hurt when palpated.

The paramedic encourages the patient to sign a refusal only to discover later that the patient has exploded their spleen.

A nasal intubation is attempted and the paramedic does not realize that the tube is too short and has accomplished nothing more than placing a fancy NPA.

Apnea is mistaken as absent breath sounds and a chest without a pneumothorax is decompressed.

Pneumonia is believed to be CHF by the paramedic and the patient receives 80mg of Lasix.

And those are just the mistakes that I can remember making in my eleven year career. I’m not saying I am a good paramedic because of the mistakes I have made. I might even be a poor paramedic by all accounts, but I own those mistakes one hundred percent and freely share the lessons I have learned with others.

Case Study
I heard the other ambulance get called to a patient with a self-inflicted traumatic injury, the kind that is often not compatible with life.

I ran in to the crew about 60 minutes after the call. They told me that they “rocked it!”

The paramedic stated that the patient became bradycardic and hypotensive, they began to pace the patient and  mechanical capture was achieved.They brought the patient to the ER where pacing was continued. I was impressed with how smoothly the call appeared to go. Congratulatory high fives were given and I told the crew that they had done a great job.

Previously I had some doubts about the competence of this paramedic but I found myself thinking that perhaps I was wrong and that they really had improved or that maybe I was just being an asshole, maybe I was not impartial in evaluating them and had let some bias slip in.

The next week I read the report.

I had to reread the report and make sure that I wasn’t confused. Things were not in fact “rocked.” Things had gone very wrong.  There were catastrophic mistakes that were apparent. The most grievous being that the paramedic did not have capture while pacing and the patient was likely dead for at least 8 minutes before it was noticed and CPR was started.


As the QA person at my service I don’t care if providers accidentally kill a patient. I mean, I care, but not too much…I certainly would look at the events that lead to the sentinel event in our system and do a root cause analysis changing anything that could be changed. The event would be used it as a learning experience and see where the system failed the patient, but there would not be any punitive action against the provider, maybe some remediation and that would be it. I care about that our system failed a patient. I care that a patient was hurt. I care that the provider may have doubts about themselves now but I don’t care all that much that someone made a mistake.


But this all hinges on the provider understanding that there was an error and them being willing to internalize the concept and learn from it.

This is the thing that bad paramedics do not do. Bad paramedics are incapable of admitting they made mistakes and it is never their fault.

When I spoke the paramedic who had a dead person in their ambulance for about eight minutes and did not know it they told me “YOU WEREN’T THERE!”

If you want to see your QA person have a systolic BP of over 200mmhg just say those words to them.

After 20 minutes of explaining how my not being present on the scene is not any kind of explanation of what did happen that day we moved on to the then next phase. “my partner could not start an IV and I had to help him, and how come the doctor said I had capture.”

The doctor felt the muscle contractions from the pacer and thought it was a pulse; an easy mistake to make. A patient can’t have an ETCO2 of 0mmhg and be paced effectively or, you know, have things like a pulse for that matter. You are welcome to your own opinions, not your own facts.

I’ll spare you the rest of the drama but let’s just say we parted ways in an unamicable manner. The provider never really seemed to internalize the lesson that should have been learned. I am not without fault in the whole situation above; I made a bunch of errors at the system level and bare some of the burden as well. I simply assumed people knew how to assess for capture with pacing. I failed to ensure that providers would not get tunnel vision by not giving them complex scenarios in training.

The cure to this is for paramedics to embrace ownership, perhaps even Extreme Ownership.[2] When a mistake is made providers need to share it with anyone who may benefit from the knowledge gained. An attitude of accountability needs to be instilled in EMS.
It is important for any QA program to assure providers that honest mistakes will not receive any punitive action. It is important that providers can discuss mistakes openly with an emphasis on learning and not have to be scared of punitive action.
1: Paraphrasing from the book The Black Swan
2: Extreme Ownership

One thought on “

  1. Extreme Ownership: This currently my favorite book about leadership, from those above me in the management food chain, and those lateral to me, leading by example (or failing spectacularly).

    I can say that Pneumonia and Lasix thing happened to me as well, with a patient that had prominent CHF amd was already on Lasix. I learned a lot about differentiation of Pn and CHF after that call, and the unnecessary ass chewing from leadership. They never once made an educational point, but what they didn’t say or do spoke much louder than the opposite. I have found this to be the norm, not the exception, and perhaps it explains why we have failed to leave the occupational mindset behind us and embrace the professional.


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