Human Sacrifice: The Cost of Being Progressive in EMS?

For every EMS provider that understands what a NNT or P value is, there are ten out there that think backboards save lives and that oxygen is somehow a pain med. For every provider that knows the difference between a Randomized Controlled Trial (RCT) and an observational study, there is an army of providers that believe asystole is an indication for naloxone. Show me an EMS provider who knows about what the AHA means with their proprietary class IIb recommendation (see below if you don’t know) and I will show you a hundred providers who are convinced that oxygen is a lifesaving intervention in a normoxic myocardial infarction patient.

Mary Baker Eddy authored the book of magical Christian Science nonsense, “Science and Health with Key to the Scriptures” in 1875.  I find myself consulting a somewhat similar book with some frequency, “EMS Protocols Version 10.” Both books deal with raising the dead and treating the sick and injured and both books are far from being what one could consider science as they rest on a large foundation of anecdotal evidence and appeal from authority.

The 2015 AHA Emergency Cardiovascular Care Guidelines (AKA ACLS) which sort of forms a default standard of care* in our industry are mostly based on opinions and limited data. Shockingly, 46% of the recommendations in the guidelines are drawn from studies with limited data sets and 23% of the recommendations being based on “expert opinion.”

Much of what we do in the name of ACLS  either does not work or does not work and might be harmful. Instead of asking if a medication works we have entered some sort of weird “the emperor has no clothes” paradigm. We now have to prove things do NOT work before we stop subjecting patients to out “treatments.” Painting with a broad brush here, for the average patient some of our treatments are about as effective as Reiki.


Some examples of what I mean:

  • Amiodarone in cardiac arrest: No better than a placebo in terms of increasing CPC scores.
  • Epinephrine in cardiac arrest: Not helpful in cardiac arrest in terms of increasing CPC scores , likely harmful
  • Saline in trauma: harmful in large doses
  • Backboards: No benefit in terms of immobilization, possibly harmful
  • C-collars: No benefit in terms of immobilization, possibly harmful
  • Lasix in acute pulmonary edema: No benefit, probably harmful in acute pulmonary edema
  • High flow oxygen in the normoxic patient: No benefit, harmful in some patients
  • Lights and sirens: Little benefit, high risk.
  • TPA ambulances: No benefit (except marketing)
  • Lucas devices: No benefit over well performed CPR with adequate rescuers, may be harmful
  • Surviving sepsis guidelines (30ml/kg for ALL patients): May be harmful to some (most?) patients
  • Some Supraglottic airways in cardiac arrests: No benefit in most cases, may be harmful

And let’s not forget a laundry list of our greatest misses involving things like MAST, high dose epinephrine in cardiac arrests, Therapeutic hypothermia following cardiac arrest, sodium bicarbonate in cardiac arrests, stacked shocks, treating “malignant” PVCs, and whatever else lurked in the drawers of the Plano box that you would give during cardiac arrests. The issue is all of these things made sense at the time; they all seemed like good ideas at the time.

The problem is the trend continues in EMS.
We simply refuse to learn from the past.

In the name of being a “progressive” agency, EMS is yet again engaging in alternative medicine.  A small study on anesthetized pigs shows promise in performing heads up CPR and suddenly an EMS agency is being progressive and performing heads up CPR. If the science does not pan out and patients end up getting a treatment that made them worse, please accept our apologies in the name of “progress.”

But what is a bit of human sacrifice when things like marketability and JEMS articles are at stake? All those dead patients are just grist for the mill, casualties in the war against the status quo.

I fully support well done randomized controlled trials in medicine and many of our current practices need to be placed under the magnifying glass of an RCT; but an agency simply rolling out a new unproven, poorly researched treatment and touting their “results” does not equal an RCT. As providers, we have very little skin in the game here, we have all the upside if the new hotness works and we have none of the downside. If the treatment turns out to be causing harm we simply wash our hands of it and talk about it in blog posts like this a few years later. We don’t consider the countless dead we left behind when the next new shiny thing comes our way.

ham and egss
Skin in the Game.


Another disturbing trend that is emerging is that of the “compounding resuscitationist” phenomenon. I agree that standard dose epinephrine either has little meaningful effects or is somewhat harmful. If I were to suffer a cardiac arrest I do not want any epinephrine given to me, and a sort of DNE form (Do Not Epi) might need to be created. I think a drug without any proven benefit and an association with harm should not be given to patients. Unfortunately many people are playing mad scientist and coming up with their own proprietary dosing regimens: adding a milligram to a liter and running it in over 20 minutes, spaced out dosing, giving some random dose of epinephrine, dosing based on etco2, giving only one or two doses, or a number of other alternative dosing regimens. This is not science, it is alternative medicine. It does not clarify anything; it only muddies the waters further.

Should we even discuss the madness that stroke ambulances are? Perhaps that is topic best left to a separate post.

There is a certain satisfaction one may get from being progressive. It feels good, it strokes the ego a bit when you have new information and do things other agencies are not doing. It may even generate some attention for you and your agency, especially if you are good at self-promotion. As long as you continue to employ the confirmation bias and only remember the few times the progressive movement was correct it is easy to continue this dangerous trend.  We owe it to the dead to proceed with caution and diligence and avoid the seductive power of progressiveness.

EMS 4.0.

We have entered the next age of medicine and are proud to present the release of EMS 4.0.

While we do offer our regrets regarding the brevity of the prior upgrade, the EMS 3.0 model was not optimized to achieve the cross-platform metrics that stakeholders demanded and will no longer be supported as of last week.

Rest assured that EMS 4.0 is both progressive and allows for enhanced marketability.

It is a bold new era with the release of EMS 4.0, the patented technology allows end-users to break free of the cycle of being needlessly constrained by things such as facts or evidence. Finally free of the burden of proving efficacy, or even any kind of tangible benefits, EMS 4.0 is sure to deliver the results you and your agency need in today’s emerging mobile healthcare solution marketplace. Continue reading “EMS 4.0.”

“What About Us?” The Uncomfortable Truth About The EMS Mental Health Movement.

The bodies were still out there in the streets, covered with makeshift body bags when they asked you to donate to the cause. Less than 18 hours had elapsed since 58 people were murder, and 500+ were injured and when they started the fundraiser.

No, this wasn’t for the victims or their families.

I have sat on this post for 19 days, wondering if I should post it or not. I decided that what I have to say, needs to be said.

I need to be clear here. The zealots have a “if you are not with us, you are against us approach.”  I want to preempt the rhetoric that is sure to follow that I am “perpetuating the stigma,” which seems to be the go-to defense when questions arise.

I support mental health initiatives for EMS providers and think people deserve care if they need it. I think every agency must feel responsible for their employee’s physical and mental injuries that occur from the job and even more for preventing these in the first place. I do not support their approach to the issue.

But, Jesus Christ…

It took less than 18 hours before the deaths of 58 people became about us, the rescuers.

For a problem that does not exist yet.

vegas cgc

We are told the money is being raised for the mental health issues that the EMS workers who responded to Las Vegas are going to suffer.

Unless the Code Green Campaign has developed clairvoyance this is speculation, perhaps not unreasonable, but still speculation.

The fundraising campaign exposes the assumption that is the foundation of the organization; when EMS responds to these calls some responders will develop mental health problems, some of them may even need inpatient treatment and rehab for substance abuse. The notion that their agencies will not pay for this and will not support their employees is implied as otherwise there would not be a need for this.

If I were a manager for a Las Vegas Fire, Law or EMS service I would be highly offended that an organization thinks I am not going to take care of my employees; that they need to set up a fundraiser to pay for things workers comp should be paying for. And it should be paying for it, just so there is no misunderstanding what I am saying.

Maybe the organizers of the fundraiser have inside info on this and I will have to eat my words, maybe I am overly optimistic about the level of caring and resources that Las Vegas EMS/Fire and Law agencies have at their disposal. If we employ Hanlon’s Razor at best this fundraising is an ill-conceived and insensitive attempt to help. At worst, it is something much different.

A line needs to be drawn in the sand. We need to stop making every tragedy about us. It is not our tragedy. How selfish is it to agree to help (by accepting the job) and within 16 hours of 58 people being shot to start saying that we need some money for us. We chose this field, we chose to help others. We were not drafted, conscripted, or otherwise forced in to some sort of EMS servitude.

We willingly agreed to this. We chose to have front row seats to all the shit that life serves up.

How about we let the families finish burying their dead before we make this about ourselves. Consider holding off on the fundraising until the funerals have finished  and let the nation mourn before the diatribes about what the rescuers had to endure that day begins. What the rescuers had to deal with is tragic, but it does not hold a comparison to the thousands of lives that were forever horribly changed that day. Go look at the dead, you owe them that much. Now imagine their families. Tell me again how bad we have it?

EMS is about serving others, at least to some degree.

I won’t go all Mother Theresa here. I am not going to blow smoke up your ass and talk about how we are always on call or tell you that I would run in to a rain of gunfire to save someone because it is bullshit. I am probably not going to do that. I am no hero and I am going home in the morning after my shift if I have any say in it.

Someone needs to speak up and be the opposition. We are not all one call away from a mental health issue. Sorry, I know that might bother some people, but it needs to be said. If you find yourself preaching resiliency while at the same time saying we are all time bombs, you are full of shit.

No. Just No.



You are going to see dead and dying people if you are in EMS. You will see people in pain and suffering. You will see humanity at their absolute god damn worst.  You may see many people die in a short period of time. You are signing up for this.

And it is not about you.

You may need to reconcile who you think you are with who you really are. This may not be a skill that the majority of the population possesses; honest self-assessment flies in the face of the Dunning-Kruger effect which has apparently become an epidemic in society.
“Maybe you are wired different, maybe you are more resilient than others, maybe you have better coping skills than others” is what I often hear. Beats me, sure, maybe I am, I have no idea. I don’t know what kind of coping skills you have. I don’t know what kind of bullshit you are dealing with outside of work.  What I do know is some jobs require specific mental and physical attributes. Perhaps it is time here to go out on a limb and say that EMS and medicine in general require a certain personality type or at a minimum specific attributes.  No, I do not know how to screen for it or if that is even possible.

Life is short, violent and often brutal and has been this way for a majority of human history. Only recently, in the past few decades, have we become insulated from the reality of how life is.

EMS can be draining; it can exert both a mental and physical toll on those who do it, but the bleating of “what about us” while the blood is still in the streets is more than bothersome.

I imagine there will be some images that rescuers saw that day that they wish they could forget. Some providers may indeed get mental health issues from being at work that night and they should get all the assistance they need. If they do not get the help they need I do not think a few dollars thrown their way is the solution; we need to hold peoples feet to the flames here. We need to demand accountability from management and workers comp insurance.  We need to demand legislative changes and cultural changes, not a gofundme account that will pay for a few people to get some help or fund the staff trip to talk about awareness.


The goal of an EMS quality assurance program (QA) should be increasing safety, satisfaction, and outcomes for both EMS providers and patients. Unfortunately, many QA programs are not healthy, they are a dysfunctional mess.

Compare your agency’s quality assurance program to the seven signs below and see how you match up. Continue reading “7 SIGNS YOUR AGENCY’S QUALITY ASSURANCE PROGRAM IS A DYSFUNCTIONAL MESS.”

Fixation Errors: Blame Aunt Jemima.


“Tell them we are really sorry and we are going to change our policy, okay?” I say to the RN on the phone. We are now going to have a strict hand washing policy when this sort of thing happens.

Perhaps in the near future, the title of this blog may change to “Mistakes that I made that you should read about so you do not make the same mistakes as I did.”
Continue reading “Fixation Errors: Blame Aunt Jemima.”

Supra-Glottic Airways Taste Like Failure.

In 2007 Elaine Bromiley went in to the hospital for an elective sinus surgery. Thirteen days later she died.  If you are unfamiliar with the case, there is a reenactment video of what happened in the OR here. Be forewarned, it is not an easy video to watch.

Recently we discussed the case at work. Providers expressed their disbelief over the events. “I don’t get it. How could that have happened?” was asked. Before doing quality assurance (QA) in EMS for several years I know I could tell you the answer, it is glaringly obvious to anyone with or without any medical knowledge – THEY ARE INCOMPETENT IDIOTS! For good measure I might also throw in some pseudo-intellectual comment about how the definition of insanity is doing the same thing over and over and expecting different results. For the coup de grace I would add they should lose their license to practice medicine.

Doing QA is hard. Sure you can just read reports and dole out sanctions for protocol violations like some sort of EMS SVU. “In the EMS justice system, QA based offenses are considered especially heinous. In the agency, the dedicated QA officers who investigate these vicious felonies are members of an elite squad known as the Special Victims Unit. These are their stories.” Chung-chung. It won’t make your system better or safer, but you can do it. It happens all the time.

To do QA right requires you to either have natural talents in things like emotional intelligence (I don’t) or to learn about yourself and come to some unpleasant realizations, things like you are wrong a lot. Even worse, after doing QA for some time you might come to find the root cause of some of the problems in the agency also involves you. The notion that second ago you were sure the providers were morons and now you are contemplating that you are perhaps a causative factor in the incident can be a bitter pill to swallow.

Growth is hard and to be honest not all that fun. It kind of sucks, actually.

Going back to the Elaine Bromiley case it is easy to be the judge, jury and executioner when we view the events that occurred with the benefit of hindsight.

The thing is if you were to present the scenario in the Bromiley case to anyone of the people that were there in there that day in the form of a question, “your patient is circling the drain, the 02 sats are in the shitter, should you keep trying to intubate?”I guarantee every single person would say “hell no!” But the truth is the people in the OR that day may never have even considered there were other choices. There probably was no choice presented in their minds. The only solution they could think of was “get the tube.” Or maybe they did have choice but the best solution from their perspective was to “get the tube.” Perhaps they though in another five seconds that tube would go through the cords and the disaster would be averted, certainly better to spend another five seconds in the airway than to cut the neck and scar this woman, right?


But they could not know that. Only with hindsight can we tell them that it would not be just another 5 seconds to get the tube. If we had the foresight to say you are never going to get the tube I assure you no one would still be mucking around in a person’s airway when their spo2 is south of 40%.

It is easy to watch the Bromiley video and believe your inner monologue, “IDIOTS.” It is harder to look at things from the provider’s perspective. It takes self-restraint to not jump to conclusion. It is very hard to look at things from their perspective and try and understand what they thought was going on then and why they made the choices they did that day. I think this is referred to as empathy.


From the outside perspective watching a fixation error unfold is a baffling ordeal, it boggles the mind how people could do what they are doing.

Fixation errors are very real. I made one once. After you experience one the world is different. You will be left with lingering doubts about your skill as a clinician. Are you a shit paramedic? How the hell did that happen in the first place? From the calm of your kitchen typing away on your computer it seems almost impossible to understand what occurred that day. You know the facts, you know what happened, but the why of it is much more elusive. Like some half remembered drunken evening you have bits and pieces of went on. What led you astray that night was not just one thing, and you know this. You know the holes of the Swiss cheese lined up just right to set the trap and you took the bait. Hook, line and sinker.

Given enough time, you can begin to understand exactly what did happen. Given enough time, you can be okay with a lot of things. You can begin to understand how others can get lulled down the same shitty path. There are few things in life as seductive as just taking one more “quick look” in your patient’s airway when you know at that moment that an ET tube is the solution to all your problems.

I think there is another component to the issue of fixation. Failure. There is a subtle sense of failure when you place a supra-glottic airway after you could not get the ET tube in, especially in a patient you paralyzed.  But you do it. You put that supra-glottic device in, because that is what is needed, that is what is right and correct and should happen, has to happen, but it still stings. It still feels like failure.

But the goal was never intubation, was it? The goal was managing the airway. Or was it? It seems when every cardiac arrest is tried by a jury of our peers the burning question is “did you get the tube?” or “Who got the tube?”

Of course, talking about this is probably going to be frowned upon be some. We are supposed to be bigger than this when it comes to ego and our own biases and patients.

On the other hand, preventable medical errors may be the third leading cause of death in the USA. Maybe it is time we start looking at some human related factors.

Let’s have the uncomfortable talk about how our cognitive biases, ego, and sense of pride might be playing in to killing a bunch of people. If you do not think this is a huge problem in EMS, I would refer you to the post about the ET tube petition. Right next to ET tubes on the NASEMSO document was a call for the removal of PEEP. Now, the thing is there is not a ton of evidence about EMS ET tubes, and what evidence there is paints the practice in a questionable light, but PEEP on the other hand seems to be pretty soundly based in science and evidence. Out of the save intubation crowd there was virtually no science or data or evidence given, only anecdote and an appeal to emotions.

Where was the petition to keep PEEP? There wasn’t one.

  • Number of people who signed the petition to keep intubation in the paramedic scope: 26,476.
  • Number of people who signed the petition to keep PEEP in the paramedic scope: What petition?

You can ask yourself why no one cared about the PEEP issue but I suspect you know the answer, you have known it all along. We, as an industry, have some weird emotional attachment to intubation; it has somehow become an integral part of our identity as a paramedic. This is not to say that intubation does not have a place in EMS, I think it does, but I think it might be time to start the conversation about why we are so god damned emotionally invested in intubation. Myself included.

How did our value as a paramedic come to rely on a 30cm piece of plastic tubing? How does self-worth hinge on shoe-horning a two dollar piece of plastic several inches in to a patient? I do not know.




Why I am Not Signing The Petition About Intubation.

So I do not have to post a lengthy comment every time the petition pops up on my feed.
If you have not seen it, here it is

Where do I begin? First, NASEMSO is not coming for our ET tubes. This was literally them publishing comments they received. The comment came from one person in an area where paramedics need additional training to be able to intubate. Agencies often solicit public comments when implementing policy change and when they do this some of comments are from people that should not comment on policies. The fact that 9000+ people could not be bothered to understand what was going on here or ask for further clarification speaks volumes about our industry.

Secondly, many people think EMS should in fact stop intubating. A petition is not going to change the minds of the shot callers. They look at things like evidence and training and standards and outcomes. A bunch of whiny rhetoric about the heroics we perform is not going to sway them in the least.

petitionThey deal in cold hard facts, not appeals to emotions. 

This petition just makes us look silly. “Allow Paramedics to continue to save lives with endotracheal intubation!” is a real stretch to say the least. While I think an ET tube is the gold standard, I do not see much in the way of life and death between it and a supra-glottic airway. Ventilation matters, not our ego.

The petition states the reason why ET tubes are on the chopping block is because we receive less training than anesthesiologists. That is wild speculation and, I don’t even know where that came from. If you are a paramedic and are not sure why people are considering that maybe we should not be intubating I would like to introduce you to the Dunning-Kruger Effect.

The petition should be calling for intubation education reform. Want to “Save The Tubes?” Then start writing NASEMSO about how we need more education on things like apneic oxygenation, peri-arrest intubation, ARDS, PEEP, etc. Show the people that write the educational guidelines that we want to be safe and educated and trained well and competent. Show them that we can demonstrate humility and are capable of using critical thinking and accepting feedback. Or keep getting mad over a non-issue and saying what heroes we are. 

When Only Outlaws will Intubate…

Get on the band wagon!!! The NASEMSO is coming for your laryngoscopes and ET tubes!

If you are on social media and in EMS you have no doubt seen the posts today. They are coming for your tubes. Soon intubating will be outlawed and only outlaws will intubate. And it is out fault because we suck at intubating, or we haven’t trained enough, perhaps our QA programs have failed, and our education is inadequate. We are getting what we deserve.

Except that is either nonsense or speculation, or some of both at this point.

First, states can do whatever they want and the national scope of practice is not a law, it is not binding and to be honest, whatever, you should have gotten your critical care cert by now. If you want to complain about EMS education and training and have not done it yet, well…let’s just say that if you complain that we aren’t taken seriously but haven’t taken a board certification exam that you could have…get off your ass. Or don’t. I don’t know. Do whatever you want.

The part about removing intubation is under the “comments received for exclusion of practice” section…right next to the comment about removing PEEP. I am not respiratory guru but I think some of the ARDS patients I transfer are going to be unhappy with removing PEEP.  Does anyone think NASEMSO is going to remove PEEP? I do not think so. This may be the EMS equivalent of Yahoo Answers or it could be the real deal. I made a comment on the 2015 AHA/ILCOR guidelines asking them to remove epi from adult cardiac arrests and it is still in the algorithm. When organizations intend to change policy they solicit comments from the public. Not everyone in the public, how do I put this…think of how bright the average person out there is, now realize 49% of people are not as bright as them, but they do have internet access. Or risk losing all your faith in the human race and get on Yahoo Answers or read the comments below a YouTube video.

Who made these comments about removing intubation? No one knows? What is going to happen with the comments? Also unknown.

Which brings me to the bigger issue here; everyone is jumping to conclusions about this. We don’t know who said it and we do not know why they said it. Could it be that EMS is bad at intubating? It is certainly possible. But there are tons of other reasons as well that could exist. Perhaps it is a lack of evidence that ET tubes actually change many outcomes? It certainly seems problematic that one comment has caused mass condemnation in EMS.

Maybe it is time to think about ET intubation is simply a risky procedure and unless you are dropping 40+ tubes a year it is extremely dangerous. Perhaps the risk is simply too great when presented with the logistical challenge of getting all the paramedics in the country 40 tubes per year. Perhaps we have been too cavalier with the whole thing and we need to own up to we simply were allowed to do an unsafe act and we need to rectify that? It does not mean we are failures.

No reason or logic was given for the comment, but that did not stop folks from piling on with comments about how EMS is a failure and doomed, and this is what we deserve, and that they are leaving EMS and other rhetoric. If an anonymous comment is all it takes to push you out of EMS, it might be time to question your commitment to it in the first place.

problem solving

Don’t get me wrong, I think intubation is a good skill to have and just like everyone else in EMS I am an above average intubator*.  I want to hang on to it because I think it is beneficial to some patients, but if I am putting patients at an unjustifyable risk, then I am okay with taking it away. There certainly is marked room for improvement in EMS education, QA and training. But before we know the facts here (if there are any at all because it may just be a nameless commentator) we should probably not condemn all of EMS. The sky is not falling; you do not need to start stock piling high capacity bougies and semi-automatic capnography monitors.

Perhaps this is the time to show that we are professionals, ask for more information, take feedback well and improve where needed.  Blaming does not fix errors.

* Dunning-Kruger

Dave’s Subs

If you are interested in learning about Just Culture I highly recommend the book Dave’s Subs by David Marx.

Dave’s Subs is an easy to read book about applying the Just Culture principals to your workplace and is not nearly as dry as some other works that exist on Just Culture.

Before I read this book I was looking for EMS or at the very least medically related Just Culture Books and education. The reality is that Just Culture principals can be applied universally across any industry.
daves subs

How to do QA Without Being an Asshole.

This is a  rambling, poorly organized blog post about EMS QA that started out as an answer to a question posted on facebook and turned in to a collection of random thoughts on the subject. People often find themselves assuming the role of QA with little to no training on the subject. I know myself and many others have learned quite a few lessons the hard way. Continue reading “How to do QA Without Being an Asshole.”