Big Mac or Porterhouse

I’ve noticed two interesting discussions going on simultaneously on EMS social media.  One discussion, which started on the National EMS Management Association list on Google Groups initially started out as a medical director trying to update his protocols.  It has since evolved (or perhaps, devolved) into a discussion about keeping endotracheal intubation as a paramedic skill.   The usual positions are being hashed out.  Again.  In short — one position is that EMS, as a whole, doesn’t do a good job at intubation — either in initial education and skills mastery or in skills retention.  The other side is the argument of “That may well be true, but things are different at the XYZ EMS System where we absolutely excel at intubation.  Here’s why and take a look at our numbers.”

Another discussion has been brought up by friend and fellow blogger Chris Kaiser.  He’s raised some very good concerns about the current American Heart Association Advanced Cardiac Life Support program sinking to the level of a merit badge course that every advanced life support EMS provider has and that most hospital staff have.

I see both of these discussions as a symptom of what I call the McDonald-ization of EMS.  In other words, we want to ensure a similar experience wherever you get EMS, regardless of previous excellence (or incompetence).  Face it, when we travel, we stop at Mickey D’s because we know what we’re getting, not because it’s the best burger anywhere.

EMS seems to be trending towards this as well.  The statistical gurus and the usual crowd of professional committee members and buzzword repeaters all bloviate (sorry for the Bill O’Reilly word there) about the need to have a common standard.  Two problems there.  First, the common standard doesn’t take into account the variations throughout the entire United States.  To me, it’s unreasonable and illogical to presume that Cut Bank, Montana and Boston, Massachusetts have the same needs for EMS, much less the same populations and sources of funding.  Second, like McDonald’s, when your chief concern is consistency, your product or service easily becomes the lowest common denominator.  What you end up with is a consensus model where pit crew CPR, good airway management (both including and excluding intubation), and even more cutting edge advances like dual defibrillation and transporting certain cardiac arrest patients straight to the cath lab end up sacrificed because “we all need to be delivering the same care everywhere.”

As for me, I’ll take the occasionally singed porterhouse in recognition that even that is better than the uniformly average Big Mac, which for the record, isn’t even prepared the way I like my burgers to begin with.  It’s time that we quit punishing the EMS services that try to deliver excellent patient care just so that everyone receives the same, consistent, AVERAGE care.

Of course, the statistician will tell me that there’s always going to be an average.  We just need to keep IMPROVING what we do so that the average keeps advancing too.


  1. Mike Smertka says:

    I have some rather strong criticisms of the AHA, but to their credit, they did introduce a “higher level” course in the form of ACLS-EP. I have both attended and taught (more accurately mediate) that course. If you have motivated participants it can be even better than “the old ACLS” (been there/done that too)

    It would make sense that people who provide emergency and acute care would be required by their institutions to take the EP course. Sadly, many just see the basic course as the path of least resistance. As always, the easiest route is rarely that of quality.

    Just some perspective.

    • I remember when ACLS-EP was launched with much fanfare several years ago. At least in my area, there isn’t much interest. From reading the current description of the course at the AHA website, I’d call it “ACLS Classic”.

      That is it has much of the content of ACLS from days of yore, with some newer content added in.

      Sadly, the vast majority of people who take ACLS take it because they have to, not because they want to. Either they are proficient in the material and find the class boring. Or they are disinterested in becoming proficient in the material and find the class boring.

  2. Yeah. So unless you’re an ambulance company owner or such I don’t see the going the McDonald’s way going away anyone soon. They see it as a totem to keep away the nasty wasty lawyers and be able to sell it to the community as following some magical standard. So much for first do no harm.

    • I don’t know that ACLS is harmful, but I don’t know that it is helpful either. Having just assisted at an ACLS course this past week I can tell you that it’s kind of painful to sit through all of the repetitious videos.

      Yes, I understand that high quality CPR and early electricity are the keys to ROSC and ultimately to survival to discharge. I don’t need to see that mentioned 20 times in 4 hours.

      There is a dramatic deemphasis in cardiology and pharmacology. While neither may be particularly important in the immediate resuscitation phase, both would seem to be important in the post resuscitation phase.

      Then again, the need for ACLS is an indictment of many paramedic programs that just meet the minimum standards for getting students to pass the NREMT (or state) exams.

      Doing without understanding as friend of mine used to call it.

  3. JoeDavola says:

    I’m not really sold on the idea that EMS standards should inherently vary from location to location. The needs of the population in LA County is really not much different than King County, WA, or San Francisco, or even the suburban counties outside NYC, or Philadelphia, etc.. I only see needs really differing between urban/suburban and very rural area (e.g. Alaska, Nevada, Utah, etc.) Ultimately, the majority of the US population lives in urban areas or urban clusters (80.7% according to the last census). Certain types of emergencies may vary in frequency, but how much does (or should) the care vary? In terms of EMS, care really shouldn’t vary much unless transport time becomes extended (the question becomes at what time interval should care begin to change). Anyhow, setting standards does not necessarily lead to “McDonald-ization” of EMS. Medical education is very much standardized and generally, there is not much variation (school are allowed to try new things, but their students must still pass all the same tests). Residency training for a given specialty is pretty well standardized, too. Nursing school? Not a whole lot of difference between programs. The question becomes does standardization set the bar at the floor, the ceiling, or somewhere in between? In EMS, the bar should be set somewhere in between, and training institutions should feel free to go above and beyond as need be. However, most EMS training institutions treat standards as the ceiling (when they’re really at the floor) and fail to go beyond. That is the problem. It isn’t the standards, its the inability of EMS education stakeholders to do anything but meet the minimum. Be that as it may, raising “standards” in certain areas may not be possible – e.g., intubation. How many medic students get more than 10 intubation during training? Not many. A lot of that is because it’s just not possible given the number of paramedics on the street and the way EMS systems are set up (low volume, all ALS) and the competition for training in ORs (med students, SRNAs, and anesthesia residents). Given the research and the known difficulties with training paramedics in ETI, why should it even be required to be taught. Just think of the things that could be taught during the time that would otherwise be spent on lectures, tubing manikins, or in the OR. If an EMS system can support ETI initial training (say, even, 20 tubes) and ongoing exposure, then sure, teach it, but if not, just teach BVM and/or SGAs.

    • Mike Smertka says:

      I must respectfully disagree with your assessment that patient populations are the same. There are many factors that require separate focuses. Even in medicine the environment you work in dictates the practice. For example, there isn’t much use to learning treatment for jellyfish stings in Ohio. Simultaneously the health status of the average hipster in Portland, cowboy in San Antonio, and hoodlum in Detroit, are going to be different. Here is another good example. In the Western world, there is no need to give prophylactic antibiotics to minor wounds requiring suturing. However, in the third world, such as in Afghanistan or Kenya, not giving antibiotics is sure to result in subsequent infection in as little as days. You don’t see too many auger injuries in NYC, nor people falling from 50 story buildings in Iowa. Those in the South West have much more need of scorpion and rattlesnake knowledge than they do about moose attacks. It is certainly possible to do the same things for everyone. But the effects will not be very desirable.

      • JoeDavola says:

        I suppose I should have put a disclaimer that I was speaking in regards to EMS in the United States and also not the care provided by physicians. I do agree that there will be some variation, but this can pretty easily be adjusted for at the local level in terms of EMS. I believe that the current curriculum of paramedics covers envenomation, and it certainly teaches about falls, lacerations, and crush injuries. A fall of 50ft in Iowa vs NYC is not going to be managed much differently and for EMS, the goals are going to be largely the same in terms of care, but, what may change will be how you get the person to definitive care. Augers are used all over the US, an injury from an auger used for farming will certain be nonexistent in Chicago, but more common in Nebraska, but how much is the care for such going to change in terms of EMS (especially when other types of augers are being used in Chicago)?

        Ultimately, a paramedic is going to encounter “typical” medical and trauma emergencies far more frequently than rattlesnake bites or moose attacks, etc. even if they are in a places where such things may be more common. The care for the typical medical or trauma emergency is not going to vary by much in the US in terms of EMS. What could vary is how you get medical care to the scene, which does become more challenging as the population becomes more spread out, which is why, in the US, I’d prefer to make distinctions between rural areas and urban areas than between specific cities or regions.

        • Mike Smertka says:

          Is the job of EMS really to handle emergencies anymore?

          As medicine evolves EMS will be confronted more with exacerbations of chronic disease.

          US EMS provides nothing for severe trauma other than a ride to the hospital, which doesn’t even require an ambulance.

          Perhaps some of the examples I used may have seemed a little extreme, but you can find third world conditions inside the US in regions from the Appalachians to the South West.

          I just don’t think that the current level of EMS education reflects the role it is being asked to do, and I don’t think turning it into “McEMS” is going to improve things, but rather make it worse.

          • JoeDavola says:

            Emergencies do still exist and will exist, so that will always be part of the mission. Just because a condition is an exacerbation of a chronic illness does not make it a non-emergency, and the converse, too: the acute onset of something doesn’t mean it is an emergency, either.

            No one is arguing for “McEMS”. Saying that there should be a minimum standard is in no way an advocation of mediocrity.

            Overall, I do somewhat agree that EMS education does not reflect the role that it is being asked to do. (I suppose I’d word it to say that it doesn’t reflect the role that is actually required during a large portion of calls, which is greater than the number of emergencies.)

            As far as third world conditions, you could say that they may also exist in Detroit, Philadelphia, Baltimore, etc.

  4. I’d argue that nearly every private EMS agency in this country especially those truly subscribing to high performance EMS theories is arguing for “McEMS” simply because it makes their “management” job easier.

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