The bigotry of low expectations in EMS

The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves

“The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.”  — Michelangelo

The biggest obstacle to the advancement of our profession is not the limitations imposed upon us by others, but the lies we tell ourselves. You see them everywhere you look, repeated as articles of faith, as immutable as if they were graven on stone tablets:

“We don’t diagnose.”

“We work under the physician’s license.”

“Right or wrong, he’s the doctor. We have to follow orders.”

“What do you expect? We’re volunteers.”

“I can do more than any nurse.”

“Increase educational standards? Why, for the meager pay we make?”

“The protocol says…”

And every time we repeat them, we play right into the hands of those who would say, “Paramedics aren’t capable of doing that.”

It’s the bigotry of low expectations, and accepting them only lends them an air of legitimacy.

A self-fulfilling prophecy
Recently, an article appeared in Albuquerque Business First about Central New Mexico Community College’s difficulty in meeting CoAEMSP standards for airway management for its paramedic students:

"Faculty members at Central New Mexico Community College say new standards for EMS programs developed by a national accreditation body can’t be met.

"In August 2012, the Committee on Accreditation for the Emergency Medical Services Professions released new standards for airway management procedures for EMS students, and the CNM faculty says in a news release they are not achievable.

“The paramedic student should have no fewer than 50 attempts at airway management across all age levels,” the new standards say, and the student “needs to be 100 percent successful in the management of their last 20 attempts at airway management.”

Okay, so the EMS program faculty states 50 attempts at airway management, with the last 20 successful, is an unreachable goal. Never mind the fact that paramedics are required to manage the same airways in more austere conditions than our in-hospital colleagues. Never mind the fact that the standard they can’t meet is only a small fraction of that required of CRNA students and anesthesiology residents.

Never mind all that. We can’t meet our goal. Let’s lower the standard.

Allow me paint for you a little self-fulfilling prophecy:

  1. Paramedics gripe because they are underpaid and disrespected, and have difficulty obtaining reciprocity in other states.
  2. ED physicians complain because we bring them patients whose airways are poorly managed.
  3. A deficiency in training and education is identified. Educator societies like NAEMSE and accrediting organizations like CoAEMSP push for more stringent educational standards. The bar is raised for education in airway management.
  4. Educational institutions struggle to meet those standards. Some of them, thinking creatively, do just that. Partnerships emerge between those institutions and the agencies who hire their students. Pockets of excellence emerge, primarily in those areas with a commitment to education and strong medical oversight. Many others, however, complain that the standards cannot be met, and push for lowering the bar.

    Meanwhile, paramedic students balk at paying higher tuition and attending school for longer just to meet those standards, so they flock to the schools with lower standards. They rationalize taking the path of least resistance because they will be paid the same as those chumps who laid out all that extra money at the big school across town.
  5. Studies emerge indicating that profession-wide, paramedics suck at airway management. Other studies are published from those pockets of excellence that show just the opposite, but they are overwhelmed by the sheer volume of negative studies from those areas served by the schools with low standards. Eventually, a meta-analysis of those studies concludes that, despite a few isolated pockets of excellence, paramedics do indeed suck at airway management, and recommends that endotracheal intubation not be allowed outside the hospital.
  6. Policy makers, seeing the handwriting on the wall, delete endotracheal intubation from subsequent revisions of the EMS Educational Standards. Some areas insist on retaining endotracheal intubation in the paramedic skill set and take steps to provide the requisite education, training and medical oversight.
  7. ED physicians complain because we bring them patients whose airways are poorly managed.
  8. Paramedics gripe because they are underpaid and disrespected, and have difficulty obtaining reciprocity in other states.

And we help do it to ourselves, because we accept the soft bigotry of low expectations.

Thinking outside the bigotry box
Are those airway standards actually unattainable? Or is CNMCC merely unwilling to try? Keep in mind that the requirement does not say “endotracheal intubation.” It says “airway management.”

“Airway management” casts a pretty broad net. Oral and nasal airways, supraglottic airways, endotracheal intubation, even suctioning and simple positioning are all elements of airway management. There are myriad ways CNMCC can meet those standards without scheduling students for an infrequent endotracheal intubation during a pre-scheduled OR rotation.

Shadow a respiratory therapist for a shift or three. You’ll suction quite a few tracheostomies, believe me. That’s airway management.

Ask if their students can bag surgical patients for a minute or so prior to insertion of an invasive airway. That’s airway management.

Sign a clinical agreement with the local animal shelter, and set up a table next to the euthanasia suite. I had an entire class of paramedic students who learned to intubate pediatric patients by practicing on freshly euthanized cats. That’s airway management.

Even better, it’s effective pediatric airway management, which was hard to get even twenty years ago.

Is it numbers or is it competency?
Instead of limiting their students to endotracheal intubations, have them drop some of those laryngeal mask airways that are so ubiquitous in operating suites these days.  That’s airway management.

The gas-passers aren’t inserting them because they’re ineffective, folks. They work. A couple of years ago, I had a student from a CoAEMSP-accredited program who obtained his very first live endotracheal intubation eleven shifts after he passed his NREMT paramedic exam. He was one shift away from being assigned his own EMT-B partner and his own truck, and he’d never intubated a live human being before.

He’d gotten his program’s five requisite successful intubations on Sim Man ... and watched nearly a hundred insertions of laryngeal mask airways without ever asking to do one. When I asked him why, he shrugged and said LMA insertions weren’t required to graduate. Endotracheal intubations were. He, and most of his classmates, had succumbed to the bigotry of low expectations.

Making it work
Fifteen years ago, my paramedic students were being denied the opportunity to intubate during OR rotations, because the CRNA students and anesthesiology residents had all the OR time at the teaching hospital sewn up, and virtually all scheduled surgeries at the other hospitals in town used one of the two private anesthesiology groups in town. I was told that they’d never let students — especially paramedic students — intubate their patients. I mined a few contacts, and wound up taking a doctor from each group to lunch. I paid them each to guest lecture and provide skills instruction on airway management to my paramedic class for a couple of hours.

And before they showed up, I made dead certain that every one of my students could fall down a flight of stairs and accidentally intubate five people on the way down.

Both doctors were genuinely impressed with my students’ skill and knowledge, and all the obstacles to them performing intubations in the OR magically disappeared. More often than not, they’d come fetch my students for the more interesting cases, and coach them through it.

High-fidelity simulation labs are expensive undertakings, to be sure, but it can be done. Grant monies are available. Consortiums with other programs are common. So are partnerships with the agencies that hire their graduates. There are ways to get it done.

Not even trying is accepting the bigotry of low expectations, and like the Michelangelo quote at the beginning of this article, the danger to our profession is that we will actually meet them. 

Correction: December 8, 2014:

Recently, I was contacted by faculty members of Central New Mexico Community College’s EMS Program regarding what they felt were factual inaccuracies in the way my column portrayed their program. Understandably, they wanted to set the record straight.

My column was based upon a news article that appeared in Albuquerque Business First on June 28, 2013. As it turns out, that article was the result of significant editing of a press release released by CNMCC on behalf of a number of New Mexico EMS education programs who had participated in research to determine the number of live intubations typically required in paramedic training programs. Ultimately, the edits of that press release by Albuquerque Business First reporter Dennis Domrzalski painted a somewhat distorted and inaccurate view of Central New Mexico Community College’s EMS program. Michael J. Voss, Associate Dean of Allied Health and Diagnostic Programs at CNMCC, explains:

“CNM meets all CoAEMSP standards for airway management and is one of the top performing programs in the country when it comes to paramedic students passing the NREMT exam on the first attempt.  Our students meet or exceed all CoA standards for entry-level competency into the profession.  The Albuquerque Business First article was not about any difficulty our program was having meeting the new interpretations of the CoA standards, rather it was about our faculty contributing to the larger body of EMS education research.  A group of EMS educators in New Mexico came together to conduct research to determine the number of live airway management experiences that are included in a typical paramedic training program.  That research formed the basis of a recommendation that paramedic programs build in at least 40 lab airway management experiences for students in order to meet the CoA airway management standard.”

I’m glad to see that not only does CNMCC exceed the current CoAEMSP accreditation standards on airway management, but is also actively participating in research to improve and bolster those standards.

This does not change the larger point in my column, however; that far too many EMS education programs accept the soft bigotry of low expectations. It is gratifying to know that the programs that participated in this research do not fall into that category. Would that more EMS education programs around the country followed their example.

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