Okay so in my town my buddy and I always question if a cardiac arrest is necessarily a need for ALS or if more BLS hands on is what it will take to make resuscitation more likely. For those who are curious we live in NJ in case someone was curious as to what scope of practice we have.

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OK - Rogue, thanks for clarifying.  I thought I missed something.

Can we talk about the subject and not get lost in debating technique again?  That becomes oh so wearisome on this forum.

Tom's argument also makes sense - if the skill is weak to start with (poor training), then is further diluted or decayed, you get worse.  No study to support it, but a simple experiment with diluting different concentrations of a substance will clearly make the point.

No surprise that some of us perceive more than one weakness in our world.


Surely you will concede that there's a difference between "skill dilution" and "never had the skill in the first place".

They are not the same problem, but they are not completely separate, either.

People satisfied with poor skills to begin with are going to be easily impressed by having a lot of people with those poor skills.

Both are problems of assessment/oversight of quality.


There's a place for worrying about skill dilution but I reject the idea that skill dilution is the primary problem when it comes to prehospital airway management.

Did I claim that skill dilution is the primary problem?

Does skill dilution have to be the most lethal problem before we address the problem of skill dilution?


That presupposes that our paramedics come out of school highly skilled in advanced airway management, which frankly, I find laughable at this point.

When have I ever suggested that we do a good job of educating paramedics?

The problem is not just skill dilution or poor educational standards or low pay or anything else. These are all problems. They all need to be addressed if we are to do more than just move patients from point A to point B while following protocol C.

We cannot separate these problems, except by fixing just one.

There is also research that addresses skill dilution in people better educated than EMS, so the never knew it problem does not appear to be a factor in that research.



Can we talk about the subject and not get lost in debating technique again?  That becomes oh so wearisome on this forum.

But how can I respond to Ben without using sarcasm?

There is nothing there to take seriously. 

I will let Ben continue to provide an imitation of Jenny McCarthy explaining science. 


Since you generally don't respond to what I actually say, I'm unsure about how you would be able to correct that defect in your presentations here.


You generally create straw man arguments that sound a little like something I said, then attack them.

When you do that, you're actually doing the Jenny McCarthy impersonation yourself.


As for science, did you SERIOUSLY use studies related to intubating cardiac arrest patients in a discussion about skills dilution related to evidence-based medicine?  Because, as we know, the evidence is that intubation has not been shown to improve cardiac arrest outcomes.   Great, you showed evidence of skills dilution in a skill that has been shown to not improve outcomes.  Pretty Jenny-esque there Rogue.


Rogue Medic said:


Can we talk about the subject and not get lost in debating technique again?  That becomes oh so wearisome on this forum.

But how can I respond to Ben without using sarcasm?

There is nothing there to take seriously. 

I will let Ben continue to provide an imitation of Jenny McCarthy explaining science. 


The problem with poor initial education and training is that the provider never knows what it's like to be competent. So instead of:


Excellent initial education and training > provider is fully trained and competent > infrequent clinical encounters dilute skill level over time > skill level is no longer optimal (and this is all measured) > provider recognizes the gap between previous skill level and current skill level > provider agitates for opportunities to train (or they are already provided because the EMS system has a conscience)


It looks like:


Substandard initial training > providers mistakes this for competence > relatively infrequent airway encounters "go however they go" > no data is collected so every provider is exactly as good as they think they are > academia speculates that EMS may generally suck at intubation > a bunch of paramedics become angry and protest that "they are trying to take our intubation away and turn us into EMTs" > people look at King County Medic One and Boston EMS and say, "the problem is too many paramedics"

There's another link between skill dilution and never had the skill in the first place that hasn't been explored yet.

If a system is awash with paramedics and a paramedic doesn't have the requisite ability to implement specific interventions, then it's easier for that paramedic to hide behind other paramedics. Now there isn't anything wrong with asking for help. The problem is that when a paramedic hides in the background and the deficiencies never come to light, then there's the real risk of that paramedic getting a patient and not having backup. This is compounded in EMS by having limited backup, in contrast to a hospital where if the EM physician fails a tube he can always page anesthesiology or RT in all but the smallest of hospitals. Additionally, EMS often has a limited number of options. If all you have is a hammer, then everything is a nail, even screws. Similarly, if all you have is a laryngoscope...

I just love it when professionals can get together and have a well rounded, intelligent discussion regarding common issues and the future of EMS.  (He says with tongue-in-cheek.)  But then being marginally educated, of limited experience and retired what the heck do I know.


On the topic of a vast quantity of "patch wears" falling all over each other on the scene, my Pappy always said, "More ain't always better."  And then thar's that one about too many cooks.

As far as skills and their retention is concerned...only you and the cow knows how good you are at milking.  Sorta like the barely competent practicianer and the patient I'd say.


If you are gonna get more money to rapidly produce somethin, the first thing that's usually sacrificed is the quality of your product.  I love my microwave oven, but it still sucks at cooking eggs.


One of my favorites....practice makes perfect.  Maintaining perfection takes more practice.


I did see a strawman earlier this month when I was vistin cousins up thar in the mountains.


Sarcasm anyone?


Scott Lancaster,


I agree that skills dilution is a known issue, but when studies are cited to support an extreme position based on personal bias, then it's fair to critique both the limitations of the studies and how at least some of them really don't support the personal bias demonstrated by the person making the claim.


When the topic (look up, the topic is "Cardiac Arrest: BlS or ALS job") then it is not only fair but expected to critique the use of studies on skills dilution that are a) based on ET intubation as the sole skill studied and b) that don't recognize the well-known fact that ET intubation hasn't been shown to improve cardiac arrest outcomes - you know, the thing we REALLY want to improve. 


As for the "professional fighting", if you don't want straw man arguments or other logical fallacies pointed out, then you should be focusing on the peple that use the logical fallacies, not the one that points it out.  If someone is incapable of discussing a point without using logical fallacies, THAT is the problem.  Why would you want to give people that use illogical, fallacious arguments about what the evidence supposedly shows a free pass?


As for that "meaning of a known term", the point I made was "known to whom"?   "You know what I meant" is not a valid argument when we're talking about science.  If we can't even define the terms, then it makes the term meaningless.  Once again, the dictionary definition for that term couldn't settle on just one interpretation, two of the three definitions were completely subjective, and the person that first used the term couldn't or wouldn't define it.   Who would have thought that asking for a definition of terms would create such a sensitive reaction?   It shouldn't - if we're going to have a discussion of the science behind what we do, definition of terms should be more than just "everyone should know what I mean" or some other call to read someone else's mind...anonymously...via the internet.


You are mischaracterizing my motives here, too.  What I want is honest, factual, and logical debate.  Sometimes we get that here, sometimes we don't.  I also want the debate to be about what was actually said, not about someone's ability to throw out juvenile ad hominem personal attacks when he can't factually rebut what someone else states and/or when he can't or won't answer questions that vary from his carefully-crafted script.  In fact, Rogue did something even sillier that I've let slide until now.


He cited a RESPONSE TIME study in a debate about skill dilution. 

Lack of association between prehospital response times and patient outcomes.
Blackwell TH, Kline JA, Willis JJ, Hicks GM.
Prehosp Emerg Care. 2009 Oct-Dec;13(4):444-50.
PMID: 19731155 [PubMed - indexed for MEDLINE]


Now there is a logical fallacy for you - his use of a study on another topic isn't evidence.  It's just diversionary.


In one of your other posts, you told me that I should provide evidence that skills dilution isn't a problem.  That doesn't demonstrate understanding of understanding research design. 


This is pretty basic to research design and review - if we are discussing study results that purport to support Working Hypothesis A, when point out flaws and limitations in that research, and point out additional flaws in claims about how that study applies in the real world, then there is no need nor obligation to find other research that may or may not support Null Hypothesis B. 


That is essentially what both you and Rogue asked me to do.  All I'm asking in return is that you don't confuse the discussion of the limitations of Hypothesis A studies with a demand that those results be blindly accepted unless Null Hypothesis B can somehow be proven.  There is no need to prove the null in order to point out flaws with the working hypothsis research and in how it is applied.


Bottom line - if we're going to claim to be evidence-based, we can't base our explanation of the evidence on logical fallacies.  We can't simply ignore variables that were not controlled in the study as if they were meaningless when in some cases, they can be critical.   If logical fallacies are used, having them pointed out should not only be accepted, it should be expected.  We should be calling out the people that use those tactics, not the ones that point it out.

Scott Lancaster said:

1) Skills dilution and lack of recurrent practice is a known issue - using ETI (which has been studied a lot pre-hospitally) is a good example. Yes it is not the be all end all, but we know there is a correlation between repetition and competency.

     A) attempting to discredit the point made by talking about ETI in cardiac arrest is a bit irrelevant - that topic is settled (for now anyway).

     B) using the example of skill deterioration and complex procedures, ETI is kind of the standard barrer, not just in cardiac arrest.

2) I agree that it's hard to measure true loss of ability without knowing the actual ability after initial training. We can look at system success rates as medic numbers grew, or BLS decreased with sustained volumes and see if there is a difference.

3) Inability to manage an airway is a problem; I don't care if it's because your aren't trained, aren't current, or simply don't care! They are all problems, of perhaps close to equal importance. Shall we only pick one problem at a time to address?

4) STOP THE PERSONAL FIGHTING! BEN: in almost every post you seem to get into a debate about semantics and throw out your term-of-the week (straw-man this week, or you fight over the meaning of a known term; gold-standard, best practice ) in an apparent attempt to show how much you know. I don't know if that is how you mean to come off, but damn does it get annoying. Debate the science, the evidence please, not someones use of the english language.

Rouge and I have gone back and forth in other dB's on this forum, I am not picking sides in this one but after further conversation with him offline (messages) it turned out that for the most part we were really both on the same side of the argument, but digging our heals in a stupid and meaningless points was getting us nowhere.

If we want to get into a thread about initial training standards, great! I really believe that the new National Educational Standards blew a golden opportunity to really address some of those issues.

Scott, show me where I have ever attacked anyone here, with the exception of responding in kind to Rogue.  Yes, I'm questioning your assertion.  Yes, that was sarcasm.


As to your call for research to "start anew", that's actually a step past asking me to prove the null, when even asking to prove the null was outside the scope of the discussion.  Since virtually every research study ever published ends with "more research is needed", isn't that what you did?   I'm not saying that's a bad thing, but look at it in the context of the thread, and it appears to be a demand that I dig up research that proves Rogue's null.   I appreciate your clarification.


You are right about using "evidence based" without really finding the evidence, but when the studies don't account for the basics of Research Design 101, is it really evidence?  If someone uses evidence to support an argument that the evidence clearly doesn't make, is THAT really evidence? 


Oh, and your "STATS 504 prof." comment is another logical fallacy - the Appeal to Authority.  I'll have to see my LOGIC 101 prof. about that one.   :-)


Scott Lancaster said:

"We should be calling out the people that use those tactics, not the ones that point it out." Agreed, but when they question your assertion the attacks and repeating of the opinion is all I see in return.

I must agree....this thread has deteriorated into a rope challenge of semantics.


Situations such as this are but one indication of why EMS does not have a united front for making the necessary changes.



Scott Lancaster said:

Also, I don't agree that ETI is the only thing that has been studied in cardiac arrest that's applicable; since there is no evidence that drugs work either you can say the only thing that HAS been proven is CPR and early defib help. Sure, not a skills dilution issue, but since that wasn't the OP's question...

Actually, CPR and defib are skills dilution issues, or at least skill decay issues. There is a whole separate body of literature on how long CPR skills are retained after training (though I don't know that any of it has been done after the 2005 or 2010 updates). Again important is how well trained people are in the first place....

If you want to talk about skill dilution, look at how many millions of CPR certified providers there are in this country! More than there are EMTs of all levels combined! :P

One of the ways that Wikipedia has solved the problem of infighting between editors has been establishing a code of conduct that includes civility (one of Wikipedia's "five pillars"). It helps promote an atmosphere of collegiality (shared responsibility and presumption of good faith). The policy is intended to make editing the Wikipedia as pleasant as possible because it's a voluntary activity and they want to attract as many talented editors as possible who would otherwise find something else to do with their valuable time. This is just a general comment and I am not accusing anyone of incivility but I do think a lot of these threads devolve into debate for the sake of argument which does not lend itself to civil, professional discourse for the purposes of learning and advancement of the EMS profession. It probably also runs off some interesting people. Not that I don't find you all fascinating! :)

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