Horses and Camels: Design by Committee
A recent study from the National Registry of Emergency Medical Technicians (NREMT) found that in their target group, for every 30 days testing is delayed, pass rates decreased by 2.5%. This was supported by a similar study from Los Angeles, California,1 and commanded my attention as it would appear that some schools might be preparing students to take a test as opposed to ensuring learning. That in turn led me to wonder if their EMT or paramedic knowledge might also deteriorate every month after graduation.
It seems logical that the exams used by states as the final part of a certification process should evaluate provider competence. After all, these tests are designed for that purpose by individuals from various backgrounds who bring their collective knowledge and experience together as committees.
If these exams have been validated, as claimed, they should be useful for evaluating the knowledge required to function autonomously in the field of EMS. It would appear from the referenced study, however, that much of the comprehension may be fleeting.
Compromise and Accommodation
“A camel is a horse designed by a committee.” This expression is a reference to committee output, which can involve compromise, accommodation, or both. Compromise includes sacrifice in order to produce a collaborative output, while accommodation can result in everyone getting what they want, leading to over-design.
In many facets of our business, we accept the concurrence of committees as representing best practice. Looking broadly at categories such as curricula, guidelines, standards, and vehicle design, a back-of-mind concern should always be whether the results actually reflect an optimal approach or merely the outcome of accommodation and compromise.
Emergency Care Guidelines
From a more global perspective, the American Heart Association (AHA) issues updated guidelines every five years covering many aspects of emergency care for patients of all ages.2 These standards arise from the consensus of the International Liaison Committee on Resuscitation (ILCOR),3 which are then edited by other committees located on both sides of the Atlantic Ocean. The resulting outputs vary somewhat based on differing amounts of accommodation and compromise.
These guidelines become the basis for much of the emergency care provided in this country. While many agencies and medical directors have discretion in what they approve, others do not and are locked into providing standardized care, which may not always be optimal. A major drawback is that much of the evidence does not differentiate between in- and out-of-hospital events.
Prehospital vs. In-Hospital
One example of this discrepancy is the late addition of enhanced pediatric cardiac arrest ventilation rates to the previous edition of the guidelines. Based on a small retrospective study of admitted patients in a critical care unit, rates more than double what had been previously promulgated were recommended. This caused great consternation among several medical directors for a few reasons.
Children in critical care units have vital signs and fluid intake and output closely monitored. There should be rapid awareness at the moment of cardiac arrest. Out-of-hospital events arise from various conditions with altered physiological states that lead to arrest. The treatment of these two categories of patients should be as varied as their precipitating events.
Real-World Results
It has been demonstrated that the reduced perfusion states that occur during cardiopulmonary resuscitation require less ventilation. Higher rates of ventilation can also increase intrathoracic pressure, which may lead to reduced cardiac output. Prehospital agencies that perform high-quality resuscitation with controlled ventilation have demonstrated enhanced rates of neurologically intact survival.
Despite prehospital evidence to the contrary, the latest guidelines still recommend a ventilation rate with CPR and an advanced airway that is not only substantially higher than what has been shown to be optimal, but is identical to that used for respiratory arrest. A basic understanding of the physiology related to both conditions should validate the logic for different approaches.
Individualized Approaches
While many advances in patient care have been born from the consensus of broad-based experts, varied presentations must be considered. The desire to create consensus should not override individual circumstances that necessitate varied approaches to produce the best outcomes.
Committees are necessary to allow the sharing of varied viewpoints, exchange of concerns and healthy debate to produce consensus that ideally leads to the best possible outcomes. In contrast, Rube Goldberg was a cartoonist whose 20th Century work often depicted devices deliberately designed to perform simple tasks in overly complicated ways.
If your committee sets out to design a herd of thoroughbreds, don’t wind up settling for a pack of camels.
References
- Kreysa PG, Martinez L, O'Lawrence H. The Adverse Impact of Delay Upon Successfully Completing the National Registry EMT Exam on the First Attempt. Adv Med Educ Pract. 2025 Dec 19;16:2341-2348.doi: 10.2147/AMEP.S562663. PMID: 41450460; PMCID: PMC12729021. https://pmc.ncbi.nlm.nih.gov/articles/PMC12729021/
- American Heart Association (2025). 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Vol. 152 No. 16 Suppl 2. https://www.ahajournals.org/toc/circ/152/16_suppl_2
- 2025 International Liaison Committee on Resuscitation Consensus on Science with Treatment Recommendations. Resuscitation. Volume 215 Supplement 2. https://www.resuscitationjournal.com/issue/S0300-9572(25)X0013-7
