Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Increased Standing Orders

Peter Canning has been writing about the 16 biggest treatment changes over his 20 years as a paramedic. He starts his list by emphasizing the positive –

Increased Standing Orders.[1]

I would probably emphasize the negative –

Decreased Mother-May-I Restrictions.

I am not criticizing Peter’s style. He has made a living as a writer before becoming a paramedic and has added to that by writing a couple of books after becoming a paramedic. I am just easing my way toward why I emphasize the negative of these requirements.

As with many other things I write about, there has never been any evidence that Mother-May-I restrictions OLMC (On-Line Medical Command) permission requirements provide any benefit. There is plenty of evidence of harm to patients from these obstacles to patient care.[2],[3]

We would be much better off with more aggressive oversight of EMS by medical directors. This magic phone call is not oversight, but only smoke and mirrors.

Then there is the bigger problem – the ridiculous idea of They have to call to do anything dangerous.

High flow oxygen has been a standing order requirement in many of these Mother-May-I systems. High flow oxygen is almost always harmful to our patients.

Dangerous paramedics need to be remediated, and if they cannot be remediated they should be terminated, not given a magic safety phone to use in cases where a competent medic is needed.

Go read the rest of the not-yet-completed list of 16 biggest changes in EMS over the past 20 years.


[1] Increased Standing Orders
Street Watch: Notes of a Paramedic
March 31, 2012

[2] Refusal of base station physicians to authorize narcotic analgesia.
Gabbay DS, Dickinson ET.
Prehosp Emerg Care. 2001 Jul-Sep;5(3):293-5. No abstract available.
PMID: 11446548 [PubMed – indexed for MEDLINE]

We report two cases where paramedics’ requests for intravenous (IV) morphine to treat isolated extremity injuries were refused by base station physicians providing online medical oversight because those physicians felt that the use of morphine would alter the patient’s ability to be consented for potential surgery after arrival at the hospital.

[3] Effects of on-line medical control in the prehospital treatment of atraumatic illness.
Klein KR, Spillane LL, Chiumento S, Schneider SM.
Prehosp Emerg Care. 1997 Apr-Jun;1(2):80-4.
PMID: 9709343 [PubMed – indexed for MEDLINE]

OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.



  1. “Online medical control” is a joke, it is a symptom of the fractured approach to EMS in US and the poor education that results. For Johnny and Roy’s sake they had 12 weeks of training in 1972 and there are some places that forty years later still give people 12 weeks of training plus a couple hundred hours of “skills internship” before licensing them as a Paramedic, and this is acceptable in at least two states. Despite the EMS Agenda for the Future being released in 1996 the millions of dollars poured into it has achieved less in nearly 20 years than similar programs in Australia, New Zealand, Canada and Ireland have achieved in less time, and still fails to deliver any real, meaningful change that will benefit patients and the profession; for frick sake GTN, entonox and salbutamol are still considered “Advanced” procedures!

    Nowhere else in the developed world (except Canada) does the concept of “medical control” and “seeking permission” to practice one’s profsession exist.. It pains me greatly and truly breaks my heart that despite the massive advances made elsewhere in the world the US broadly speaking, falls far, far, far behind with no end in sight.

    Hello? medical control? Yes we have somebody in pain, can we get 2mg of morphine please?