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

- Rogue Medic

50 Plus Shades of Grey – Protocols

Continuing from the first two 50 Shades of Grey parts, David adds Part 3.

And that same medical director is usually the ones whose license paramedics work under.[1]

Paramedics do not work under a doctor’s license.

If I authorize you to drive my car, you are not operating the car on my license.

I could do street-side surgery and not endanger the doctor’s license.

However, when a system puts something in black and white, then this is what is to be followed. No Grey.[1]

Anything written in black and white has shades of grey. If not, there would not be much reason for a Supreme Court and all decisions by the court would be unanimous. They are working with black and white.

The question is whether our highest priority is the patient or the protocol.

Patients often do not present as black and white, but as grey.

Image source.

The requirement for a Mother-May-I phone call is based on mythology and has never been shown to protect patients. On the contrary, these magic phone call requirements endanger patients.

Epinephrine is not required in ACLS (Advanced Cardiac Life Support), but generally is required in EMS protocols in the US.

In the next revision of ACLS, don’t be surprised if the AHA (American Heart Association) changes their wording from consider to something that is less likely to produce the reflexive everybody dead gets epi that is in so many EMS protocols.

It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).[2]

Black and white. (OK, it is orange and white.)

ACLS does not provide us with any ALS (Advanced Life Support) treatment that improves outcomes, but we convince ourselves that ALS treatments improve outcomes based on wishful thinking and seeing it in black and white.

It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of out-of-hospital cardiac arrest.[2]

For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.128,–,133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.31,33,134,–,138 [2]

Understanding the importance of diagnosing and treating the underlying cause is fundamental to management of all cardiac arrest rhythms.[2]

It is important to understand that the routine ALS treatments probably harm patients, but our protocols tend to prevent us from following the ACLS guidelines.

We are only required to consider epinephrine. Unfortunately, the people writing the protocols do not seem to understand black and white, so the protocols tend to make epinephrine mandatory.

In the example David cites (the pdf does not open), the medic clearly should have called medical command to ask if he should have brought his gear on a call for a patient with difficulty breathing. He also should have called medical command to ask if he should have checked vital signs on the difficulty breathing patient, who apparently was not having difficult breathing due to death.

Magic phone calls encourage medical directors to keep these medics working, because they have to call to do anything dangerous.

That is the idea. That is not the reality, as this example makes clear.

Walking a patient to the ambulance is also something that should only have been done after a Mother-May-I phone call. The same for the IV medication – giving it or withholding it. We can’t be too careful.

It is not at all clear that either the walking or the lack of however much IV medication (probably just saline solution) contributed to the death of the patient.

It is also not clear that the death would have been prevented or that a lawsuit over the death would have been prevented.

The apparent mandatory nature of protocol makes this a protocol violation and therefore grounds for a law suit.

The failure to bring equipment on a difficulty breathing (or cardiac arrest) call and the failure to assess for vital signs are signs of horrible judgment that were not addressed by Mother-May-I phone call requirements. The failure is the dependence on the Mother-May-I phone call, rather than a requirement to assess the competence of the care delivered to patients by the paramedic.

Poorly written, inflexible protocols are not oversight. A magic phone call requirement is not oversight.


[1] 50 Shades of Grey…Protocols (Part 3)
David Aber
The EMS Difference
July 13, 2012

[2] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Free Full Text from Circulation



  1. As a Brit I’ve always found the concept of a ‘mother may I’ phone call an odd concept. I’d love to see if there is a significant difference in training that warrants it.
    U.S paras certainly seem knowledgeable from what I’ve read.

  2. Tim,
    I think we can agree that we disagree on this subject. I will leave you with few points from my post.
    1) Where I work we DO operate under a physicians license.

    (22) “State EMS Medical Director” shall mean a physician who is board-certified by the American Board of Emergency Medicine and/or by the Osteopathic Board of Emergency Medicine and who shall be the chief physician for the statewide emergency medical system and under whose license all EMS providers shall operate for the purpose of delivering the standing orders of the statewide standard treatment protocol
    From reading other states DOH regulations, it looks the same. Yes, I have a pretty piece of paper that has the word license on it, but a doctor gave approval for me to get this after meeting conditions. And that same doctor can take it away if I violate those conditions. Go right ahead and try street side surgery outside of you scope and I am sure you won’t be providing paramedic services much longer, because that top doc will revoke your privileges to practice medicine. If that’s not the case where you work, I am still looking to try my hand at some cool surgery I saw on TV. Where do I apply?

    2)Would you please go out on your next cardiac arrest and reasonably consider not giving Epinephrine to your patient. You know that it states in Part 8 of the 2010 AH…Well, you know where it is and what it says. But you will push it because it is in your protocols. We are there for the patient not the protocol…Right? But if you did this I am sure that the doctors might just say something to you.

    3) The point in the two cases was to show examples of protocol violations that providers get questioned on when taken to a court of law. Sorry the one would not open for you, but it is now fixed.

    I am all for what is best for the patient, just like most people in EMS. But we are constrained by protocols and they are not always best for every patient in every situation. But there are correct steps to change them if you feel they can be improved upon.

    I do thank you for the responses as it has made me go back and take a good hard look at my protocols and various issues with them. I have several ideas into those that review protocols.

  3. Gosh darnit!!! Forgot to end the blockquote

  4. Good topic. One of the reasons I moved away from California was because of the “mother may I” system. I’m happy with the freedom I have now, but wish we had more drugs.

    The problem I see isn’t within the protocols, but more to due with education. Schooling for Paramedics varies so much state to state. Even county to county. There needs to be a set criteria which every single school in the States has to follow. There should be strict prerequisites as well as formal school training lasting 2 years long. Didactic should focus more on airway management. Diagnosing, and treatment modalities in sick patients. Internships should be twice if not three times as long. With more education provided for Paramedics, less protocols would be written.

  5. I am sitting here looking at my SOs and Protocols and all I see is grey. Every one of the different standing orders I have say that I “may consider” this or that with the treatments. Every one of my standing orders start at the BLS level prior to the ALS treatments. If they were black and white I would have to treat an asthmatic patient with High Flow O2, duoNeb, SoluMedrol, Breathine or Epi, and CPAP, every one, every time. If I progressed through all of that and still had an unstable patient does that mean I would have to call before I went to the RSI Standing order? By the thinking of black and white I would have to make a call before turning the page of the book.

    Protocols or standing orders are nothing more than guidelines that spell out the maximum amount of care a Paramedic is able to perform without contacting Online Medical Control for additional orders to exceed things like maximum amounts of narcotics. I have a protocol for A-Fib that allows me to cardiovert an unstable patient. It also says that if I see a ventricular rate over 100 I can consider Cardizem after consulting medical control. Does that mean I should call for an order of Cardizem with a HR of 110 and stable patient with no CHF present or Hx of CHF? If you read them as black and white you will make that call and look like an idiot as much as if you administered the Cardizem if it was a SO. Is it an educational issue that keeps that from becoming an SO? No, it is a competence issue.

    We live in a world of grey in EMS, in the entire field of emergency medicine for that matter, and there is no room for black and white. Hell, that is what makes the job a blast and that is why they call it “Practicing Medicine” in the hospital…

    Some say the education is not enough and needs to be rebuilt, I agree. The only problem is that everyone wants to put the focus on didactic hours. The issue I have with that is it does not matter how many hours you put into a classroom when a prospective Paramedic does not get any real experience in the field until they graduate, become certified, and get a job. If you want to see education get real and effective shut down the “Paramedic Factories” that allow a student to get a BLS cert the day before the Paramedic class starts. To me it is messed up that they even require that certification to start a Paramedic class if a student is not going to use it to get experience. If only those that had 5+ years of experience in EMS were allowed to start a Paramedic class then the training would be adequate. One thing that cannot be taught well in a class and is learned on the streets or doing actual patient care somewhere is critical thinking skills. That is what my paramedic students lack and 400 hours of truck time is not enough to teach that and the time to learn it is not on your first difficult run that does not follow the black and white print of the protocols…