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

- Rogue Medic

Protocol Deviation and Mother-May-I Silliness

In response to the conversation David Aber and I had at the end of last week’s episode of EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, David Aber and I discuss the problems with requiring permission to deviate from protocols that cannot possibly cover every patient. I was on a call for the first 45 minutes of the show, but I do get on the show at the end.

EMS Protocol Deviation

When is the right time to talk with a doctor for protocol deviation?

Is the protocol badly written?

Before the new protocol is finalized is the best time, but not all of us can attend protocol development meetings.

Next would be after the protocol is written, contacting the medical director(s) to change the protocol.

The best time to change a bad protocol is before the call, but that is not always possible.


Protocol deviations are NOT a bad thing.

The protocols are guidelines and cannot be intended to cover all patient care situations, except in systems where the medical director is discouraging competence.

Rigid protocols are part of the the same idea that is behind on line medical command permission requirements. Both encourage incompetence and discourage competence.

I know he’s incompetent, but he can’t do anything dangerous without calling, so the patients are safe.

I used to regularly hear variations on this from a county medical director as a justification for ignoring incompetence, but requiring rigid protocols and medical command permission for almost everything.

What kind of education is required to follow rigid protocols?

Very very little.

What kind of education is required to follow on line medical command permission requirements?

Very very little.

Skills training – IV training, minimal intubation training, an ability to ignore the harm we are causing, a ruthless devotion to the protocol, and not much else.



Really. There is no requirement for an understanding of assessment.

There is no need, since that would suggest that a paramedic is capable of understanding what to assess for without calling command or without reading it out of the protocol.

If a medic understands what to assess for, who knows what kind of things the medic might do next. Assessment involves thinking and we cannot have thinking.

Image credit.

This is what our EMS education is geared toward in too many places.

Doctors are encouraging bad EMS care because they do not trust EMS.

They don’t trust EMS for a variety of reasons, but a big one is the low quality of education.

Our education is based on handing down traditional treatments and only discarding treatments reluctantly, and only when told to by someone in a position of unquestioned authority.


We don’t know and we don’t care. It isn’t going to be on the test.

How do we know what works?


What is the quickest way to scare away medics, nurses, and doctors?

Start talking about research.

This is changing as more understanding of research is required in medical school, but even medical schools are ignoring research and adopting alternative medicine.[1]

What are two things NOT supported by research?

Rigid protocols.

Medical command permission requirements.

Where is the evidence to support these dangerous practices?

But that’s the way we’ve always done it.

Put that in a translator and out comes –

But we like being incompetent. You can’t expect us to change now.

What is required to get a medic card? A multiple choice written test and a highly structured practical exam. Does this have anything to do with ability to work independently?

We cannot even take the test without first completing a paramedic course, because if we were to allow untrained people to take the test, too many would pass.

A valid test does not need to limit candidates to only those who have taken a full course. If the candidates do not know what they are doing, they cannot pass a valid test.

Well, they sat through all of paramedic school, so how dangerous can they be?

How bad can we be?

Look at how bad we are at treating tension pneumothorax.[2]

Click on the image to make it larger.

How dangerous is that?

It depends on which side of the needle you are on.

We are sticking needles in the chests of patients who do not have any reason to be harpooned.

What kind of remediation was there? None was mentioned in the study.

How bad can we be?

Look at how bad we are at intubation.[3]

How dangerous is that?

It depends on which side of the endotracheal tube you are on.

Go listen to the podcast.


[1] Evil Spirits, Shock Trauma, Anecdotes, and Gullibility
Rogue Medic
Sun, 26 Sep 2010

[2] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011

[3] In Defense of Intubation Incompetence – Part II
Rogue Medic
Sun, 21 Aug 2011