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

- Rogue Medic

Calling Medical Command for Deviation from Standing Orders

I occasionally have conversations with paramedics who have been written up for violating protocol, even though they received permission from a medical command doctor.

Some systems that require medical command contact do not permit deviations from the protocols listed, even with permission from a medical command physician.

What is the point of requiring medical command permission for some treatments, but prohibiting medical command permission on things that have not been included in protocols?

1. The medical command physician could recommend something dangerous.

There is nothing about medical command permission that prevents dangerous orders.

2. Paramedics must be limited to really simple things, because paramedics cannot understand anything complicated.

Reading 12 lead ECGs (ElectroCardioGrams) is something that is expected of paramedics in many places, but 12 lead ECG interpretation is not at all simple. Ask a cardiologist.

3. We mustn’t permit paramedics to think. They must pick a protocol and follow it to the end.

The end of the ride, end of the protocol, end of the patient (but not in a Braselow way), . . . .

4. We mustn’t require that QA/QI/CYA employees understand patient care, only that they look for deviations from protocol.

One benefit of this is the ability to reassign paramedics who are too dangerous to be treating patients. It is easier to enforce a protocol as an absolute rule, much more important than appropriate patient care, if there is no understanding of appropriate patient care.

5. Laziness.

A computer program can match treatment and protocol and identify deviations. No staff is required. No thought is required.

6. We have to control the information the medical directors receives.

We don’t understand medical treatment well enough to explain protocol deviations to our medical director, so we do all protocol-related discipline in-house. Better to kill some patients with ignorance, than to expect us to actually understand what we are doing.



My protocols do not prevent deviation.

Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS personnel to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances. When the practitioner believes that following a protocol is not in the best interest of the patient, the EMS practitioner must contact a medical command physician if possible. Cases where deviation from a protocol is justified are rare. The reason for any deviation should be documented. All deviations are subject to investigation to determine whether or not they were appropriate. In all cases, EMS personnel are expected to deliver care within the scope of practice for their level of certification.[1]

That is from my protocols.

There is no requirement that paramedics in Pennsylvania kill patients to protect protocols. Why do the people who write protocols in other places think that the protocol is more important than the patient?

How many patients really want to be treated by someone who is prevented from using judgment – even when in contact with an approved medical command doctor?

Essentially, these kinds of protocols prevent the medical command doctors from using judgment just as much as they prevent the paramedic from using judgment.


[1] Pennsylvania Statewide Advanced Life Support Protocols
2008 protocols page 6/121
2011 protocols page 6/128
Page with links to protocols



  1. The next step is making sure that “investigation” is not a synonym for “witchhunt”.

  2. I think part of the reason for this is the great number of administrators/managers of EMS have little to medical background. When you have business majors, or even worse, fire chiefs trying to run ambulance services, the only thing they understand are straight forward, simple to follow flow charts. That is what protocols give them, and the less wiggle room within those protocols the better for their understanding.

  3. What about, I want to deviate from the golden protocol of they might’ve fallen and we must always immobilize? what about the altered that only gets combative if you attempt to “immobilize” them? I say call(shouldn’t have to, but it’s the idiotic american system we have) and get “permission” to deviate and not immobilize. Why do so many medics(and med command doctors too) rather think the best answer is to just immobilize anyway, or at best sedate them enough that you can immobilize when there’s no evidence to suggest the patient needs that anyway?