A problem that will not go away

Improper use of medical protocols and guidelines

As I was scrolling through my social media today, I saw a post from a friend complaining about paramedics following protocols without thinking or concern of patient presentation and condition, which inspired my own take on the matter…Again…Because as the title suggests, it is a recurring problem.

One of the first things I was required to do on my very first shift when I started as a fire cadet was read the standard operating procedures binder and the Emergency Medical Service(EMS) provider protocol binder. Our fire Department also provided EMS service after taking it over from the Police Department.

The first page of that binder was entirely blank except for 1 sentence, centered in the middle of the page.

”These protocols are meant to act as guidelines to patient care and are not a substitute nor replace sound clinical judgement…”

That must have been an important sentence to not only be on the first page, but the only thing on the first page…

After a couple of weeks, there was a multiple choice test on those protocols.

Subsequently, I found employ at different agencies over a series of years, each of them had a similar exclamation and examination.

Eventually I wound up as a member on a medical protocol committee, an ancillary duty to working as a lead paramedic on an emergency ambulance, tasked with reviewing, updating, researching, and suggesting new standing order protocols to meet the needs of the EMS provider as well as that of the patients.

The very first “new” protocol suggestion I was involved in (in 2003) was clinical clearance of patients for spinal injury to remove them from “full spinal precautions,” including being strapped down to a long spine board.

It took about a month of research, including finding the 6 or so published scientific articles, from multiple medical and ancillary disciplines, demonstrating not only was spinal immobilization as we practiced it by protocol, not effective, it caused harm and presented serious health risks to patients beyond any benefit that would be derived.

While this particular agency adopted the protocol and initiated training right away, nearly 10 years later, I was still trying to convince other agencies to adopt the practice.

The resistance was extreme. Providers constantly repeated absolutely unfounded medical dogma back to me. Even though more and more studies added to the body of evidence, still today, hospitals, especially radiology departments, are demanding patients with the same outdated classical findings we used to justify it in 2002, transport patients to them on rigid spine boards.

Rather than act as patient advocates to reduce potential harm to patients, the emergency departments simply relent to their radiology colleagues in an effort to “maintain relationships.”

Think about that for a moment...

Use an outdated treatment, that is shown to be risky, and cause harm to a patient, for the benefit of a non-expert doctor in emergency or trauma care…

No wonder many doctors and paramedics are afraid of lawyers…Or the news media…

I could fill pages and pages of examples of malpractice I have witnessed from providers strictly adhering to protocols and using guidelines like the 10 Commandments.

But I will not bore you with that today or name and shame people who probably should be.

Instead, I would like to offer some insights on how to actually use protocols and guidelines, and some examples how not to.

Benefits of using protocols.

Protocols are meant to be standing orders from a physician directing medical treatment for a condition that:

A. Requires immediate action to stabilize (prevent the patient from getting worse,) or immediately treat a condition that will result in disability or death if not acted on immediately.

B. Is commonly seen and having a standardized treatment reduces workload and number of decisions to be made by the provider (for those of you with no background in industrial safety, published scientific studies in both safety and neurology, demonstrate people have limited decision making capability in a given time before a demonstrable increase in mistakes or poor decision making)

D. To permit cognitive offloading in order to focus more critically in a given situation.

E. To define roles and responsibilities of team members providing patient care.

F. To give clear, easy to follow steps, in a sequential manner, for rarely used procedures or treatments.

Those are some very good reasons to have and use protocols.

When protocols should not be used.

1. When a patient does not present in a way that clearly and easily falls under the criteria for a given protocol.

2. When the patient has had a negative outcome from the protocol in part or in whole, at that moment, or in the past.

3. For a condition in which the patient does not have.

4. In order to make the provider feel like they are doing something.

5. When no protocol exists.

Once again for the slow learners.

”These protocols are meant to act as guidelines to patient care and are not a substitute nor replace sound clinical judgement…”

Pitfalls.

The simple fact is, it is impossible to create protocols for every possible patient presentation or disease state. Such an effort would be thousands of pages long.

Even if it could be done, it is unlikely that any human could remember them all. While technology may “help” by creating searchable databases, color-coded instructions, etc., treating patients entirely by protocol removes the need of providers to make decisions.

That may sound like a benefit, especially economically, by removing the time and cost of education as well as labor costs to institutions and businesses, it comes with 2 major drawbacks.

1. It is dependent on user input.

It may come as a shock to non-medical providers reading this, but protocols and guidelines are all based on “magic words” or key words, which if not included, obfuscate which if any, protocol or guideline a patient may fall under.

2. Saying the wrong words may cause AI or other technological provision of medicine to misdiagnose or treat a non-existing condition in error.

This can be especially dangerous when the treatment for 2 different conditions are diametrically opposed.

A few examples of this include:

Pain which is indicative of a myocardial infarction vs. pain from a ruptured aortic aneurysm.

Endometriosis vs. Endometritis.

Primary vs. Secondary hypertension.

Symptoms and laboratory values consistent with ovarian cancer and gonorrhea.

These are not hypothetical, I have seen first hand all these mistakes made by providers functioning in way that tries to fit patients into protocols, rather than protocols into patients, which in all cases resulted in permanent disability or death.

I was once told by a surgical mentor of mine:

”If you try to treat a patient with a surgical illness with medicine, all you do is delay or deny that patient the care they need.”

(On more than one occasion, I was so demeaned by this doctor, I spent days contemplating my life choices, but ultimately, the benefits I received were far in excess of the psychological duress caused.)

Medicine changes over time.

I spend time nearly every day reading and searching for recent scientific publications in medicine. Generally of 2 kinds, things I am directly interested in and significant advances in any discipline of medicine.

The medicine I learned (and consequently the medical protocols I used) in 1989 was very different from 2002. Was very different from 2006. Was very different from 2012, 2014, and today in 2025.

In that time, I have been involved in updating medical protocols internationally on multiple occasions. Sometimes for individual hospitals and agencies, sometimes for entire medical specialties, sometimes for specific medical conditions, once for a major organization that publishes world-wide medical practice guidelines.

I am quite fond of pointing out:

”If you are using medicine from the 1970s, you are using medicine that is closer to World War 2 than today.” -Me.

A lot has changed since WWII. Like widespread use of antibiotics. Development and advancement of the medical specialty of Intensive care. More technology than I could possibly list in a single article, like invention of ultrasound, computer tomography, gas chromatographs, and genetic sequencing. More advances in medical and scientific knowledge than I could list here similarly, including advances I don’t even know about yet.

It is commonly said that there have been more advancements in medicine in the last 20 years than in the History of Western Medicine combined. That is more than 2000 years!

So when I see that as a profession, we are making the same mistakes repetitively, for decades, it pains me.

Another anecdote pertinent to what I will speak of next…

Sometime in 2003, I responded as the paramedic in charge of an advanced life support ambulance to:

”A man who says his pacemaker is not working…”

Fortunately, in paramedic school we learned just the solution for this. The procedure of overdrive pacing. We would (if needed) use a magnet to shut down somebody’s internal pacemaker and defibrillator and then apply our transcutaneous pacing pads and set the rate and capture amperage with our own machine.

The agency I was with had no protocol for this very thing. (Keep this in mind it will be important later.)

So my EMT partner and I jumped in the ambulance, in less than our 60-second chute-time (time from getting the 911 call to wheels rolling in the ambulance.) and drove with lights and sirens for nearly an hour on a 55 MPH speed limit country road.

When we got to the house, we were greeting by a loving and concerned family who led us right to our patient.

This guy looked fucked up! (and that is always a bad sign)

I first laid eyes on him from across the room. He was almost as pale as me. (I have been described by my South Indian friend and colleague as “whiter than Casper the friendly ghost.”)

He was tripoding, which is the medical term for leaning on his hands, to use his chest muscles to help breathe.

He was breathing about 60 times a minute. (Once every second or so.)

Southern Louisiana is normally hot in the summer, but even in the airconditioned house, this man was sweating so bad, it looked like he just got out of the tub.

If you are a trained emergency provider (and if you are not, you have been duly informed) this man was in profound shock.

The local medical providers would have described him as “FTD” (Fixin’ To Die.) Being a Yankee myself, I would prefer “CTD” (Circling The Drain.)

What is the protocol for shock?

Establish a large-bore IV line, apply 100% oxygen by nonrebreather mask, infuse 10ml/kg body weight of 0.9% NaCl, attach the heart monitor and…

I observed Ventricular Tachycardia(V-Tach) at a rate of 260 (heart) beats per minute. A pulse oximetry reading (Spo2) of 86, and a blood pressure of 90/50.

Textbook shock…Clinical symptoms, quantitative values, heart rhythm inconsistent with life. Using a lot of energy…and he had been doing this for at least the hour it took us to get to him…

Every trained paramedic in the USA knows the protocol for Vtach in an unstable patient…

Immediate synchronized cardioversion (a specific form of defibrillation) with 200Joules. (the scientific measure of force transfer)

This man fit into 4 protocols simultaneously…He had a failed internal pacemaker (1). He was in profound shock. Most likely a combination of cardiogenic(2) and hypovolemic(3). His heart rhythm was Vtach at a rate of 260+(4).

So much for cognitive offloading…

So…In a moment of clarity, I chose door number 1. Overdrive pacing. My partner looked at me like I was either mad or the worst paramedic ever on the planet.

(Perhaps the greatest skill of paramedics is that they are taught to make decisions. Clinical as well as operational as part of their initial education. Because in the USA, except in the rarest circumstances, you will be the senior medical decision maker attending the patient. You will be the one responsible for performing the interventions by your own hand mostly. You will be responsible for the safety of your vehicle, equipment, crew, bystanders, and the general public. Welcome to EMS…)

So I wiped the man off with one of those white towels we would always steal from the hospital linen cart…Placed those pacing pads, and turned those milliamps to max for capture; set the rate to 80, and took a turn spinning the wheel of misfortune…

Why max milliamps? Because I was trained in an unstable patient, start at maximum, work your way down to the lowest needed. (The opposite for a stable patient.) Why 80 beats per minute? No real answer…Gestalt…didn’t seem too low or too high...Humans like numbers divisible by 2?

I watched the pacer spikes appear on the heart monitor. I watched Vtach at 260 turn into a paced, narrow complex rhythm at a rate of 80. Pulse oximetry went up to 99. BP I honestly don’t remember, but something I was happy with…

The man got the 5ml/kg IV bolus for cardiogenic shock patients, not the 10ml/kg for hypovolemia. Oxygen was turned down to 2 liters on nasal cannula.

Hail the conquering hero!!! Veni, Vidi, Vici…

Let’s go for a ride to the hospital that will fix your pacemaker…

The next shift, the supervisor was waiting for me to arrive…He had questions about that call… Most notably, why I paced the patient instead of cardioverting him, which seemed more important to him and the protocols.

My answer was simply: “We were called for a failed pacemaker. The patient was ok until it failed. So replicating it seemed like the logical course of action…”

Apparently that was the correct answer as there were no more questions.

But what if I had followed another protocol? What if I had cardioverted him? Would his heart have stopped and never restarted? Would I have burned away what remaining physiologic pacemaker or heart muscle cells he had left? Would it have even converted the rhythm or just went back into vtach?

What if I had given him a 10ml/kg bolus or opened the IV flow rate wide open?

We will never know…

As I said, there was no protocol for overdrive pacing… But you know what else the agency didn’t have a protocol for? Hemorrhage (bleeding) control…Were we not supposed to stop bleeding? Where should we have learned it? Why did we have equipment for it?

Perhaps…Something… Something…Clinical Judgement?

Somehow I doubt very much I was supposed to call a superior and ask for permission to stop the bleeding of a patient bleeding to death or ask them how to do it…

The least common denominator… (an industry term for the lowest performing medical provider still permitted to have a license to practice.)

How are people like this permitted to practice? One word…”Barely…”

In another one of those protocol committee meetings, I had a call where I used magnesium sulfate to sedate a combative psych patient for interfacility transport from the ED to a psych facility.

This lady was not a few fries short of a happy meal or a wave short of a shipwreck, she could have won an award for her impression of the possessed girl in “The Exorcist…”

For my non-US readers, in the States, physical restraint is normally used prior to chemical restraint of patients with an altered mental status who pose a danger to themselves or others…

For safety we are quick to react an initiate our 3 step program for unruly psychiatric patients.

1st. We tackle them to the ground with at least 6 people. (one for each limb, the body and the neck)

2nd. We tie their arms, legs, and if needed neck to the bed. (both soft and hard leather restraints are used for the arms and legs, additionally, we use disposable baby diapers to fold and hold their hands in a closed fist so they cannot scratch or claw. We then put a rigid cervical collar on them and attach a strap to that to safely hold their head to the bed, and apply the “spit sock” which is a device which catches spit but permits airflow, to keep them from spitting on us.


3rd. We dose them with the B52. (A B52 is the designation of the US Air Force Strategic, nuclear capable bomber.) But it is used in this context for 50mg of Benadryl, aka diphenhydramine, 5mg of haloperidol, and 2 mg of lorazepam.

Sitting in an ED bed next to her was a Sheriff’s Deputy whom the patient had bitten part of his ear off of as they tried to restrain her.

It was going to be a long ride…

So…I called the online medical control doctor…For permission (top cover) to ensure she would not wake up for the duration of our multiple-hour journey together…

”Doctor X (name withheld) Sir I would like to fast push 2g of magnesium sulfate on this psych patient...”

”Where did you learn that Mike? Because it wasn’t in the USA.”

”No sir, i learned it when I was on an exchange paramedic program in Slovakia.”

”You have permission to give 2grams of mag sulfate fast push.”

(Dr. X was trained in Kenya. 2 grams of mag sulfate fast pushed will cause enough CNS depression to cause a patient to sleep for nearly 24 hours…)

The psych facility was pissed! :) :) :)

So they called my physician medical director…

Apparently they have to do an intake exam on patients and it is really hard to do that on a non-responsive one who was chemically sedated…

At the next protocol meeting, I formally suggested we make it a protocol. The medical director looked at me with a dour face and said simply…

”Mike, I have no problem with your knowledge or ability concerning patient care or off-label uses for medication. But protocols are written for the least common denominators, and the last thing I need is for them to try to replicate anything you do…Protocols are written for them, not you.”

My take home lesson…”Protocols are written for the least common denominator.”

So why do individual providers as well as entire systems put such a focus on protocols?

They labor under the delusion as long as they were “just following orders,” “guidelines,” or “standards,” it will protect them from getting sued by patients for negative outcomes…

News Flash! It will not. I detailed why in a prior post.

It also brings them mental security, that they are doing the right thing…

Remember medicine changes?

I have done stuff to people according to protocol they were lucky to survive. They would have been better off without any medical care at all…

Because we found out years later, those treatments and their protocols were harming patients. Even killing some.

We performed them with expertise. I was given awards for it!

Those protocols have been revised and changed…

But I still have to live with what I may have done.

I cope by promising myself I will be better tomorrow than I am today. That I will learn more, do more, and most importantly, critically examine everything we do in medicine. From operations to scientific knowledge.

I can’t change the past, but I can make sure mistakes aren’t repeated. Even if those mistakes were enshrined in protocols and guidelines.

There is solace to be found in knowing for certain we have done our very best. Even when the outcome is not what we would like.

People and systems that function solely or have an over-reliance on guideline and protocol scare me.

First, it requires a mentality that we do know it all and what is best…Which in medicine is an arrogance that kills and disables.

Second, it means that any patient not fitting into or responding to the limited amount of written protocols is simply an acceptable loss. The wrong number in a numbers game.

I don’t accept any patient is an acceptable loss.

Sure there are some at the end of their days where palliation and withdrawing care is the most humane thing that can be done. That is life.

But to say “you don’t fit the mold so you’re fucked…” is not something I will ever do.

Third, systems that strictly adhere to protocols measure their success not by patient outcome or satisfaction, but by how strictly they followed “the rules.”

Blind, mindless, obedience… The stuff of Tyranny. Inhumanity. Gulags and concentration camps.

Where patients are not people or even human. They are numbers…Nothing more and without value.

”Just following orders…” Like the Romans, Nazis, or US ICE…

Conformity will never yield excellence. It only produces the least common denominator.

Is that what you want to be? Is that the paramedic or doctor you want treating you or your loved ones?

If I walked into an emergency department waiting room, an ICU family area, or a surgical ward and asked “How many of you volunteer to be an acceptable loss so we can follow our protocols” how many people would raise their hands?

How many people would say “If my mom or dad or child dies for your standards, I am ok with that..?”

”The operation was successful, but the patient still died…” is supposed to be a sarcastic joke, not standard procedure.

Leonardo Da Vinci did not paint by number…FFS, he didn’t even write in a standard way. We know his name. Nobody will remember the provider who is ok with “acceptable losses.”

Protocols and guidelines are meant to be the lowest acceptable care, that is what they were designed for. They were never meant to be or measure excellence.

How did that message get lost?

I implore you! Be better!