The Permisson Paradox

Rogue Medic has a great  post about medical oversight for EMS, and I am looking forward to reading part 2.  It reminded me of a JEMS column Bryan Bledsoe wrote a few years ago titled Adios Rampart.

Both debunk the myth that patients can be kept safe if paramedics must request permission before doing something that might be dangerous.  Unfortunately the highest risk/lowest frequency interventions are the ones that must be done most quickly.  Instead of focusing on what the patient needs, paramedics in mother-may-I systems must pick up a phone and clearly articulate why a patient needs a surgical airway, cardioversion, chest decompression, or chemical restraint.

This puts everyone in a difficult position.  If the paramedic does not sound like they know what they are doing over the phone (not an uncommon occurrence), but the patient needs an invasive procedure, what is the doctor supposed to do?  Allow a paramedic to deliver potentially life-saving treatment and be on the hook if they screw up, or deny their request and hope the patient stays alive long enough to get to the hospital?

A paramedic, already in a stressful situation, must decide if they should follow the order, not follow it and risk getting in trouble, or “lose cell phone service.”  Other interventions that require permission simply don’t get offered, such as pain management or steroids.  None of the options are good for anyone, especially the patient.

Medical command should be available for advice in complicated situations, just as  ED physicians have specialists available.  It is useful to ask for advice when a number of treatment options are available, or which hospital is best equipped to handle a particular patient.  If a patient refuses to be transported, having them talk to a physician on a taped line gives us some extra liability protection.  Advice is good, permission is not.

If paramedics  cannot be trusted to work independently in critical situations, their medical director needs to be involved way before they are actually in one.  We need medical directors who knows what education we have, understand the environment we work in, and are familiar with the strengths and weaknesses of their particular service.

Give us direction before the next call, don’t make us ask for it when we’re on one.


  1. Bob,

    Thank you.

    We agree on this completely.

    Part II is up. 🙂


  2. Well written Bob.
    All one needs to do is swoop a view to foreign shores, and the realisation will come that without on line medical command…well, paramedics can actually do their job! Our maximum amount of morphine or fentanyl? As much as the patient needs. Obstructed airway and surgical intervention needed? Cricothyroidotomy please, like you were taught and trained in school.
    We still have a number to call for clinical questions if we need assistance, but in a supportive, rather than a “please may I” role. Works well 🙂

    • emspatientperspective says:

      Thank you Flobach.
      I wish that this is true, but we have a lot of certified paramedics in the US who cannot do their jobs. EMS providers on some foreign shores seem to be much more prepared than we are. Paramedic programs were started to respond to heart attacks and bad trauma, and our education requirements have not caught up to the added responsibilities. Instead of going back to the drawing board, building a stronger foundation of knowledge, and ensuring that new graduates can safely function independently in complex situations, we try to compensate by having people ask a doctor for permission to do things that might be dangerous.

  3. Skip Kirkwood says:

    Except for the occasional “consult” there is no utility whatsoever in calling anyone for the competent paramedic.

    The problem is that there are more than a few who attended inadequate training programs, then passed a licensure exam with the minimum passing score, who then went to work for services where they are virtually unsupervised and where nobody cares much about clinical medicine. That is the least common denominator – that is the bar that the state regulatory body sets, so everybody gets to pay the price for inadequate education, weak licensing standards, and poor organizational climates.

    Time to raise the bar, ladies and gentlemen. Want to practice independently like paramedics in Australia do? Start with their national-minimum bachelor’s degree to become a paramedic……

    • emspatientperspective says:

      The ironic thing is that asking permission does nothin to manage the risk of the LCD screwing up, it only gets more people in trouble. I’d be happy starting with Canada’s model.

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