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Disclaimer:
This article is not a call for paramedics to ignore or override written protocols. Protocols are critical tools that guide safe, evidence-based care. Providers must always follow the clinical guidelines set by their regional or institutional medical director. However, it is also important to recognize that protocols cannot account for every complex or rapidly evolving situation we face in the field. This article aims to raise awareness about the need for clearer protections for providers who act under direct physician supervision in exceptional circumstances.

The Real-World Dilemma

You’re trained. You’re experienced. You’ve been tested in chaos.
You arrive on scene to find a critically injured patient — unstable, fading fast.
Protocols guide you through your decision-making, but you’re already at their edge.

You contact Medical Control. A licensed emergency physician gives you a direct order:
Perform a procedure that is within your scope and training — but falls outside the written protocol [1][2].

You follow that order, acting in good faith under medical direction.

Despite your efforts, the patient dies.
Not because of what you did — but because their injuries were incompatible with life.
You tried. The physician tried. The system, however, doesn’t seem to care.

You’re Now Under Investigation

Not the physician who gave the order.
Not the system that designed rigid, inflexible protocols.
You — the paramedic who followed clinical direction and did everything right.

Why?

Because the intervention, while something you were trained to do, fell outside the written protocol [3].

Protocols Aren’t Perfect — And They’re Not Meant to Be

Let’s be clear: Protocols are essential. They ensure consistency, safety, and accountability in patient care. They guide thousands of decisions every day.

But protocols aren’t all-knowing. They can’t anticipate every chaotic trauma, every grey-area cardiac arrest, or every environmental obstacle in the prehospital world [4]. That’s why we have Medical Control — to provide oversight when the complexity of the moment exceeds what’s written on a laminated card [5].

Yet, despite acting under a physician’s directive, many providers still find themselves vulnerable — targeted by licensing bodies or regulatory authorities that disregard the nuance of the situation, the supervision involved, or the context that made the decision necessary [6].

Fear-Based Medicine Is a Dangerous Game

This is the dangerous message being sent to EMS providers across the globe:

“Stick to the protocol — even if it means letting someone die.”
“Don’t rely on the physician who is guiding your care.”
“If it’s not written down, don’t do it — even under orders.”

The result?
Providers begin to second-guess themselves. They become more focused on protecting their licenses than protecting their patients.

They hesitate. They hold back.
And sometimes… they don’t act when it matters most [7].

That’s not medicine.
That’s fear.
And patients suffer for it.

We Need to Talk About System Accountability

Why aren’t physician directives respected as part of a provider’s defense in regulatory investigations [8]?
Why are providers thrown under the bus — despite acting under direct medical oversight — when outcomes are unfavorable?

We need to ask:

• Are we protecting patients or just protecting procedures?

• Are we encouraging sound clinical judgment, or punishing providers for adapting in real time?

• Shouldn’t a system built on team-based care protect its front-line providers when they act within their scope and training under legitimate physician orders [9]?

If not, what’s the point of Medical Control?

A Culture Shift Is Needed

Let’s be clear: This is not a call to abandon protocols.
It’s a call to acknowledge their limits and to protect those who, in the rarest of cases, must make difficult decisions under physician guidance when the protocol doesn’t provide a clear answer.

It’s a call to:

• Respect Medical Control as part of the clinical decision-making chain.

• Reform investigative processes to include the physician’s role and directives.

• Protect providers acting in good faith within their training and scope.

Because no one should be punished for trying to save a life — especially not when they followed orders from a licensed emergency physician [10].

Final Thoughts

Emergency medicine is messy, unpredictable, and full of ethical landmines.
We must build systems that recognize this complexity and support the clinicians doing the hard work in real time.

If we continue to punish providers for doing the right thing under medical supervision — especially when the outcome is already inevitable — we’ll lose more than just medics.

We’ll lose trust, initiative, and lives.

Let’s fix that.

References

1. American College of Emergency Physicians (ACEP). EMS Medical Direction. Annals of Emergency Medicine, Vol. 60, No. 4, October 2012.

2. National Association of EMS Physicians (NAEMSP). Position Statement: The Role of EMS Medical Directors. January 2020.

3. Gausche-Hill, M., Brown, J., et al. Pediatric Prehospital Protocol Variability in the United States. Prehospital Emergency Care, 2015; 19(4): 517–523.

4. Institute of Medicine. Emergency Medical Services: At the Crossroads. The National Academies Press, 2007.

5. Cone, D. C., et al. Legal Issues in EMS Medical Direction. Prehospital Emergency Care, 2010; 14(3): 379–385.

6. Kue, R., et al. Challenges in EMS Oversight: Medical Control in Real-World Practice. Journal of Emergency Medical Services, 2014.

7. Iserson, K. V., et al. Triage in Medicine, Part II: Underlying Values and Principles. Annals of Emergency Medicine, 2003; 42(6): 689–697.

8. Wang, H. E., et al. Medicolegal Considerations in EMS Systems. Emergency Medicine Clinics of North America, 2016.

9. American Medical Association (AMA). Liability of Physicians Providing Medical Direction to EMS Personnel. AMA Policy H-130.954.

10. Slovis, C. M., & Wang, H. E. EMS Medical Direction: Strengthening Support for EMS Personnel. Prehospital Emergency Care, 2006; 10(3): 341–344.