there are rules and then there are rules

Tuesday, June 19, 2018

According to commentators and purists, Phil Mickelson did something bad this weekend. He willfully broke one of the rules of golf to minimize that damager that an errant putt might have caused him. Not only did he break the written rule, but he also broke the intention of the rule book, and that is supposedly a mortal sin, whether playing in a tournament or having a leisurely round of golf with friends.

In medicine, rules are probably the lowest in the hierarchy of clinical decision making and taking action to care for a patient. Rules, guidelines and protocols are not the same. Clinical rules in medicine help measure potential for both good and bad outcomes. A rule is developed to help with guidance for a specific clinical situation and the doctor at the bedside needs to decide whether they are appropriate to use.


The Canadian Head CT Rules help decide whether a scan is appropriate to perform in a patient with a head injury. If the patient meets all the criteria, then a scan may not be needed…but there are caveats. It has been validated for patients from age 16 to 65, and may not be used in the pediatric population. PECARN (the Pediatric Emergency Care Applied Research Network) has developed rules for head injury in that age group. But should a doc use the Canadian or PECARN rules for a 15-year-old football player who is 6 feet tall, weighs 200 pounds and looks like an adult? The rules of nine, help measure the body surface area when caring for burn victims and calculating how much skin has been burned. It needs to be modified for infants and children whose heads are larger compared to the rest of their body, and some studies suggest the rule doesn’t necessarily work for people heavier than 80 kg (176 lb.)



Guidelines are written from a clinical perspective to help guide the medical care of patients. Rules may be used to develop guidelines ort may be incorporated into them. The American Heart Association routinely publishes and updates guidelines on the steps to care from acute emergencies like heart attack and stroke to guidelines on controlling chronic conditions like high blood pressure and high cholesterol. But there may be completing guidelines for the same situation and it is up to the doctor and the patient to decide what might be the best treatment strategy to consider.

  • The American Academy of Family Physicians and the American Urological Association sometimes spar about the use of PSA, a blood test to screen for prostate cancer.
  • For cancer patients who develop blood clots, treatment options recommended by the American College of Chest Physicians and the National Comprehensive Cancer Network differ. One isn’t right or wrong; both are out there.

Protocols are rigid. They are a recipe with specific steps that need to be taken when caring for a patient. Often, they are provided by a medical provider to allow others to care for patients. Imagine EMTs or paramedics caring for patients at the side of the road or nurses working in an extended care or nursing facility.

So the sequence might look like this. A doctor caring for a burn patient would use the rule of nines to calculate the percent of the body that was burned. That percentage would be plugged into the Parkland formula to calculate, as a guideline, how much intravenous fluid that would be needed to rehydrated the patient and the hospital protocol would require that all major burn patients be transported to a burn unit for further care.

The art of medicine is to keep up with the rules, guidelines and protocols and understand that they are ever changing. There may be times when it is appropriate to deviate from the mainstream recommendations when the individual patient may benefit. The standard line is that guidelines and protocols work until they don’t. In that way, Phil Mickelson and the medical community have found common ground. Rules can be bent or broken when the goal is to maximize benefit.

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guidelines, rules and head injury

Monday, February 25, 2013

In sports, there are rules to be followed, for the god of the game and for the good of the athlete. In medicine, rules are few and far between. Instead there are guidelines that as the term implies, guide the physician in the care of a patient. Sometimes, athletes treat rules like guidelines, situationally bending them, hoping to seek an advantage. Sometimes, doctors rigidly adhering to guidelines, forget that bedside skills may be more important than following an algorithm. And sometimes, the two worlds come together for a teaching point.

During the second period of the American Hockey League game Springfield forward Wade McLeod hits his head while being checked into the boards by Brandon Manning of the Adirondack Phantoms. Boarding is against the rules in hockey but it is a hard call for the referees to make because of the speed of the game. Was it a penalty because the hitter that drove the player into the boards or was it the momentum of the hittee, making the collision unavoidable? A penalty was called but it was perhaps the best penalty in the career of both players. After bouncing off the boards, MacLeod suffered a seizure and was taken to the hospital for further evaluation.

Post traumatic seizures are not uncommon. The brain gets rattled inside the skull affecting the electrical patterns in the brain. Every brain has a seizure threshold, meaning that there is a possibility for outside forces to cause a seizure. In infants and child4en, that threshold is rather low and high fevers can commonly cause a child to seize. As the child grows, the threshold rises and the risk of febrile seizures decreases and then disappears. Some people have continued low threshold, develop lifelong seizure disorder and need medications to raise the bar to prevent recurrent seizures.

Each part of the body is controlled by a separate section of the brain and controlled electrical impulses within the brain allow purposeful movement. When the electricity short circuits, the brain doesn’t particularly like it and turns off, the electrical activity stimulates body parts to move and you get the classic unconscious, convulsing patient, rigid, arms and legs twitching, responding to all those brains signals. And just like a computer that locks up after being dropped, the brain needs to reset itself and reboot. During this time, the post- ictal (or after seizure) phase, the patient gradually wakens but has a hard time processing information, just like the computer. When the flag or apple is waving on the screen, the computer isn’t ready to receive information regardless of how fast or hard you type on the keyboard or click on the mouse. Same with the brain; waking up and responding to the surrounding world needs to wait for the brain to wake up.

Mr. MacLeod is taken to the hospital where a brain CT scan is done and reveals a benign brain tumor. Perhaps it wasn’t the hit into the boards and concussion that caused the seizure but rather this underlying structural problem of the brain that had gone unnoticed and the boarding penalty was just a coincidence. But why was the CT ordered? The head injury guidelines specifically mention that imaging the brain after a concussion is not warranted unless the patient is not fully awake, has evidence of skull fracture or has persistent vomiting.

Having a seizure is supposedly not a reason to do a CT scan according to the Consensus Statement on Concussion in Sport:

“A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.”

Statements aren’t rules and are meant only to be a guide to patient care and the consensus statement recognized this reality:

“It was recognised by the panellists that conventional structural neuroimaging is normal in concussive injury. Given that caveat, the following suggestions are made: brain CT (or where available, MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intracerebral structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms.”

Had the doctors caring for Mr. MacLeod followed the letter of the Ottawa Head CT Rules or the Zurich Statement on Concussion, the CT likely would not have been done, but it was the bedside evaluation, the hunch that something was not just right, the intuition that develops with experience that caused the brain scan to be done and the culprit tumor to be found.

Watson, the IBM supercomputer Chess and Jeopardy wiz, is being upgraded to practice medicine and will likely be more efficient in making diagnoses and recommending treatments in most situations. It can crunch numbers and follow all the rules, but as is often the case, the best doctors know when to ignore the guidelines because of bedside experience. The on-ice seizure was frightening but the seizure was likely due to a structural problem in the brain and not the hit into the boards. Timing is everything. Imagine if the seizure would have struck a couple hours earlier or later while Mr. MacLeod was driving his car.

While the hockey game was suspended after MacLeod was taken off the ice. The doctors got the win that evening because they remembered that guidelines are not rules.

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