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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concussion: looking out for those who are injured

Monday, November 13, 2017

As the NFL again takes flak this week for its head injury awareness with potential injuries to the Seahawks’ Russell Wilson, the Colts’ Jacoby Brissett and the Falcons’ Devonta Freeman, it’s important to remember that concussion symptoms can be subtle and have a delayed onset. The concept that a brief assessment on the sideline is sufficient to say yeah or nay on the diagnosis fails to meet the criteria set in the most recent consensus statemen from the 5th international conference on concussion in sport, held in Berlin in late 2016.

The bottom line for initial assessment is that all athletes, regardless on level of competition, should be removed from the field of play, if concussion is suspected. If the diagnosis is not in doubt, for example a player who is knocked out, briefly confused or has difficulty with balance, the player should not return to the game. If the diagnosis isn’t confirmed but suspicion exists, then the player needs to undergo sideline testing. But there is not one perfect test that can confirm or deny the diagnosis. Sideline screening can be done but it takes at least 10 minutes for most testing to be completed. While it can occur on the sideline, it is often better to find a quiet place to interview and examine the potentially injured player.

From the consensus guidelines:

“In cases where the physician may have been concerned about a possible concussion, but after the sideline assessment (including additional information from the athlete, the assessment itself and/or inspection of videotape of the incident) concussion is no longer suspected, then the physician can determine the disposition and timing of return to play for that athlete.”

And also from the same guidelines, an athlete with a sport related concussion should not be allowed to return to play on the day of injury.

There is a caveat that symptoms may be delayed and repeated evaluations are warranted. The problem is that the symptoms can be very subtle, from difficulty concentrating, to sleep disturbances, to changes in personality. The ability for the brain to function and process information may be affected so that concussed high school and college athletes may drop a full grade point in their classes for the ensuing semester.

As hard as it is to diagnose subtle head injury, it’s just as hard to decide when the brain has healed enough to allow the athlete to return to play. There is no test that confirms brain healing and most athletes recover within a month. Practically, return to play strategies take about a week if the athlete remains symptom free. That said, concussion symptoms may last for months.

Unfortunately for those who decide whether a Seahawk or Colt or Falcon can return to play, instant replay allows fans at home and in the stadium to witness the consequences of a hit to the head and judge for themselves whether the possibility of a concussion might exist. And when a referee sends a player off because of concussion concern, it’s incumbent upon the team’s medical staff to follow through with a thorough assessment. The player may not know what happened or realize that they were concussed; it’s up to the coaching and medical staff to protect the brain, even if the player actively refuses that help.

Until that is the standard of care, the NFL will continue to get flak.

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