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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