Intent and Use of Protocols

1.1 Intent and Use of Protocols



These medical treatment protocols have been developed as a part of the medical direction program for participating Emergency Medical Services (EMS) agencies. The medical director of an individual EMS provider may choose to modify certain treatment recommendations. In addition, some patients may require therapy not specified in these protocols. The treatment protocols should not be construed as prohibiting such flexibility. The paramedic/EMT must use his/her judgment in administering treatment in the following manner:

  • The paramedic may determine that no specific treatment is needed; or
  • The paramedic may consult medical direction before initiating any specific treatment; or
  • The paramedic may follow the appropriate treatment protocol and then consult medical direction.
  • The paramedic/EMT may contact medical direction at any time he/ she deems necessary.

When the paramedic/EMT is unable to make contact with other forms of medical direction, he/she may contact the receiving hospital for consultation with the emergency department physician. It is recommended that the paramedic/EMT make contact with the physician for consultation on complicated patients whenever possible. When the paramedic is unable to make contact with a physician for medical direction, the paramedic may administer BLS treatment according to his/her judgment. In this instance, the paramedic may administer ALS treatment only as authorized in the treatment protocols.

The treatment protocols are divided into adult and pediatric sections, each with three parts:

Supportive Care

Actions authorized for the EMT or paramedic that are supportive in nature. EMT (BLS) and paramedic (BLS and ALS) actions are specified within each of these protocols.

ALS Level 1

Actions authorized prior to physician contact.

ALS Level 2

Actions authorized only for the paramedic that require a physician consult.

Authorization of procedures prior to physician contact in Level 1 allows the paramedic to initiate care promptly while getting a better idea of the patient's condition and evaluating his/her response to initial treatment.

The general protocols outline care for a typical case. As the protocol continues, the assumption is usually made that previous steps were ineffective. For example, the protocol for ventricular fibrillation authorizes three unstacked countershocks; however, the second countershock and third countershock are given only if the previous countershock was unsuccessful and the patient remains in ventricular fibrillation. If the patient went into asystole/PEA following the first countershock, the second countershock would not be given. The paramedic would then use the asystole/PEA protocol to guide further treatment. In this or other situations where a switch is made to a different protocol during the course of care, the paramedic's judgment must determine where entry into the new protocol sequence is appropriate.

It would be impractical to write protocols that specify every possible sequence of events. The order of treatment listed here may not be appropriate for all situations. In fact, not all treatment options may be indicated in every situation. The paramedic's judgment must be relied upon to determine which of the authorized treatment procedures are appropriate for a given situation. The treatment guidelines are given in bulleted list form as a general order of the steps necessary to treat the patient; however, it is assumed that interventions such as patient assessment, airway management, establishing medication access, applying AED/heart monitor, and so forth can be performed simultaneously.

Orders listed in ALS Level 2 may be expected from the physician. They may or may not be the orders that are actually given, however. The intention in listing ALS Level 2 orders is to allow for appropriate preparation and to guide the paramedic who wishes to request specific orders. The physician directing care in the field retains discretion in ordering specific treatment, even if that treatment conflicts with these protocols. ALS Level 2 orders require consultation with a physician.

The name of the physician authorizing ALS Level 2 orders must be documented in the patient care report (PCR). Physicians authorized to approve ALS Level 2 orders include the following individuals:

  1. EMS provider's medical director (a).
  2. Receiving hospital emergency department physician (a).
  3. Physician present in his/her own office (b).
  4. Online medical control physician (a).
  5. Bystander physician personally known to the paramedic (c).
  6. Bystander physician who presents a valid M.D. or D.O. (c).
  7. Poison information center (d).


(a) Contact for ALS Level 2 orders by the EMS provider's medical director, online medical control physician, or emergency department physician should be initiated in the following order:

  1. Medcom.
  2. Telephone.
  3. Relay of information via dispatch.

(b) Only verbal or written orders that are signed by the physician that are given directly to the paramedic by a physician in his/her office are acceptable.

(c) A bystander physician, as described above, must accept full responsibility for patient care and accompany the patient in the ambulance to the hospital to give Level 2 orders.

(d) The Poison Information Center is authorized to direct all medical care (Supportive Care, ALS Level 1, and ALS Level 2) for the toxicology and hazardous material exposure patient. The Poison Information Center must be contacted via telephone at 800-222-1222