We Compared 53 EMS Protocols From Across the Country. This Is What We Found.

Each one was uploaded to ProtoQuiz by an EMT or medic studying their own agency's rules — so these are protocols people actually use on the job.

Reading all of them took an AI model about 47 million tokens over six days, page by page, pulling every drug, algorithm, procedure, and oddity into one comparable format. Every fact below is tied to the page it came from and was checked by three independent passes before it made the cut. Here is what stood out.

Where the protocols came from

The 53 protocols come from 30 states and regions, plus the NASEMSO national model, St John New Zealand, and Alberta. The map shades each state by how many landed from there. Colorado and California lead with six each; most states show one.

Alabama and Vermont are new since the last version of this survey. Together, the 53 protocols add up to 5,556 medication entries, 2,470 algorithms, and 1,393 procedures.

Medications

Formulary size alone ranges from 4 drugs (Davidson County, NC) to 177 (Kentucky) — a 44-fold spread. A few that stand out:

• The same drug, very different starting dose. Most systems start adenosine at 6 mg; a cluster (Boulder, Denver Metro, San Antonio, West Palm Beach) skips straight to 12 mg. TXA splits cleanly between 1 g and 2 g camps. San Antonio gives half-dose arrest epinephrine, 0.5 mg.
• D10 is quietly replacing D50. Santa Cruz uses D10 for all hypoglycemia — no D50 or D25 anywhere — and LA County does the same, citing vein damage and rebound highs from concentrated dextrose (p.228, p.25).
• Drugs you don't expect in a field bag. Mayo carries an ICU transfer formulary (inhaled nitric oxide, nitroprusside, insulin). St John New Zealand stocks metaraminol — a pressor no US system here carries — plus Penthrox inhalers (p.508). Kentucky's 2021 book still lists streptokinase and MAST trousers (p.331).
• Field addiction medicine is arriving. San Diego paramedics score the COWS scale and start buprenorphine-naloxone in withdrawal, with leave-behind naloxone (p.85); Massachusetts pushes buprenorphine down to EMT level (p.109).

Algorithms & decision trees

The same emergency is rarely handled the same way twice. A few of the sharpest forks:

• Cardiac arrest is not standardized. Berrien County picks lidocaine over amiodarone outright (p.91). Vasopressin survives in Kentucky and Miami despite the AHA dropping it in 2020 (p.54). Oklahoma makes you call medical control before repeating epi on anyone over 50 or hypertensive (p.209). San Diego and San Antonio route refractory arrests to ECMO (p.61, p.107) — and San Diego bans naloxone in arrest outright, in red text (p.57).
• When you can stop varies widely. Alameda lets you terminate only if 2 or fewer shocks were given — a third shock makes the patient ineligible (p.92). LA County runs refractory VF up to 40 minutes on scene (p.45). Santa Cruz uses a sustained EtCO2 ≤10 as the stop signal (p.305).
• Stroke screening has no standard. Nearly every system picked a different LVO scale and cutoff (LAMS, FAST-ED, C-STAT, RACE). Alabama dropped FAST for a scale where "Eyes" is a gaze-tracking test, not facial droop (p.206). Pennsylvania's scale uses the phrase "The sky is blue in Pennsylvania" (p.149). The thrombectomy-routing window ranges from 3.5 hours to 24 (p.136).
• Who decides, and when. Pennsylvania flips the usual gate — opioids are a standing order only for severe pain; mild pain needs a phone call (p.139). The NASEMSO national model puts cardiac-arrest victims ahead of the walking wounded in lightning strikes, and says fixed pupils are not a death sign there (p.352).

Procedures & skills

Advanced procedures cluster in a few systems rather than spreading evenly. The far end:

• Surgery in the field. Mayo Clinic Ambulance — a critical-care transport service — authorizes a perimortem cesarean at 4 minutes without ROSC (p.255). Massachusetts carries field amputation (p.143). Lake Cities' tactical medics can do incision-and-drainage, dental blocks, and wound repair (p.132).
• Whole blood is no longer rare — roughly a third of these systems carry it — but who's allowed varies from a Critical Care endorsement (Denver Metro) down to EMT-Intermediate (Salem Health, p.127).
• Hospital-grade ultrasound on a 911 truck. Thurston County (WA), a ground service, authorizes POCUS-guided pericardiocentesis and central lines (p.211) — the kind of scope you'd normally only see on a critical-care unit like Mayo, which does prehospital fetal heart-rate monitoring (p.337).
• The evidence is changing practice. Mountain West makes the iGel the first-line airway, citing the AIRWAYS-2 trial (p.126). San Diego moved needle decompression to the axilla, the military site (p.16). Santa Cruz outright bans oxygen-powered ventilators and nasotracheal intubation (p.286).

Scope of practice

EMS school teaches one answer. The National EMS Scope of Practice Model — the baseline behind the NREMT exam — defines what each certification level can do. Real systems treat it as a floor, a ceiling, or a suggestion. Compare the national standard to what these 53 actually allow:

The deviations from that baseline are where it gets interesting:

• Drugs pushed down to EMT. New York lets EMTs give oral moxifloxacin for open fractures (p.86) and administer flu and COVID vaccines (p.66). Massachusetts pushes buprenorphine and oral antipsychotics to EMT level (p.107). Santa Cruz EMTs draw up and inject epinephrine, not just fire an auto-injector (p.222).
• Procedures pushed down, too. West Virginia lets AEMTs access indwelling PICC lines (p.188). New York authorizes joint reductions and tooth reimplantation down to first-responder level (p.153). Davidson County (NC) runs Swan-Ganz catheters and arterial lines at plain paramedic level.
• RSI is the dividing line. Alabama bans paramedic RSI entirely — Critical Care only (p.189). Denver Metro, Boulder, San Antonio, and Kentucky each gate it behind a special endorsement above paramedic.
• And one that goes the other way. Alberta tops out at EMT — no intubation at any level, no seizure benzo in the whole formulary (p.7, p.33).

Where the most progressive scopes are

We scored each system 0–30 on how "progressive" its scope is: how much a medic can do without calling medical control, how far advanced skills are pushed down to EMTs, and how many cutting-edge interventions it carries (TXA, ketamine, whole blood, POCUS, field antibiotics, ECMO routing). It's one lens, not a quality measure. The map shades each state by its top ground system; air and critical-care transport are scored separately, since their scope reflects mission, not local trust.

Tier 1 — Ground / 911 systems (scored)

The ranking that drives the map. Top systems by composite; where a system publishes multiple documents, its highest is shown.

California spans the whole range — LA County scores 14 (conservative, heavily medical-control-driven) while San Diego hits 24; the state's tile reflects San Diego. Mountain West (UT) is held back from the headline after a second pass found its score overstated. New Zealand is excluded as non-US.

Statewide model documents are likewise held separate from the ground ranking, since they define a floor for many agencies rather than one agency's practice. On the same composite: New York State EMS Collaborative Protocols (25), Massachusetts Statewide Treatment Protocols (25), New Jersey EMS Clinical Practice Guidelines (24), West Virginia Office of EMS Statewide Protocols (23), Michigan MDHHS Statewide Protocols (23), Northwest Community EMSS (22), Pennsylvania Statewide ALS Protocols (21), Vermont EMS Statewide Protocols (20), and Alabama Statewide EMS Protocols (18). Vermont and Alabama are the only states whose single uploaded document is a statewide model, so on the map above they are shaded from these scores rather than from a ground agency.

System policies

The protocols differ on the non-clinical rules too — who you can divert, who you can leave, who you have to call:

• Riverside bans ambulance diversion outright. A STEMI or stroke center that tries to divert loses its designation pending review (p.340).
• Ketamine is audited per dose. Pennsylvania reports every ketamine administration to the state quarterly (p.139); Colorado requires a waiver and CDPHE report for each use.
• Spine boards are out in places. Davidson County (NC) bans rigid boards for transport, saying they cause harm without benefit; Oklahoma drops spinal restriction for penetrating trauma (p.284).
• Hard stops on controlled drugs. Thompson Valley requires transport after any opioid, benzo, ketamine, or etomidate — refusal needs a physician on the phone (p.489). Pennsylvania caps standing-order sedation to ages 16–65 (p.165).

Outliers & quirks

And the ones that don't fit anywhere else:

• Maple syrup is approved oral glucose in Vermont — found nowhere else.
• Field thrombolytics for STEMI. St John New Zealand gives tenecteplase on a standing order (p.62). No US system here does.
• Transvenous pacing shows up in exactly one ground service, Boulder County, restricted to critical-care interfacility transport (p.199).
• The double EpiPen. Greater Miami Valley has patients over 30 kg fire both an adult and a junior auto-injector at once, 0.45 mg total.

How we did this

These 53 protocols are exactly the ones that real ProtoQuiz users uploaded to study — we did not go looking for them, providers brought them. Each PDF was read page by page by an AI model, in roughly 20-page chunks, pulling out the same set of fields every time: which service it is, its treatment algorithms, its medications (with dose, route, and page), its procedures, and anything unusual. Every fact in this post is tied to the page it came from. The reading ran quietly on a Raspberry Pi over several days. Every number here is counted across those same 53 protocols.

Every standout in this survey was then independently fact-checked by three separate AI skeptic agents, each instructed to re-open the cited file and page and default to refuting the claim unless the source plainly supported it. An item appears here only if at least two of the three confirmed it.

Sources

We don't host these documents — every system below is linked to the protocol its own agency publishes publicly. A handful of services (Mayo Clinic Ambulance, West Palm Beach, Berrien County, Lake Cities, Mountain West, Salem Health/Polk County) don't post their protocols publicly, so they're cited here without a link.

• Ada County (ID)
• Alabama (state)
• Alameda County (CA)
• Boulder County (CO)
• Central Arizona (AEMS)
• Davidson County (NC)
• Denver Metro (CO)
• Greater Miami Valley (OH)
• Kentucky (state)
• Los Angeles County (CA)
• Massachusetts (state)
• Michigan (state)
• NASEMSO national model
• New Jersey (state)
• New York State / NYC REMAC
• Oklahoma (state)
• Pennsylvania (state ALS)
• Riverside County / REMSA (CA)
• San Antonio / STRAC (TX)
• San Diego County (CA)
• Santa Cruz County (CA)
• Thompson Valley (CO)
• Thurston County (WA)
• Vermont (state)
• West Virginia (state)
• St John New Zealand

Why this matters for studying

The breadth is the point. Across these 53 systems there is no single right answer for most of prehospital care — not the adenosine start, not the anaphylaxis epi dose, not who is allowed to perform CPAP or RSI, not whether your service can divert or carry whole blood, not even whether maple syrup counts as oral glucose. Generic NREMT material teaches the conventional version; your agency's protocol is the one that holds up on a call.

And that is exactly why this dataset exists: every document here was uploaded by someone who needed to know their own protocol cold. ProtoQuiz was built around that gap: upload your agency's protocol PDF and it quizzes you on your actual doses, routes, scope, and standing-order rules, with every answer page-cited back to the source. The same page-by-page reading behind this survey is what powers the app.

Back to the blog for more EMS data and study tips.