Each was uploaded to ProtoQuiz by an EMT or medic studying their own agency's rules. An AI model read them page by page (about 47 million tokens over six days). Every fact below is page-cited and fact-checked.
Five interesting findings
Maple syrup is an approved oral glucose in Vermont. Vermont EMS Statewide Protocols
Naloxone is banned in cardiac arrest, in red text. San Diego County, against the common "it won't hurt" habit. San Diego County EMS, p.57
A gaze test instead of FAST. Alabama's EMSA stroke scale uses gaze tracking, not facial droop. Alabama Statewide EMS Protocols, p.206
Field thrombolytics for STEMI. St John New Zealand gives tenecteplase plus heparin 5000 U on a standing order; no US system here does. St John New Zealand, p.62
Field perimortem cesarean. Mayo Clinic Ambulance (critical-care transport) authorizes it at 4 minutes without ROSC, ≥20 weeks. Mayo Clinic Ambulance, p.255
Where the protocols came from
30 states and regions, plus the NASEMSO national model, St John New Zealand and Alberta. Colorado and California lead with six each; most states have one.
Protocols uploaded per state. Three came from outside the map: the NASEMSO national model, St John New Zealand, and Alberta. One spans Minnesota and Wisconsin (Mayo Clinic Ambulance).
Don't see your state? Upload your EMS protocols to ProtoQuiz and it gets added.
Together: 5,556 medication entries, 2,470 algorithms and 1,393 procedures.
What varies most
- Formularies run from 4 drugs (Davidson County, NC) to 177 (Kentucky).
- Starting doses. Most start adenosine at 6 mg; Boulder, Denver Metro, San Antonio and West Palm Beach start at 12. TXA splits between 1 g and 2 g.
- D10 is replacing D50. Santa Cruz and LA County use D10 for all hypoglycemia (p.228, p.25).
- Arrest. Berrien County uses lidocaine over amiodarone (p.91). Vasopressin survives in Kentucky and Miami (p.54). San Diego and San Antonio route refractory arrests to ECMO (p.61, p.107). Alameda allows termination only with 2 or fewer shocks (p.92).
- Stroke. Almost every system uses a different LVO scale; thrombectomy windows run from 3.5 to 24 hours (p.136).
- Procedures. About a third carry whole blood. Thurston County (WA) authorizes POCUS-guided pericardiocentesis (p.211). Massachusetts carries field amputation (p.143).
Scope of practice
The National EMS Scope of Practice Model is the baseline behind the NREMT. Real systems treat it as a floor, a ceiling or a suggestion:
| Skill | National standard | Across real systems |
|---|---|---|
| Tourniquet | EMR | EMR in most; some restrict to EMT+ |
| CPAP | EMT | EMT in ~20 systems, paramedic-only in others |
| IO access | AEMT | AEMT baseline; some push to EMT, some hold at paramedic |
| Intubation | Paramedic | Paramedic standard; Alberta's program doesn't authorize it at all |
| RSI | — (not in model) | Paramedic in many; Critical-Care-only in Alabama, Kentucky, Denver, Boulder |
New York EMTs give oral moxifloxacin for open fractures (p.86). West Virginia AEMTs access PICC lines (p.188). Alabama makes RSI Critical Care only (p.189). Alberta tops out at EMT, with no intubation at all (p.7).
Where the most progressive scopes are
We scored each system 0–30 on autonomy, skills pushed to lower certs, and cutting-edge interventions. It's one lens, not a quality measure.
Each state shaded by its highest ground-system score (/30), from uploaded protocols only, not every system in the state. * Utah is shaded conservatively; Alabama and Vermont are shaded from their statewide model.
Ground / 911 systems
| # | System | State | Total /30 | A | S | C |
|---|---|---|---|---|---|---|
| 1 | Thurston County Medic One | WA | 28 | 8 | 10 | 10 |
| 2 | Palm Beach Gardens Fire Rescue | FL | 27 | 9 | 8 | 10 |
| 3 | San Antonio / STRAC (Bexar-Frio) | TX | 27 | 8 | 9 | 10 |
| 4 | Aurora South WI EMS | WI | 26 | 8 | 9 | 9 |
| 5 | West Palm Beach Fire Dept EMS | FL | 26 | 7 | 9 | 10 |
| 6 | Boulder County EMS | CO | 26 | 9 | 9 | 8 |
| 7 | Denver Metro EMS (Jan 2026) | CO | 25 | 7 | 9 | 9 |
| 8 | San Diego County EMS | CA | 24 | 8 | 7 | 9 |
| 9 | Salem Health West Valley / Polk County | OR | 24 | 8 | 8 | 8 |
| 10 | Ada County Paramedics (ACCESS) | ID | 23 | 8 | 7 | 8 |
| 11 | Riverside County EMS Agency (REMSA) | CA | 22 | 6 | 8 | 8 |
| 12 | Central Arizona Regional EMS (CAREMSG) | AZ | 22 | 8 | 7 | 7 |
| 13 | Davidson County EMS | NC | 22 | 7 | 9 | 6 |
LA County scores 14, San Diego 24. Mountain West (UT) is held back; a second pass found its score overstated.
Air-medical / CCT (not on the map)
ICU-level scope is their mission, so they aren't compared with ground 911 systems.
Mayo Clinic Ambulance (MN) · 28 AirCare / MobileCare — Univ. of Iowa (IA) · 26 UT LIFESTAR (TN) · 25 Air Care (OH) · 22 Hartford Hospital LIFE STAR (CT) · 21
Statewide models are also held out of the ground ranking, since they set a floor for many agencies: New York (25), Massachusetts (25), New Jersey (24), West Virginia (23), Michigan (23), Northwest Community EMSS (22), Pennsylvania ALS (21), Vermont (20), Alabama (18).
How we did this
An AI model on a Raspberry Pi read each PDF in roughly 20-page chunks, pulling the same fields every time. Three separate AI skeptic agents then re-checked each standout against the cited page; it made the cut only if at least two confirmed it.
Sources
Links go to each agency's own public copy. Mayo Clinic Ambulance, West Palm Beach, Berrien County, Lake Cities, Mountain West and Salem Health/Polk County don't publish theirs.
- 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
For most of prehospital care there is no single right answer across these 53 systems. NREMT material teaches the conventional version; your agency's protocol is what holds up on a call. ProtoQuiz quizzes you on your own protocol PDF, every answer page-cited, using the same reading behind this survey.
Back to the blog for more EMS data and study tips.
Keep reading: Get the ProtoQuiz app · How to study EMS protocols · EMS as an essential service · US EMS Protocol Census
