Protocol reform is the Coalition’s first priority. Massachusetts protocols trail the rest of New England and the United States, and the gap is widening. We intend to start with realistic goals and address one issue at a time.

• A comprehensive rewrite of the Statewide Treatment Protocols. The Massachusetts Prehospital Coalition calls for a comprehensive rewrite of the Statewide Treatment Protocols, in line with the protocols of other New England states. The rewrite should meet the following standards:

  • Clinical context. Every protocol shall include an abundance of clinical PEARLS and differential diagnoses, as protocols throughout New England already do.

  • Evidence-based care. Protocols shall keep pace with New England, the United States, the world and, most importantly, the evidence.

  • Protocol matches the truck. Any treatment written into protocol as a standing order shall be required equipment or medication on every ambulance that operates under that protocol.

  • Transparency. Protocol changes shall be published with their rationale and supporting evidence. Waivers and special projects shall be publicly listed.

  • Provider input. EMTs and paramedics shall have a defined way to comment on proposed protocol changes before they take effect.

• Medical Director Option limitations. Medical Director Options shall be renamed to “Pre-Requisite Protocols”, in allignement with neighboring New England States.

• Pre-requisite protocols shall be limited, and never be used to block essential, paramedic-level care or evidence-based practice.

  • Under the current system, an intervention listed as a Medical Director Option is unavailable to every patient whose service has not opted in. That turns a tool meant to manage risk into a ceiling on clinical practice. Every option shall instead work as a floor, with published training and equipment requirements. Any service that meets those requirements may adopt the option, and no service shall be prevented from doing so provided they meet the set requirements.

  • The Pre-Requisite Protocol designation shall be reserved for two categories only:

    • High-risk procedures where training and skill maintenance are paramount. These include rapid or delayed sequence intubation and finger thoracostomy. These interventions carry real risk when performed infrequently or without proper training. A service that adopts them shall meet published standards for initial training, competency verification, continuing education and quality review.

    • Genuine system constraints. These are interventions that depend on equipment, supply chains or infrastructure that not every service can reasonably maintain. Where a service cannot provide these interventions itself, regional resources and mutual aid agreements shall make them available. This may include pre-hospital blood transfusion and antibiotics in sepsis. Any intervention that does not fall into either category shall be part of the standard protocol, available to every patient in the Commonwealth regardless of which service responds.

    • Not all-or-nothing. A specific service may limit a protocol to specific providers (for example, RSI/DSI available to EMS supervisors only at a specific service) and sanction providers if necessary.

• Phased Reforms:

  • IV Infusion Pumps. IV pumps shall be mandated on all frontline 911 ALS ambulances by the year 2030.

  • Point-of-care ultrasound (POCUS). Point-of-care ultrasound shall be required on all 911 ALS ambulances by 2032. It shall move from a medical director option to a standing order in the appropriate protocols for paramedics under a statewide training, credentialing, and quality-review standard, which OEMS shall publish in the Statewide Treatment Protocols. Indications shall include, at minimum: pulmonary assessment (BLUE protocol), cardiac arrest, medical hypotension (RUSH protocol), obstetric assessment, abdominal, optic nerve sheath, pacing confirmation, endotracheal tube confirmation, and any exam with which the provider has been trained and credentialed to perform. Multi-system trauma (eFAST) and IV access shall be listed as a secondary indication.

  Pre-Requisite Protocol Additions:

  • Rapid Sequence and Delayed Sequence Intubation. RSI and DSI shall move from the special project waiver (SPW) process to a published prerequisite protocol with stated requirements. The current SPW process is entirely undemocratic and does not give responsible agencies a clear or transparent path to adoption, and it leaves access dependent on informal relationships and politics rather than published standards. The state’s own data shows RSI/DSI can be done safely: OEMS has reported a 91% success rate across the services currently operating under special project waivers.

  • Finger thoracostomy. Simple (finger) thoracostomy shall be added as a pre-requisite protocol that requires additional training and credentialing.

  Other Protocol Additions:

  • Double sequential external defibrillation. Double sequential external defibrillation (DSED) and vector-change defibrillation shall be added for refractory ventricular fibrillation or pulseless ventricular tachycardia persisting after three consecutive standard shocks. The protocol shall specify pad placement for the second set (anterior-posterior), sequential rather than simultaneous shock delivery, and documentation, consistent with the DOSE-VF randomized trial (Cheskes et al., NEJM 2022), which found improved survival to hospital discharge with both DSED and vector change compared with standard defibrillation.

  • Sedation for noninvasive positive-pressure ventilation (NIPPV). A sedation protocol shall be added for patients who cannot tolerate CPAP or BiPAP because of anxiety or agitation, using low-dose ketamine as the preferred agent (due to ketamine’s specific bronchodilatory effect), with defined dosing, continuous waveform capnography and SpO₂ monitoring, and reassessment criteria for escalation to a definitive airway. This protocol is intended to keep patients on noninvasive ventilation and avoid intubation.

  • Withholding and cessation of resuscitation as a Standing Order

    Massachusetts paramedics should be able to terminate resuscitation in the field as a standing order, not as a “Medical Director Option” granted service by service. A Medical Control call would still be required in every case, and termination would be supported by objective criteria: end-tidal CO₂ findings and point-of-care ultrasound confirmation of cardiac standstill, with an exception for fast, organized PEA. Transporting a patient who cannot be resuscitated does not improve survival, and it puts crews, other motorists and pedestrians at risk during a lights-and-sirens transport. The American Heart Association and the National Association of EMS Physicians both support field termination, and most of New England already permits it as a matter of course. Massachusetts should bring its protocol in line with that standard.

  • Distal femur IO in cardiac arrest. Massachusetts paramedics are currently limited to the tibia and humerus. A humeral IO gets in the way of compressions and pad placement, and it can dislodge during CPR. In a large prehospital cardiac arrest cohort, the distal femur performed as well as the other sites.

  • IV nitroglycerin for acute pulmonary edema. Sublingual and topical nitroglycerin are absorbed unpredictably, especially in patients with SCAPE. These patients are often diaphoretic and vasoconstricted, and they can have a dry mouth from CPAP. Services with an infusion pump should be required to carry IV nitroglycerin and give it as a bolus followed by an infusion. Services without a pump should be required to give it as a bolus. Massachusetts already has Bolus and Infusion Nitroglycerin as a “Medical Director Option” but must become mandatory.

  • TASER probe removal. Removal of conducted electrical weapon probes shall be added to the Statewide Treatment Protocols, with exclusions for probes embedded in the face, eyes, neck, genitals, hands, feet, or over joints, and for barbs that cannot be removed with steady traction, which shall be left in place and transported. The protocol shall require a full assessment for injuries sustained during the incident, evaluation for underlying causes of agitation, wound care, tetanus status documentation, and transport or refusal per protocol. Probe removal shall be a clinical decision of the EMS provider and shall not substitute for patient assessment.

  • Nitrous oxide at the BLS level. EMTs shall be allowed to provide self-administered nitrous oxide for moderate to severe pain, as an optional medication at a service level, with defined training and equipment standards.

  • Tourniquet conversion and replacement. Tourniquet conversion and replacement shall be added as a BLS skill in the Statewide Treatment Protocols, consistent with TCCC guidelines. EMTs shall be authorized to replace improvised or ineffective tourniquets with a commercial tourniquet, and to convert a tourniquet to a pressure dressing or hemostatic packing when bleeding can be controlled with other methods, transport time is prolonged, and the patient is not in shock. Conversion should occur within two hours of application when feasible, and shall not be attempted when the tourniquet has been in place for more than six hours, on traumatic amputations, or when the patient cannot be continuously monitored. The protocol shall require documentation of application and conversion times, distal neurovascular reassessment, and immediate tourniquet reapplication if bleeding recurs.

  • Methylene Blue: Intentional overdoses with sodium nitrite are rising, and roughly 30% of reported cases are fatal. Many patients go into cardiac arrest before even reaching a hospital. The antidote, methylene blue, takes about 30 minutes to work, so waiting until the emergency department can be too late. The Coalition supports regionalizing methylene blue, the same way Cyanokits are regionalized for cyanide poisoning, so every Massachusetts community can get the antidote in time.

  • Hypertonic saline. Hypertonic saline is currently authorized only for pediatric patients. OEMS shall extend it to adults with suspected traumatic brain injury who show signs of herniation or rising intracranial pressure, using a single standardized concentration and dose.

  • Patellar dislocation reduction. Reduction of lateral patellar dislocation shall be added to the Statewide Treatment Protocols as a Medical Control order, with neurovascular reassessment and documentation after reduction.

  • Fentanyl for AEMTs. AEMTs shall be authorized to give fentanyl under statewide standing order, subject to capnography requirements, paramedic backup criteria, and safeguards against downstaffing of paramedic units.

  • Procainamide. Procainamide shall be added for stable wide-complex tachycardia, including suspected pre-excited atrial fibrillation, where AV nodal blocking agents are contraindicated. The protocol shall specify dose limits and stopping criteria: hypotension, QRS widening of 50% or more, or arrhythmia termination.

  • Droperidol. Droperidol shall be added for severe agitation and for refractory nausea and vomiting, with cardiac monitoring and a defined maximum dose.

  • Cefazolin. Cefazolin shall be a standing order for open fractures, traumatic amputations, and grossly contaminated soft-tissue wounds. It should be given as early as possible, ideally within one hour of injury. The protocol shall specify weight-based dosing and an alternative for patients with a severe beta-lactam allergy.

  Required Equipment:

  • PEEP valves. PEEP valves shall be required equipment on all bag-valve-mask devices and shall be added to the Statewide Treatment Protocols for ventilated patients. The protocol shall specify a starting PEEP of 5 cmH₂O, titration to oxygenation, and cautions for hypotension, hypovolemia, and suspected pneumothorax.

  • Large-bore suction catheters. Large-bore rigid suction catheters (such as the SSCOR SDC Catheter) shall be required equipment on all EMS units. The airway protocol shall include the SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) technique for contaminated airways.

The Coalition holds that the bodies shaping EMS policy in the Commonwealth shall be transparent, accountable, conflict-free, and representative of the clinicians who deliver and teach care.

• Committee reform. The Medical Services Committee shall be reformed into a transparent, democratic EMS advisory committee.

• Conflict of interest. Members of the Medical Services Committee and Office of EMS shall file annual disclosures and recuse themselves where they or their employers hold a stake in a decision.

• Elected representation. Certified EMS providers, including paramedics, AEMTs, EMTs, EMS educators, and physicians, shall elect their own representatives to the MSC at a District Level, with staggered terms and term limits.

• Public town halls. OEMS shall hold regular public town halls, at least quarterly and rotating across the EMS regions with a virtual option, where providers, services, and the public can raise concerns and comment on proposed protocol changes before adoption. Modeled on Vermont OEMS, these forums would restore the open provider input the Emergency Medical Care Advisory Board (EMCAB) once provided. OEMS shall publish minutes and written responses to the issues raised.

• Advisory bodies. Elected provider representation shall be increased on the Emergency Medical Care Advisory Board and the regional EMS councils.

• Decision deadlines. Any item referred to the committee shall receive a public decision, or a published written explanation, within a defined period.

The Coalition holds that paramedic education and career pathways must be rigorous, transparent, and aligned with the demands of modern practice.

• Instructional hours. Paramedic graduation requirements shall require a minimum of 1500 didactic and clinical instruction hours, documented via FISDAP.

• Degree requirement. OEMS shall publish an action plan toward an associate degree requirement, with full grandfathering and degree-completion pathways. The cost barrier is already largely solved: community college in Massachusetts is tuition- and fee-free for residents who haven’t earned a bachelor’s degree (MassEducate / MassReconnect). And the gap between a certified and a degreed paramedic is small. A certificate-trained paramedic is typically only a handful of general education courses short of an associate degree.

• Program audit. OEMS shall conduct and publish an audit of every paramedic education program, covering pass rates, attrition, clinical verification, and accreditation status.

• Required skills training. OEMS shall require every Massachusetts paramedic training program to provide didactic, laboratory, and simulation-based instruction, with documented competency verification before graduation, in point-of-care ultrasound; surgical cricothyrotomy; video laryngoscopy; endotracheal tube introducers (bougies); rapid and delayed sequence intubation, including simulation; and finger thoracostomy. OEMS shall implement this through its minimum paramedic training requirements [1] and the accreditation standards for paramedic training institutions.

• Compliance. OEMS shall publish the competency standards and a phase-in timeline, and each program shall maintain the equipment, simulation or cadaver resources, and qualified instructors the standards require.

• Critical Care Paramedic. The Commonwealth shall establish a published Critical Care Paramedic licensure tier keyed to national certification.

The Coalition holds that emergency medical services are an essential public service and must be funded and governed accordingly.

• Regionalization of Advanced Resources: The Massachusetts Prehospital Coalition holds that every patient in the Commonwealth should be able to reach prehospital blood, medication-facilitated airway management, and surgical chest decompression within a defined time, whether or not their local ambulance service carries them.

  Not every service can, or should, sustain these capabilities on its own. Low call volume, the cost of blood inventory, and the training and call-volume needed to stay competent make a service-by-service model unrealistic for much of the state. The answer is regionalization: designated, credentialed agencies that any service in a region can request and intercept with, backed by a published state standard rather than a one-off waiver.

  The Coalition calls on the Office of Emergency Medical Services (OEMS) to create that standard, and on regional EMS councils, hospitals, and municipalities to build the teams that meet it. OEMS should also create an Advanced Practice Paramedic designation for paramedics who hold both critical care certification and state-mandated training.

• Essential service. The Commonwealth shall designate EMS an essential service, with a dedicated state fund, statewide delivery and response standards, and annual public reporting on workforce and funding.

• Ambulance billing. The Commonwealth shall enact patient balance-billing protections for ground ambulance services, paired with a reimbursement floor.

• Treatment in place. The Commonwealth shall provide reimbursement for on-scene treatment, community paramedicine, and alternate destination transport.

• Off-duty practice. The Commonwealth shall address the limits imposed by Advisory 25-11-01 so that event medicine, standby, and volunteer service remain permissible.

• Licensure compact. The Commonwealth shall join the interstate EMS licensure compact.

• Paramedic title. The Massachusetts Paramedic Coalition calls on OEMS to retire the title “EMT-Paramedic” and recognize Massachusetts Paramedics as Paramedics, in line with the National Registry standard and the National EMS Scope of Practice Model. As a National Registry state, the Commonwealth shall update its website, licensing cards, regulations, and official materials to reflect this change, and shall sanction a new patch that identifies Massachusetts Paramedics as Paramedics, not EMTs. The Coalition supports corresponding amendments to 105 CMR 170 and M.G.L. c. 111C.