⚕️ Medical Authority

Medical Directives

The physician-authorized protocols that govern what NJRP EMS providers are legally and operationally permitted to do. Every intervention we perform is backed by these directives.

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Medical Director — Yoroblox372

NJRP EMS operates under the medical license and authority of our Medical Director. All protocols, standing orders, and scope of practice authorizations flow from this physician oversight relationship. The Medical Director is responsible for the clinical quality and safety of all EMS operations.

MD FACEP FAEMS CCP EMT-P
What Are Medical Directives?
Medical directives are written authorizations from a licensed physician that allow EMS providers to perform specific medical interventions without direct physician presence. In real EMS, providers cannot administer medications or perform advanced procedures on their own authority — they act as extensions of the medical director's license.

There are two types: Standing Orders (pre-authorized interventions you can perform based on your assessment alone) and Medical Control Orders (interventions that require you to contact online medical direction first). All interventions in the Protocol Reference are covered by standing orders from our Medical Director.

Why does this matter in ERLC? Following medical directives makes our roleplay accurate, consistent, and professional. When an EMT gives oral glucose or a Paramedic pushes epinephrine, they're acting within a legally defined scope backed by a real medical framework — not freelancing. It also means that exceeding your scope (e.g., an EMT giving IV medications) is a genuine protocol violation, not just a preference.
Standing Order vs. Medical Control: The vast majority of NJRP EMS protocols are standing orders — meaning you assess, determine the intervention is indicated, and act. Medical control contact is reserved for unusual situations: pronouncing death in the field, withholding resuscitation for a DNR, or a treatment decision outside standard protocols. In ERLC, treat all standard protocols as standing orders unless an FTO directs otherwise.
Scope of Practice by Certification Level

Your certification determines your authorized scope. Performing interventions above your certification level — even if you think they're indicated — is a scope violation and a serious breach of medical directives. When in doubt, call for ALS.

🚑 EMT — BLS Scope

  • Airway: OPA, NPA, BVM, suction
  • O₂ administration (NRB, NC, BVM)
  • CPR and AED operation
  • Hemorrhage control: direct pressure, tourniquet, wound packing
  • Spinal motion restriction (C-collar, backboard)
  • Medications: Oral glucose, aspirin (324mg PO), epinephrine auto-injector (EpiPen) for anaphylaxis, patient-assisted nitro/MDI
  • Splinting and bandaging
  • Childbirth assistance

⚕️ Paramedic — ALS Scope

  • All BLS interventions
  • Advanced airway: ETT, supraglottic airways, RSI
  • IV/IO access and fluid administration
  • Cardiac monitoring (12-lead ECG)
  • Manual defibrillation and cardioversion
  • Transcutaneous pacing
  • Needle decompression
  • Full medication formulary: epinephrine, amiodarone, adenosine, atropine, nitroglycerin, morphine/fentanyl, midazolam, ketamine, succinylcholine, dextrose, albuterol, and more

👮 NJSP BLS First Responder

  • CPR and AED
  • Basic airway (OPA/NPA, BVM)
  • Hemorrhage control: tourniquet, direct pressure
  • Epinephrine IM (0.3mg) for anaphylaxis
  • Oral glucose (BG <60, conscious)
  • O₂ via NRB mask
  • Spinal precautions
  • Not in scope: IV access, ALS medications, advanced airways

📋 All Levels — Universal

  • Scene safety assessment
  • Patient assessment (primary/secondary survey)
  • SAMPLE history, OPQRST
  • Patient positioning
  • Documentation (PCR required for all calls)
  • Refusal of care documentation
  • Inter-agency handoff / SBAR report
  • Infection control and PPE
Standing Order Directives

Click any directive to expand the full authorization, indications, and ERLC application notes.

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Directive 01 — Cardiac Arrest & Resuscitation
CPR, AED, ACLS drug administration
BLSALSStanding Order
▼

Authorization: All NJRP EMS providers are authorized to initiate and continue resuscitation on any patient found in cardiac arrest. Paramedics are additionally authorized to administer ACLS medications per the cardiac arrest algorithm.

  • BLS: Immediate CPR (30:2), AED as soon as available, BVM ventilation
  • ALS additions: IV/IO access, epinephrine 1mg q3–5 min, amiodarone 300mg after 3rd shock, advanced airway management
  • Continue resuscitation until ROSC, patient pronounced by medical control, or exhaustion of efforts (typically 20–30 min in field)
  • DNR: If a valid DNR is presented, contact medical control before withholding resuscitation
Why this directive exists: Cardiac arrest is immediately reversible — every minute without CPR decreases survival by ~10%. Pre-authorization allows providers to act in the first critical seconds without waiting for physician contact. This directive also ensures EMTs never wait for a Paramedic to arrive before starting CPR.
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Directive 02 — Airway Management
Basic and advanced airway interventions, RSI authorization
BLSALSStanding Order
▼
  • BLS: OPA/NPA insertion, BVM ventilation, suction, O₂ administration at any flow rate indicated by patient condition
  • ALS: All BLS interventions plus endotracheal intubation, supraglottic airways (King LT, i-gel), RSI with authorized medications
  • RSI medications authorized: Ketamine 1–2 mg/kg IV or Etomidate 0.3 mg/kg IV (sedation) + Succinylcholine 1.5 mg/kg IV or Rocuronium 1.2 mg/kg IV (paralytic)
  • All intubations must be confirmed by EtCO₂ waveform capnography
  • SpO₂ target: ≥94% in all patients; post-ROSC: 94–98%
Why this directive exists: Airway management is the foundational skill of EMS. Pre-authorizing all levels to manage the airway removes hesitation in the most time-sensitive interventions. RSI authorization specifically is restricted to Paramedics because the paralytic component removes the patient's ability to breathe independently — a Paramedic must be capable of securing the airway definitively before paralyzing a patient.
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Directive 03 — Hemorrhage Control
Tourniquet, wound packing, junctional hemorrhage
BLSALSStanding Order
▼
  • Apply tourniquet for any life-threatening extremity hemorrhage uncontrolled by direct pressure — apply 2–3 inches proximal to wound
  • Note exact time of tourniquet application on the device itself
  • Never remove a tourniquet in the field once applied
  • Wound packing with hemostatic gauze (if available) for junctional wounds not amenable to tourniquet
  • Pressure dressings for moderate bleeding
  • TXA (Tranexamic Acid): Authorized for Paramedics for major trauma with suspected hemorrhagic shock within 3 hours of injury (1g IV over 10 min)
Why this directive exists: Hemorrhage is the #1 preventable cause of trauma death. The transition to tourniquet-first care (rather than direct pressure first) was driven by military combat casualty research showing that extremity tourniquets save lives with minimal risk when applied correctly. The time documentation requirement is critical — ischemia risk begins at ~2 hours, and surgeons need this information immediately on arrival.
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Directive 04 — Anaphylaxis & Allergic Reaction
Epinephrine authorization for all levels
BLSALSStanding Order
▼
  • BLS/NJSP: Epinephrine 0.3mg IM (anterolateral thigh) for signs of anaphylaxis — may repeat × 1 after 5–15 min
  • ALS additions: IV epinephrine 0.1mg (1:10,000) for refractory anaphylaxis with hypotension, diphenhydramine 25–50mg IV, NS bolus 1L for hypotension, albuterol nebulized for bronchospasm
  • Anaphylaxis criteria: acute onset, multi-system involvement (skin + airway/cardiovascular), history of exposure to allergen
  • All levels authorized to use epinephrine auto-injector regardless of whether the patient's own EpiPen or a service-supplied unit
Why this directive exists: Anaphylaxis can cause death within minutes from airway obstruction or cardiovascular collapse. Epinephrine is the only definitive treatment and has an extraordinary safety profile in anaphylaxis — the risks of withholding it far exceed the risks of giving it unnecessarily. This directive ensures EMTs and even NJSP first responders never have to wait for a Paramedic to administer the one drug that can save the patient's life.
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Directive 05 — Chest Pain & ACS Protocol
Aspirin, nitroglycerin, 12-lead ECG, fibrinolysis screening
BLSALSStanding Order
▼
  • BLS: Aspirin 324mg PO chewed (if no contraindications), patient-assisted nitroglycerin (patient's own prescription), O₂ if SpO₂ <94%
  • ALS: Nitroglycerin 0.4mg SL (service supply), 12-lead ECG acquisition and interpretation, IV access, fentanyl 1 mcg/kg IV for pain (preferred over morphine)
  • STEMI identification → transmit 12-lead to receiving hospital, activate STEMI alert, priority transport
  • Avoid morphine in ACS — associated with worse outcomes. Use fentanyl.
  • Nitroglycerin contraindications: SBP <90, suspected right-sided MI (obtain V4R), PDE-5 inhibitor use in past 24–48h
Why this directive exists: ACS is time-critical — "time is muscle." Every minute of coronary occlusion kills cardiomyocytes permanently. Pre-authorizing aspirin and 12-lead ECG allows BLS providers to initiate treatment and identify STEMIs before ALS arrives. The explicit fentanyl-over-morphine instruction exists because research showed morphine increases mortality in NSTEMI — this directive directly incorporates evidence-based medicine into standing orders.
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Directive 06 — Diabetic Emergencies
Oral glucose, D50, glucagon authorization
BLSALSStanding Order
▼
  • BLS: Oral glucose 15–25g for BG <60 with intact gag reflex and ability to swallow
  • ALS: Dextrose 50% (D50) 25g IV/IO for BG <60 and unable to swallow; Glucagon 1mg IM if no IV access
  • Recheck BG 15 minutes after treatment — repeat if still <70
  • Hyperglycemia: IV fluid resuscitation only in field — insulin is in-hospital
  • Do not delay transport for hyperglycemic patients — DKA requires hospital management
Why this directive exists: Hypoglycemia is one of the most common EMS calls and one of the most rapidly correctable emergencies. Oral glucose is an extremely safe intervention — the only real risk is aspiration if given to an unconscious patient, which is why the directive restricts it to conscious patients with intact swallow. D50 is authorized for Paramedics because IV access and medication administration is within their scope.
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Directive 07 — Refusal of Care & Patient Rights
Capacity assessment, informed refusal, AMA documentation
BLSALSStanding Order
▼
  • Any alert and oriented adult patient has the legal right to refuse EMS care or transport
  • Capacity assessment: Patient must be alert, oriented (person/place/time/event), and demonstrate understanding of their condition and consequences of refusal
  • Diminished capacity (intoxication, altered mental status, <18 years old, severe psychological crisis) = patient may not have legal capacity to refuse
  • Advise patient of risks of refusal, recommend they call back if symptoms worsen
  • Required documentation (PCR Refusal form): Capacity assessment, patient's stated reason, warnings given, witness if available
  • If capacity is in question, consult with online medical control or law enforcement before leaving scene
Why this directive exists: Forced treatment of a competent adult is assault — even with the best intentions. This directive balances respect for patient autonomy with our duty to ensure the refusal is truly informed and that the patient has the cognitive capacity to make that decision. The documentation requirements protect both the patient (evidence that they were properly informed) and the provider (liability protection showing the refusal was handled correctly).
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Directive 08 — Documentation Requirements
PCR completion, mandatory reporting
BLSALSStanding Order
▼
  • A Patient Care Report (PCR) is required for every patient contact regardless of outcome
  • PCRs must be submitted within a reasonable time after the call concludes
  • Minimum required documentation: dispatch info, patient identifier (Roblox username), chief complaint, assessment findings, all interventions with times, patient response, and disposition
  • Refusals require the separate Refusal of Care form in addition to or in place of a standard PCR
  • Incomplete or missing PCRs are a protocol violation subject to remediation by FTO staff
  • PCRs are reviewed by the Medical Director for quality assurance
Why this directive exists: Documentation is the legal record of care provided. In real EMS, "if it wasn't documented, it wasn't done" — the PCR is what protects providers legally, enables QA/QI review, provides continuity of care to the receiving hospital, and creates the data needed to improve protocols over time. Completing a PCR after every call isn't paperwork for its own sake — it's a professional obligation and a direct component of patient care.

These directives are implemented through our clinical protocols.

📖 View Protocol Reference →