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Quick summary

The crew kicks off year 3 of the Pre-Hospital Paradigm Podcast with a team update (AJ joining as a recurring host; Ray Pace stepping back to focus on chief/education duties). Then they jump into a fresh Ohio Scope of Practice release—talking through how Ohio’s scope/protocol structure works, why “scope ≠ protocol,” and walking listeners through major updates (especially EMT-level meds, blood products initiation, and new/expanded procedures like finger thoracostomy and ultrasound use).

Opening: Team update + what’s coming in 2026

• AJ is welcomed back and announced as a more regular part of the team.
  
  

• Ray Pace is stepping away from routine hosting to focus on leadership and education responsibilities (still planning occasional appearances).
  
  

• The show is entering year 3, and the team plans to rotate more voices (physicians with different practice environments/viewpoints).
  
  

• Tease of expanded offshoot projects and more “workforce” to build additional podcast products in 2026.
  
  

Big framing concept: How Ohio got here

1) The “decoupling” shift

• Historically, Ohio’s scope of practice was closely tied to initial education standards.
  
  

• Ohio changed the structure so scope could evolve without requiring everyone to “go back to school” for every advancement.
  
  

• This created more flexibility for the EMS Board and local medical directors to approve/authorize added interventions—without turning paramedicine into “medical school.”
  
  

2) Ohio = local medical director protocols (not state protocols)

• Ohio protocols are locally dictated (within state scope boundaries).
  
  

• A medical director can authorize within scope (e.g., invasive airway procedures), but cannot authorize things that exceed scope (tongue-in-cheek examples like appendectomies/C-sections).
  
  

• Key takeaway: Scope sets the ceiling; your medical director and protocol determine what you actually do.
  
  

3) The scope matrix (why it’s actually user-friendly)

• Ohio scope is presented as a grid/matrix:
  
  

  • Columns: EMR / EMT / AEMT / Paramedic
    
    

  • Rows: procedures
    
    

  • “X” marks permitted procedures by certification level
    
    

• The crew emphasizes that every provider should:
  
  

  • know where to find it,
    
    

  • know what it says,
    
    

  • and understand the difference between student role vs certified role.
    
    

Core competencies vs Added competencies

• Ohio now differentiates between:
  
  

  • Core competencies (baseline expectations)
    
    

  • Added competencies (require medical director approval + training + oversight)
    
    

• Repeated emphasis: Just because it’s in scope doesn’t mean you can do it tomorrow.
  Training + authorization + local protocol still matter.
  
  

Medical director relationship: privilege, trust, and accountability

“Working under license” matters

• EMS practice is described as a privilege under physician medical direction.
  
  

• Trust can be withdrawn quickly—especially after major violations.
  
  

Reporting mistakes: timing changes everything

• Immediate self-reporting → education, remediation, system improvement.
  
  

• Hiding errors → escalates consequences (discipline, demotion, loss of trust).
  
  

• The team reinforces a “professional adult conversation” model:
  
  

  • what happened,
    
    

  • why it happened,
    
    

  • what you’ll change moving forward.
    
    

Why some agencies get “advanced” privileges and others don’t

• Not personal—based on:
  
  

  • call volume,
    
    

  • skill maintenance opportunities,
    
    

  • performance metrics (IV success, first-pass airway rates, etc.),
    
    

  • training infrastructure,
    
    

  • medical director comfort with risk.
    
    

• Example: RSI requires significant ongoing training and quality benchmarks before a medical director should approve it.
  
  

Walkthrough: Major scope updates discussed

EMT-level changes (big wins)

1) IM epinephrine via syringe (not just auto-injector)

• Huge access/affordability improvement.
  
  

• More epinephrine deployed systemwide for the same cost.
  
  

• Emphasizes that anaphylaxis deaths are often “lack of epinephrine” deaths.
  
  

2) Bronchodilators (MDI/nebulized) without the old “patient-assisted” workaround

• Moves from “call med control / patient-assisted” language to clearer EMT authorization (with training + protocol).
  
  

• Reinforces patient-centered care: many physicians were already going to say “yes” on the phone anyway.
  
  

3) Glucagon (intranasal or IM) for hypoglycemia

• Recognized as lifesaving when IV access isn’t available at the EMT level.
  
  

• Requires new training because:
  
  

  • medication draw-up and reconstitution are new skills for EMT scope.
    
    

• The crew shares real-world error examples:
  
  

  • glucagon given without reconstitution,
    
    

  • mixing errors / inability to draw medication back up.
    
    

Paramedic changes (high impact)

Blood / blood products: initiation (not just continuation)

• Previously: paramedics could continue blood already running (common in interfacility).
  
  

• Now: paramedics can initiate blood/blood products (within protocol/authorization).
  
  

• Discussion includes MCI/extended scene care considerations:
  
  

  • logistics of getting blood to the scene,
    
    

  • need for blood bank prep, coolant systems, and time delays.
    
    

• Strong message: if EMS wants blood, EMS must also help solve the blood shortage.
  
  

  • The team mentions sponsoring blood drives and growing collection efforts.
    
    

Devices and procedures (the “spicier” stuff)

1) Doppler devices

• Not expected as a daily tool, but useful for:
  
  

  • LVAD patients (where manual pulse/BP can be unreliable),
    
    

  • suspected limb ischemia / arterial occlusion.
    
    

• Caution about fetal doppler use at home (can create anxiety when hard to find tones).
  
  

2) Finger thoracostomy

• Discussed as a response to needle decompression failure rates.
  
  

• Failure points highlighted:
  
  

  • depth/technique (stopping after “air” instead of fully advancing/hubbing),
    
    

  • catheter not truly entering pleural space,
    
    

  • angle/placement errors,
    
    

  • occlusion issues in hemothorax (clotting).
    
    

• Practical reality:
  
  

  • likely limited to specialized teams/supervisors/critical care due to training/volume needs.
    
    

• Brief side discussion on higher-level trauma interventions (REBOA, thoracotomy in ED context).
  
  

3) Ultrasound utilization (beyond IV access)

• Expanded from US-guided IV access into broader field use at medical director discretion.
  
  

• Potential advantages discussed:
  
  

  • lung exam (sliding / pneumothorax support),
    
    

  • FAST exam (free fluid suggesting hemorrhage),
    
    

  • cardiac standstill confirmation (especially if clips could be transmitted for physician over-read),
    
    

  • objective documentation and QA support (telemetry/recording supports good care).
    
    

4) Urinary catheter initiation/maintenance

• Met with skepticism for typical 9-1-1 EMS relevance.
  
  

• Possible fit discussed for:
  
  

  • interfacility,
    
    

  • community paramedicine / home-care avoidance of ED visits.
    
    

• Considered “medical director interpretation dependent,” with doubt many EMS systems will operationalize it broadly.
  
  

Medication updates: nausea/vomiting + harm reduction

1) EMT oral ondansetron (Zofran)

• EMTs: oral ondansetron for age ≥12 (as discussed).
  
  

• Seen as common-sense, safe, and practical.
  
  

2) AEMT expanded ondansetron access

• The crew highlights relief that AEMTs aren’t boxed in the same way anymore.
  
  

• QT prolongation discussion:
  
  

  • risk higher in complex adults / polypharmacy / baseline prolonged QTc,
    
    

  • less concern in healthy pediatric patients,
    
    

  • ED vs homegoing considerations.
    
    

3) AEMT + paramedic buprenorphine for opioid withdrawal

• Mentioned as part of pilot programs and harm reduction expansion.
  
  

• Teased as covered in other dedicated episodes (harm reduction + an upcoming episode not yet released at time of recording).
  
  

4) AEMT tracheostomy/tracheal tube replacement

• Presented as a sensible expansion (and potentially core competency).
  
  

• Emphasis on practical lifesaving implications:
  
  

  • suctioning trachs,
    
    

  • replacing tubes when dislodged,
    
    

  • bridging airway management without waiting on a paramedic.
    
    

Notable quotes / moments (paraphrased)

• “Scope is the ceiling—protocol and medical director authorization determine what you actually do.”
  
  

• “Working under medical direction is a privilege. Trust can be withdrawn.”
  
  

• “If you mess up: when did you catch it, and when did you report it?”
  
  

• “We can train anyone to do ultrasound—it’s lots of small skills done well.”
  
  

• “If EMS wants blood, EMS has to help replenish blood.”
  
  

(Plus plenty of levity: Dunning–Kruger jokes, Super Troopers references, and the running catheter humor.)

Practical takeaways for listeners

• Read your Ohio scope matrix—know where it is and what it actually says.
  
  

• Remember: Scope change ≠ automatic green light. You still need:
  
  

  • protocol inclusion,
    
    

  • medical director authorization,
    
    

  • training + competency validation.
    
    

• Advanced skills should match system realities:
  
  

  • call volume,
    
    

  • training infrastructure,
    
    

  • QA processes,
    
    

  • risk tolerance and patient safety.
    
    

• New EMT tools (IM epi, glucagon, bronchodilators) are system-changing and can improve outcomes quickly when implemented well.
  
  

• Blood products require a system plan, not just clinical enthusiasm.
  
  

Suggested show links / callbacks (episodes to reference)

• Blood / whole blood series (EMS transfusion + logistics + stewardship)
  
  

• Harm reduction episode (buprenorphine context)
  
  

• Upcoming buprenorphine-focused episode (teased)
  
  

• Pediatric outcomes discussion episode referenced with Dr. Regina Jasky (steroids / peds outcomes)
  
  

Outro

The team closes by reinforcing that many “can we do this?” questions are now clearly defined at the state level—but the deciding factor remains your local medical director and protocol. They sign off and tease more to come as 2026 approaches.

From The Episode