Statewide Treatment Protocols

The EMS Statewide Treatment Protocols Version 12.3 have been released and are effective as of September 6, 2014. There are some important changes to the protocols of which emergency physicians in the state should be aware.

1.       The protocols have been altered to add a protocol for behavioral emergencies. This protocol puts haloperidol on paramedic level 
ambulances. In the case of dangerously combative patients or those exhibiting signs of agitated delirium, paramedics have standing orders to administer haloperidol in conjunction with the benzodiazepine (either midazolam or lorazepam). The standing order is for a dose of 5 mg of haloperidol to be administered intramuscularly, intravenously, or via intra-osseous route. This medication may be administered by itself or in combination with either lorazepam 2 mg IV/IO/IM, or 2.5 to 5 mg of midazolam him IV/I/O/IM/IN.

2.       Selective spinal assessment remains a medical director option providing that the medical director has approved a clinical policy allowing its use and has ensured that the providers have been adequately trained on its use. This protocol, if approved by the medical director, allows services to utilize a select immobilization protocol for patients whose mechanism of injury would normally require cervical immobilization. Patients must be under the age of 65, the reliable for assessment (meaning not intoxicated and not displaying an alteration of mental status), has no focal neurologic symptoms, have no distracting injury, and have no midline tenderness on palpation of the cervical spine. The upper age limit of 65 years of age was added as an emergency change because of concern for missed injuries in older patients.

Clinical Policy

3.       The spinal immobilization protocol does not specify the means of immobilization. Within the selective spinal assessment protocol, however, there is a description of the standard of care of cervical spine immobilization. This is description specifically states that the long spine board is not considered the standard of care. A patient may be immobilized with a properly fitted cervical collar and the ambulance cot. Backboards may be used as needed as extrication devices but their routine use is no longer encouraged. This is in keeping with a growing literature that demonstrates a lack of benefit from long spine board immobilization and is also in keeping with state protocols and other regional states.

4.       The statewide treatment protocols include a new protocol designated as the routine care protocol. This protocol specifies multiple items that should take place for routine care. Amongst these is a comment about judicious use of warning lights and sirens for the transport of patients. This is a response to initiatives by MACEP. The protocol states:

“Use of lights and sirens should be justified by the need for immediate medical intervention that is beyond the capabilities of the ambulance crew using available supplies and equipment.”

It is hoped that this protocol and its close monitoring by medical directors throughout the state will help reduce the number of unnecessary warning lights and siren transports and thereby reduce the risk to patients, providers, and the general public posts by use of lights and sirens.

An example clinical policy regarding warning lights and siren use is included here.
Below is a link to the statewide treatment protocols on the Department of Public Health/Office of Emergency Medical Services, website:
Download the revised protocols, change chart and training slides at

This training has been assigned a blanket OEMS approval number, 140493, for two hours of either local or individual credit, all levels. The quizzes have also been updated and were sent to service-associated Training Officers to maintain exam security. Do not use quizzes which were based on version 12.01.

Ambulance services must ensure their EMS personnel have successfully completed this Department-provided training before implementing these Protocols no later than 9/6/14.  Documentation of successful completion of Protocol training for all service EMS personnel, including the quizzes, will be reviewed by Department inspectors and investigators.

Direct questions about the protocol revisions or education component to OEMS at 617-753-7300.