Alabama EMS Protocols: Provider Levels, Scope, and DNR Orders

Alabama’s EMS scope of practice is set by statute and spelled out in detail in the 11th Edition Patient Care Protocols, effective July 1, 2025.¹ Four licensure levels — EMT, Advanced EMT, EMT-Intermediate, and Paramedic — carry progressively broader authority, and no provider at any level may administer a medication or perform a procedure that falls outside the manual, even if it was covered in their training program.

What Defines the Scope

Two documents govern what an Alabama EMS provider can do. The Code of Alabama, Title 22, Chapter 18 sets the statutory framework for personnel qualifications and licensure.² The Patient Care Protocols, issued by the Alabama Department of Public Health’s Office of Emergency Medical Services (OEMS) after approval by the State Committee of Public Health, list every authorized medication and procedure for each level.¹

Local EMS agencies can maintain their own operational guidelines, but any local patient care protocol must meet or exceed the statewide standard.³ The protocols organize skills and medications by clinical area — cardiac, trauma, respiratory, neurological, pediatric — so a provider can locate the applicable authority quickly in the field.

Emergency Medical Technician (EMT)

The EMT scope covers patient assessment, vital signs, supplemental oxygen, and basic airway management with oropharyngeal and nasopharyngeal airways, bag-valve masks, and suction. EMTs perform CPR, use automated external defibrillators, control bleeding with direct pressure, tourniquets, and hemostatic agents, and apply splints, including traction splints for long-bone fractures.¹

Under the 11th Edition, EMTs are also authorized to administer aspirin for suspected cardiac chest pain, use automated glucometers, place Blind Insertion Airway Devices (BIADs) for advanced airway management, apply CPAP or BiPAP for respiratory distress, and use capnography to monitor exhaled carbon dioxide. EMTs give medications listed on the EMT Medication Formulary and may assist patients with their own prescribed auto-injectors.¹

Advanced EMT (AEMT)

AEMTs carry the full EMT scope and add invasive vascular access. They can start peripheral IVs and perform intraosseous (IO) cannulation at approved sites in adults and pediatric patients. Approved adult IO sites are the proximal humerus, sternum (with an approved sternal device), and proximal tibia. Approved pediatric sites are the proximal humerus, proximal tibia, and distal femur.¹

AEMTs gain ECG monitoring capability during interfacility transfers and emergency calls, with one hard limit: if a lethal rhythm is recognized, the AEMT must switch to AED mode rather than interpret independently. ECG use also requires additional training and approval from the service medical director. AEMT medications may be given through IV, IO, intranasal, subcutaneous, intramuscular, oral, and sublingual routes, drawing from the AEMT Medication Formulary.¹

EMT-Intermediate

EMT-Intermediate is a legacy classification that sits between AEMT and Paramedic. At this level, providers gain endotracheal intubation, full cardiac monitoring with ECG interpretation, manual defibrillation, and synchronized cardioversion.¹

Paramedic

The Paramedic scope is the highest level of pre-hospital care in Alabama and includes every skill authorized for EMTs, AEMTs, and EMT-Intermediates. On top of that, Paramedics may perform external cardiac pacing, needle decompression for tension pneumothorax at approved anatomical sites, nasogastric or orogastric tube placement, blood draws, and blood product administration. Needle cricothyroidotomy is available as an optional Paramedic procedure, subject to approval from the service medical director.¹

Paramedics draw from the broadest formulary, covering drugs used in advanced cardiac care, pain management, sedation, and other critical interventions.¹

Standing Orders and Online Medical Direction

The written protocols function as standing orders, sometimes called off-line medical direction. Following the protocol for a given situation means you’re already acting under pre-authorized medical direction, without needing a phone call. That is what lets an EMT give aspirin for chest pain or a Paramedic pace a bradycardic patient without waiting on a physician.

Situations outside the standing protocols, or higher-risk interventions, require Online Medical Direction (OLMD). A physician on OLMD can order treatments beyond what the standing protocols cover, but the order cannot exceed the provider’s scope of practice. If a physician orders a procedure the provider is not licensed to perform, the provider is expected to decline the order.¹

Specific situations that direct providers to contact OLMD include pain management for patients with altered mental status or low blood pressure, blood pressure treatment decisions during an acute stroke, and cases where transport necessity is uncertain. Patient destination preference also involves OLMD: a competent patient’s choice of hospital supersedes default routing, provided both the field provider and OLMD agree the patient can make that decision.¹

Prerequisites for Practicing at an Advanced Level

Holding an AEMT, EMT-Intermediate, or Paramedic license is not enough on its own. To practice at an advanced level, a provider must hold a valid Alabama license, stay current on all protocol updates approved by the board, and be listed on the personnel roster of a licensed ALS provider service. Meeting the education and exam requirements without an operational link to an active service does not authorize advanced practice.⁴

Baseline personnel requirements set by statute apply at every level: at least 18 years old, completion of an approved training program for the licensure level, passage of the corresponding state examination, and issuance of a license by the board. The statute also provides that a college degree cannot be required for paramedic licensure.⁵

Practicing Outside Your Scope

Alabama Code Section 22-18-6(f) lists ten grounds under which the OEMS can suspend, revoke, or refuse to grant a license. Two of them target scope directly. Performing any act that requires licensure without holding the right credential is a violation, and so is performing any act beyond the scope or privilege of the license level actually held. Providing substandard care that jeopardizes a patient’s life, health, or safety is a separate ground, as is any misconduct that violates a board rule.

The board can place a license on probation for up to one year when a deficiency is serious but potentially correctable, rather than moving straight to suspension or revocation. A revoked license terminates EMS practice privileges entirely, and a license that is not renewed by its expiration date shifts to expired status.⁶⁴ Medical directors, both online and service-level, are required to report improper care or complaints about licensed providers directly to the OEMS.⁷

Providers Licensed in Other States

Alabama joined the EMS Personnel Licensure Interstate Compact (REPLICA) on May 17, 2017, as the 11th state to sign on. A provider licensed in another compact state can practice in Alabama without a separate Alabama license, as long as the work is being performed under an appropriate authority’s assignment. Alabama-licensed providers get the same privilege in other compact states.⁸ The privilege matters most for border-area calls, mutual aid, and disaster response. It does not, however, expand the underlying scope of practice: a provider practicing under REPLICA still works within the scope authorized for their home-state license level.

Do Not Resuscitate Orders

Scope also has an important negative dimension. Alabama authorizes EMS personnel to honor portable physician Do Not Attempt Resuscitation (DNAR) orders when the order is available, known to the provider, and was executed under state rules. The order stays valid until the patient or an authorized person revokes it, and licensed providers in any facility, program, or organization are authorized to follow it, giving field crews the legal backing to withhold resuscitation when a valid DNAR is presented.⁹

1
Alabama Department of Public Health. Alabama EMS Patient Care Protocols – 11th Edition
2
Alabama Department of Public Health. Code of Alabama Section 22-18-1
3
Alabama Department of Public Health. Rules, Protocols, and Guidelines
4
Alabama Department of Public Health. Alabama Administrative Code Chapter 420-2-1 – Emergency Medical Services
5
Alabama Legislature. Alabama Code Title 22-18-1 – Definitions
6
Alabama Department of Public Health. Office of Emergency Medical Services License Deniability Policy
7
Alabama Administrative Code. Alabama Administrative Code Rule 420-2-1-.06 – Medical Direction
8
Alabama Department of Public Health. EMS Compact
9
Legal Information Institute. Alabama Administrative Code Rule 420-5-19-.02 – Portable Physician Do Not Resuscitate Orders