Protocols are usually more liberal for smaller systems because the medical director actually knows everyone that works under his license. In my system, we have a duel responce system with an ALS ambulance (my home) and two ALS fire departments. The ambulance has around 100 paramedics, and there are an additional 250 working for the two fire systems. We have a Medical Control Board (seven ER MD's, plus a rep from each service) that sets our protocols. We have had to fight tooth and nail to expand our practice. We have been successful but weeding out the wild cards, and keeping to the set protocols established. In 13 years, our protocols have greatly expanded, and our "mother may I" list is now relitively short. Eightball.