Scope of Practice model". Without federal mandate, each state's office of emergency medical services may alter their respective standing orders. The purpose of the model is to provide a guide toward standardization in patient care that both improves patient outcomes but allows for reciprocity between states. Prior to certification as a paramedic, candidates must be a certified EMT. Traditionally, a paramedic is allowed to perform all skills an EMT may perform. Below are some of the key skills and procedures expected of a paramedic in the United States. Key skills and procedures Assessment and evaluation of general incident scene safety. Triage of patients in a mass casualty incident. Patient primary and secondary assessments. Effective verbal and written reporting skills (Documentation). Carrying/Lifting/Extrication of patients. Peripheral intravenous cannulation. Cardiac monitoring and manual defibrillation. ECG acquisition and interpretation. Orotracheal intubation. Medications One of the primary differences between emergency medical technicians and paramedics includes the breadth and number of medications paramedic ambulances typically carry. Due to the variation between each state EMS office it would be cumbersome and unrealistic to list each and every single medication paramedics carry across the United States. Instead, different medications are carried to serve similar patient-care scenarios. Most services carry medications like albuterol or ipratropium to alleviate bronchospasm during an acute asthma attack. They carry cardiac medications to reverse deadly heart rhythms like amiodarone and lidocaine. They can also use medications like atropine, adenosine and different types of beta-blockers as heart rate controls. Paramedics may also utilize a number of other medications for analgesia, such as antiemetics and anti-convulsants. In the setting of inter-facility transfers providers may continue the administration of other medications that are not typically carried in the field (Heparin, Blood products, Potassium). Variations in scope The aforementioned skills and medications are often standing orders in state protocols. The expectations and responsibilities of providers varies across state lines. There are instances where special waivers granted by states allowing paramedic services to go beyond their protocols. For example, some paramedics in New Hampshire may be allowed to perform a surgical cricothyrotomy, medics in Virginia are allowed to use ultrasound as a diagnostic technique and paramedics in Arizona are allowed to perform rapid-sequence intubation utilizing paralytic and sedating medication to completely control a patient's airway. Employment Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, public safety or police departments,