How to get RSI, blood or ketamine on your card

No course puts these skills on your license by itself. In most states your agency's medical director credentials you after training. In others the agency needs state approval first, or the skill belongs to a critical care credential. Work out which route your state uses, then aim for it.

The three routes

Your agency credentials you. The skill is in the state's scope or protocols, and the medical director decides who uses it. You get it by joining a service that runs it: you train with them, hit their case or simulation requirements, and get signed off.
The agency needs state approval. Only services holding a state or regional approval, waiver or pilot can run it. Your route is a job at one of those services. Ask the state EMS office or the regional council which agencies hold approval.
It takes a critical care credential. The skill sits with a critical care or flight level, not the standard paramedic license. You need that credential, which usually means a course plus a national exam and a job in critical care transport or flight.

Which route, skill by skill

Counts are for all 50 states and DC. The state-by-state detail, with sources, is on the paramedic skills by state page.

RSI

21 states: your agency credentials you.

21 states: the agency needs approval (AZ, AR, CA, CO, DE, GA, IL, KY, MD, MA, NH, NJ, NY, NC, OK, RI, UT, VT, WV, WI, WY).

6 states: critical care credential (AL, ID, MS, MT, NM, PA).

3 states: not in paramedic protocols (DC, ME, MI).

Starting blood

25 states: your agency credentials you.

15 states: the agency needs approval (AR, CO, DE, GA, IL, KY, MD, MA, MI, NV, OK, PA, WV, WI, WY).

3 states: critical care credential (AZ, CA, NH).

7 states: paramedics may only continue blood a hospital started (HI, IN, LA, RI, SC, SD, VT).

1 state: not in paramedic protocols (ME).

Ketamine

43 states: your agency credentials you.

7 states: the agency needs approval (CO, IL, NM, NC, OK, PA, WI).

1 state: not in paramedic protocols (HI).

TXA

45 states: your agency credentials you.

5 states: the agency needs approval (CO, IL, MI, NC, OK).

1 state: not in paramedic protocols (HI).

Surgical cric

42 states: your agency credentials you.

1 state: the agency needs approval (MD).

4 states: critical care credential (AL, GA, IA, MS).

2 states: needle or percutaneous only (CA, DC).

1 state: set by regional protocols (NY).

1 state: not in paramedic protocols (HI).

States where a critical care credential is the route

Alabama — RSI: RSI drugs are listed at the Critical Care level, not for standard paramedics. State source
Idaho — RSI: RSI is an optional module for paramedics who hold FP-C or CCP-C certification, approved by their medical director, following the EMSPC protocol. State source
Mississippi — RSI: Paralytics are in the Critical Care Paramedic column only of the state scope (August 2024). State source
Montana — RSI: Drug-assisted intubation needs the Paramedic Critical Care Endorsement. State source
New Mexico — RSI: RSI is a critical care transport special skill: it needs a bureau-approved critical care course and exam, and an agency with an approved critical care special skill. State source
Pennsylvania — RSI: Statewide ALS protocols give paramedics sedation-assisted intubation only; RSI appears only for prehospital RNs under approved air ambulance protocols. State source
Arizona — Starting blood: Authorized only for paramedics with the Critical Care Endorsement. State source
California — Starting blood: Critical care and flight paramedics on interfacility transports; anything else needs a state-approved local optional scope. State source
New Hampshire — Starting blood: Patient Care Protocols v9.3 (Nov 7, 2025): starting blood is under the Critical Care protocol, which only units authorized by the state can use. Paramedics on credentialed interfacility transfers may continue blood started before departure. State source
Alabama — Surgical cric: Needle cric is a paramedic skill; surgical cric is for critical care and tactical medics. State source
Georgia — Surgical cric: Paramedics may do percutaneous cric; surgical cric is limited to critical care. State source
Iowa — Surgical cric: Percutaneous cric is in the paramedic scope; surgical cric is in the critical care paramedic scope. State source
Mississippi — Surgical cric: Percutaneous cric for paramedics; surgical cric only for critical care paramedics (August 2024 scope). State source

Courses and exams that count

FP-C and CCP-C (IBSC). National flight and critical care paramedic exams. The IBSC requires "a current unrestricted paramedic license in the state or country of practice", and it recommends a foundational critical care course and three years in critical care, air transport, community or tactical work. IBSC exam requirements
CCEMTP (UMBC). The best-known critical care transport course, run at UMBC each July and at licensed host sites through the year. Every location requires a current paramedic or nursing license; host sites may add prerequisites such as a year as a paramedic and ACLS, PALS and PHTLS. UMBC CCEMTP
Your state's critical care level. Where a state has its own critical care endorsement or level, its EMS office sets the course and exam. Use the state links above.
Agency training. RSI, blood and ketamine programs are mostly taught in-house: a didactic module, airway or transfusion labs, supervised cases and ongoing quality review. That training is tied to the agency that delivers it, so expect to repeat it when you change services.

Find critical care, flight and refresher courses in the training directory, and see what these jobs pay on the jobs board.

What to ask an employer

Do your paramedics do RSI, start blood or give ketamine today? Under which protocol or state approval?
How long after hire until I'm credentialed, and what does it take: a course, a number of supervised cases, simulation, a test?
Do you pay for the training and the exam (CCEMTP, FP-C, CCP-C)? Is there a payback clause if I leave?
How many cases does a medic here see in a year? Who reviews them?
If I already hold FP-C or CCP-C, or was credentialed at another service, what carries over?