**9. High-risk procedures**

When reading through NHTSA's "National Scope of EMS Model," some of the more notable complex procedures within the paramedic's minimum psychomotor skill set include intubation, decompression of the pleural space, and percutaneous cricothyrotomy [39]. It is important to clarify that these are minimums, and the potential for even riskier procedures, such as rapid sequence intubation using paralytics, finger thoracostomy, and surgical cricothyrotomy, could be included in an ALS clinician's scope at the discretion of the individual state and agency medical director. These procedures, along with other procedures within the ALS scope of practice, are inherent of higher risk because they require a higher level of understanding of anatomy and physiology, are performed infrequently, require both more initial and continuing education, and come with significant risk to the patient if improperly performed [39]. To improve patient outcomes and decrease risk, adjuncts such as checklists, procedural competency assessments, and clinical simulations should be taken into consideration for inclusion into agency performance improvement algorithms.
