The NYC REMAC (Regional Emergency Medical Advisory Committee) ALS Exam is widely recognized among paramedics as one of the most detail-heavy regional protocol tests in the country. Passing requires a strict shift in mindset from standard NREMT clinical reasoning to exact adherence to NYC Regional Protocols, General Operating Procedures (GOPs), and Appendices.

Essential NYC REMAC Study Tips & Tactics

1. Master Standing Orders vs. OLMC Orders

The exam tests your exact knowledge of where Standing Orders stop and Online Medical Control (OLMC) orders begin.

• Rule: If a scenario specifies that standing orders are exhausted or the condition requires physician approval (e.g., secondary med doses or non-standard cardioversion), calling OLMC is often the correct next step.

2. Memorize Precise Medication Dosages & Age Brackets

Pediatric vs. Adult classifications in NYC protocols differ from standard NREMT.

• Pediatric Age Cutoff:In NYC protocols, a pediatric patient is defined as < 15 years old.
• Neonates/Infants: Neonate is < 28 days; Infant is 1 month to 1 year.
• Key Dosing Nuances to Memorize:
  • Ondansetron (Zofran):0.1 mg/kg IV/IM/PO (max 8 mg) for patients 6 months.
  • Pediatric Dextrose:0.5g/kg (Max 25 g)—use D10W for neonates (< 28 days) vs. D25W for ages 1 month to 14 years.

3. Know Special Destination Policies Cold

Destination protocols are heavily tested:

• Trauma / STEMI / Stroke / Burn Centers: Understand which patient presentations require transport to a specialty facility vs. the nearest emergency department.
• Unmanageable Airway Override:An unmanageable airway or cardiac arrest generally overrides specialty destination routing—transport immediately to the nearest emergency department.

4. Master General Operating Procedures (GOPs)

Updated as of August 2026 Protocol > Link to NYC REMSCO Unified Protocols

Practice Protocol Questions & Rationales

Question 1: Dysrhythmia / Cardioversion

Scenario: You arrive on scene for a 62-year-old male presenting with chest pain, diaphoresis, a blood pressure of 82/50 mmHg, and an ECG showing ventricular tachycardia with a pulse at a rate of 180 bpm. What is the initial energy setting for synchronized cardioversion under NYC REMAC standing orders?

• A) 50 Joules
• B) 100 Joules
• C) 150 Joules
• D) 200 Joules

Correct Answer:B) 100 Joules

Rationale: For an unstable patient with monomorphic ventricular tachycardia with a pulse, standing orders call for synchronized cardioversion starting at 100 Joules, followed by 200 J, 300 J, and 360 J if unsuccessful.

Question 2: Pediatric Hypoglycemia

Scenario: You are treating a 3-week-old neonate who is lethargic with a blood glucose level of 38mg/dl. What is the correct concentration and weight-based dose of Dextrose under NYC REMAC protocols?

• A) D50W at 1 ml/kg
• B) D25W at 2 ml/kg (0.5g/kg)
• C) D10W at 5ml/Kg
• D) D5W at 10ml/Kg

Correct Answer: C) D10W

Rationale: Under NYC REMAC pediatric protocols, hypoglycemia in neonates (up to 28 days) is treated with D10W at 0.5g/kg (5 mL/kg) max 25 g. D25W is reserved for pediatric patients older than 28 days up to 14 years.

Question 3: Special Destinations / Airway Management

Scenario: A 55-year-old female shows signs of an acute ischemic stroke with symptom onset 2 hours ago. During transport, the patient’s airway becomes severely compromised and cannot be safely managed with basic or advanced airways. What is the appropriate transport destination decision?

• A) Continue to the nearest designated Stroke Center regardless of distance.
• B) Transport immediately to the nearest Emergency Department.
• C) Divert to the nearest Trauma Center.
• D) Pull over and wait for a flying physician team.

Correct Answer: B) Transport immediately to the nearest Emergency Department.

Rationale: Per NYC REMAC GOPs, an unmanageable airway supersedes specialty hospital transport protocols (including STEMI, Stroke, and Trauma destinations).The priority is immediate airway management at the nearest ED.

Question 4: Transfer of Care to BLS

Scenario: A paramedic unit attends to a 40-year-old conscious patient complaining of minor nausea. Vital signs are within normal limits, blood glucose is 110mg/dl, and no medication has been administered. Under what conditions may care be transferred to a BLS unit for transport?

• A) If the patient has no history of ACS in the past 24 hours, is hemodynamically stable, and requires no ALS interventions.
• B) BLS transfer of care is never permitted under NYC protocols.
• C) Only if an IV line has already been established and normal saline is infusing.
• D) Only with direct Online Medical Control authorization.

Correct Answer: A) If the patient has no history of ACS in the past 24 hours, is hemodynamically stable, and requires no ALS interventions.

Rationale: NYC REMAC guidelines permit transfer of care to a BLS unit if the patient is hemodynamically stable, follows simple commands, has normal blood glucose, has not received and is not expected to require ALS medications, and has reported no ACS symptoms within the last 24 hours.

Suggested Revision Strategy

Practice Timed Mock Exams: Take 120-question practice sets using a 3-hour timer to build pacing and stamina for test day.

Daily Protocol Drills: Focus on 2–3 protocols per day, testing yourself specifically on drug names, indications, contraindications, and maximum doses.

Chart Out Differences: Create a cheat-sheet table comparing Adult vs. Pediatric protocols for Asthma, Anaphylaxis, Seizures, and Hypoglycemia.

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