San Antonio Fire Department applies the latest in cutting-edge trauma care. This advanced level of trauma care is possible because Texas is a delegated medical practice state. This means that the EMS Medical Director can train and deploy advanced trauma care paramedics for critically injured trauma patients. San Antonio also deploys EMS Physicians in the prehospital setting. Discussion of open thoracostomies performed by all paramedics and a modified clamshell thoracotomy performed by EMS physicians will be discussed. The department has deployed and is reviewing the use of an abdominal aortic junctional tourniquet for critically injured trauma patients. SAFD medial special operations team has developed a novel prehospital amputation process where the paramedics will perform the amputation. San Antonio Fire Department has deployed digital blocks prehospital, resulting in true pain control for the injured digit. There will be a discussion about these advanced trauma tactics and how they can be deployed in EMS systems to treat patients and save lives.