Introduction: Emergency department (ED) crowding is a national challenge. Initiatives to help address this at our ED include the use of a six-bed fast-track unit staffed by advanced-care paramedics (ACPs). Institutional byelaws only allow diagnostic imaging (DI) ordering by physicians (MD). An ACP requesting DI at the time of first assessment would likely improve patient flow. We investigated whether ACPs can safely and cost-effectively request DI for extremity injuries without increasing cost or exposing patients to unnecessary radiation. Methods: A prospective evaluation of a convenience sample of patients presenting with an extremity injury sustained within 48 hours of presentation. At time of initial assessment, the ACP, following specific guidelines, recorded whether or not they believed an x-ray was indicated, and if so, what DI views they felt appropriate. Their opinion was blinded from the physician subsequently assessing the patient. An ACP opinion of the need for DI was compared with the subsequent test ordered by the MD. The MD decision to order DI was considered ‘gold standard’. Opinions were considered “matched” if the MD ordered DI of the same body part that the ACP believed was indicated. Sensitivity, specificity, positive predictive and negative predictive values (PPV, NPV) were calculated. Using data from our ED information system, we estimated the time that would have been saved by allowing ACPs to order DI. Results: Of 199 patients 192 images were ordered and 89 fractures were diagnosed. ACPs and MDs agreed that DI was necessary 94.70% of the time (95% CI: {90.6%, 97.4%}). There were 8 x-rays the ACP did not order that the MD did order, of which one showed a fracture. Twice, the ACP would have ordered an x-ray that the MD did not. In terms of identifying the need for DI, ACPs were 95.8% sensitive and 71.4% specific. The PPV was 98.9% (95% CI: {95.8%, 99.8%}), and the NPV was 38.5% (95% CI: {15.1%, 67.7%}). On average, ACP opinion of DI indication was made 54.1 minutes (95% CI: {48.0, 60.2}) earlier that of the MD. Conclusion: The overall agreement between MDs and ACPs was almost 95%. ACPs are more likely to under-order x-rays than to over-order them, lowering the risk of increasing radiation exposure and cost. ACP DI ordering may decrease the time of processing of patients with extremity injuries by almost an hour.