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Old 09-25-2007, 09:52   #1
Truckee
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Licensure vs Certification of Paramedics

FirNaTine informs me within another thread that Maryland licenses Paramedics. The licensure vs. certification debate has been ongoing for some time throughout the industry.

Some specific questions:

I'm asking anyone having information concerning this issue. Especially those Medics that have experience with both 'ways' of doing this. I apologize in advance that I'm asking a 'labor intensive' question, but I'm truly interested in your responses. Have some fun here too... dry discussions bore us all.

1) Generically, what are the pros / cons of licensure vs. certification?

I have been a certified Medic for many years. Although not my primary scope, I have a working knowledge of certain 'benefits' of being certified vs. licensed... such as liability and being able to "hide" from certain issues.

2) Which states "certify," and which states "license?" Are there different criteria within states... meaning if one is municipal [i.e. FD], they are "certified," and if they're private do they "license?" Or any variation of this arrangement. (this is a researchable issue, but I would prefer actual experience talking).

3) What has licensure done for your pay scales? Are 'licensed' Medics pay scales in line with RN salaries / hourly wage -- as it should be?

4) Are 'licensed' medics required to secure their own liability insurance?

5) Do 'licensed' Medics still have to operate beneath an OMD and from strict protocols?

6) {following in-line with #5} I do understand that physicians will be involved and being licensed is not a permit to free-lance. However, what direct involvement is required by physicians for licensed Medics?

7) Does licensure eliminate the requirement of "re-qualification" every two years? What about the requirement for CE?

8) Please adlib anything that I've forgotten to ask or any other information you wish.

FirNaTine,

You mention that you're FD. Therefore I suspect that liability insurance etc. is handled through the FD and via governmental immunity. However, could you please speak to this issue less that asset / prejudice? I also would 'hope' that private agencies pay the liability insurance for its Medics... but, privates cannot claim 'governmental immunity' if something goes awry. How is this all handled?

And... Virginia is a "certification" state.
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Old 09-25-2007, 10:44   #2
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1. Licensing was in place by the time I went ALS, so I am not familiar with how it was under certification. I understand it was for "respect" as much as anything, by making us also licensed health care providers.

2. MD certifies EMT-B, and licenses EMT-I and EMT-P. EMT-I and EMT-P scope is very similar except EMT-P generally consults for less, and there are certain optional skills (RSI,Cric) that are P only.

3. I don't know that it has done anything to pay. It is more a supply/demand issue where I am. DC/Baltimore metro areas need more P's than they are producing. So pay is going up. Also most are fire based, and have unions so that is also a heavy influence on pay. Hourly pay is slightly lower than RN to start in some depts because of longer than 40hr workweeks. We are now on a 42hr/wk schedule, others are 48hr/wk. Pay for a P is around 42k/yr to start where I am, and we are somewhere near the middle of the road here. Pay is going up to almost 90k/yr on the top end over the next couple years though. That is more than most nurses I know of, unless they have moved into management.

4. Liability insurance is optional. My dept. is self-insured and I currently do not carry any additional liability insurance, but am considering it. Governmental immunity is a tricky concept anymore also, as more courts are allowing suits to go ahead against governments.

5. Yes, we work under several medical directors actually. There is a state medical director that approves the over all protocols for the state, and a program medical director (I think there are some regional ones in between, but I never have any contact with them). For the most part the program director ensures we are in compliance with state guidelines, and our care is appropriate. There are also some optional programs that the local medical director decides, whether or not to implement (RSI). The protocols though are guidelines, though you better have a very good justification for going outside them.

6.For certain procedures and medications, we are supposed to consult a base station physician. As I mentioned above, one of the main differences between EMT-I and EMT-P in MD is whether a drug or skill is standing order or consult. An example would be diazepam in active seizures, I as a P can administer 2.5-10mg (adult) before talking to a physician. An EMT-I gets the same range, but are supposed to consult first. Anytime consult is genuinely unavailable, or consulting would endanger the patient's life we can provide all care within protocol without consult. You must then justify and document a call like that afterward very well though.

7. To maintain licensure in MD, I must maintain my NREMT-P, and a jurisdictional affiliation . So continuing education requirements are the same for me as many other places.
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Old 09-25-2007, 13:20   #3
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In order to be employed by the private company that I work for, I am both licensed and certified. When I work on the ground, in Oregon, I am certified. When I work in the air ambulance, which primarily flies out of California, I am licensed.

1. I don't notice any differences, positive or negative, as I conduct my work under either my cert or license. In the air, with a license, I am often with an RN who would presumably take the brunt of any liability, but this is not a function of license vs. cert.

2. Oregon is certified regardless of type of service. I don't know about Cali.

3. No paramedic pay scale is in line with RNs. I make alot more in Cali than Oregon, but that is because I'm in the air, and I don't make as much as the RN sitting next to me, doing the exact same thing I am doing. On the ground, I make more than a Cali medic.

4. The company pays for liability insurance in Cali. and Oregon. i am also considering getting some more, on my dime.

5. Yes. We sort of have free reign in the air, but the Cali ground medics that I know complain about being hobbled by OLMC. They have to call in for alot of things that Intermediates can do in Oregon without contact, and their scope is much smaller than ours in Oregon- no RSI, no cric, no CX decomp, no CPAP, a much smaller drug box, etc. The up side to this is the Cali. system is something that I can tap into if I have a question. For example, I recently had a pt. with a stoma that was edemous to the point that I was initially only able to pass a 4.5 tube into. Since Oregon is mostly off-line, it would have taken at least a couple of minutes to get an MD to talk to, but Cali. is set up for on line contact, so the MD was right there to talk to.

6. I've never seen my cali. medical director. I'm not sure what his name is either.

7. From what I understand, Cali. recerts are more stringent than Oregon, but our air training is much more stringent than either, so our 2 year CEs are usually finished in 4 or 5 months.

I hope it helps.
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Old 09-25-2007, 13:58   #4
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Here in Alabama one must be licensed at the level they wish to perform. I let my license go when I retired out but will be certified for life because certification here only means successful completion of an accredited program. A certificate of completion.
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Old 09-26-2007, 01:46   #5
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Good and very detailed information posted here guys. I wish to thank each of you for your time. I encourage the posts to continue from others... and/or ask questions among ourselves.

Basically what I'm reading is...

There is no true separation between certified or licensed. Either way, this is more of a "title / nomenclature" issue than a difference of expectations and obligations.
***
OMDs are still required.
CE and re-qualification is still required.
SOPs and protocols still rule the treatment approach.
Liability seems basically the same concern... not lessened or expanded beneath either situation.
Medics still don't rate RN pay scales (bullbunk IMO).

FirNaTine,
You mention a "respect" factor to licensure. I have always heard of this being an aspect of the issue. However, in my 25 +/- years in the field, I've found that those whom respect 'us' have an understanding of what 'it is' that we do, regardless of license or certification... whilst the majority still view the "medic" as just an ambulance driver. The unknowing have no concept or expectation of the specialized levels of training involved... and most do not fathom that a rolling ED containing extremely educated health care professionals just pulled up into their driveway or ambulance bay.

Another aspect of licensure vs. certification that I've always heard hyped is that "licensure" of a person's profession establishes the expectation that one's skills and education have been committed to this person for a lifetime of practice and use. That the expectation of skill levels are established as a "known/given." I'm not reading from you guys that being licensed waves any requirement to maintain the same CE and re-training as a "certified" Medic is responsible for.

I find that I get more 'respect' when I arrive on an ambulance wearing turnouts, than I do when I arrive wearing a 'private' uniform. Something about being identified as an "FD" provider subconsciously adds to others perceptions of my skill level. Riding aeromedical also gains that reaction... same medic divided by different uniform and/or ambulance = different reaction from clinical personnel and the GP alike.

Also, and as I suspected, Maryland and Virginia are almost parallel with systems and set-up. FYI, I worked with the AACo.FD and we were 'certified' during that time. I'd like to know where you're working, PM if you prefer.

G21FAN,
Virginia is phasing out its 'certification programs' for Paramedic. The shove is here to AAS Degree in EHS (Emergency Health Sciences). Once one degrees, that cannot be taken away {of course}. However, Medics are not "certified for life." If one fails to re-up NREMTP q two years and/or fails to affiliate with an ALS agency, one is not allowed to practice within the Commonwealth. If one lets the certification lapse, he/she will have to affiliate, complete re-entry CE and complete NR written and skills testing before being again allowed to practice, in spite of holding an EHS degree.

Here's a gripe about this whole thing [rant warning]... during college, we train/educate along side of RN students. There are some variations with the curriculum, but basically they're parallel educations. As was alluded to, Medics are taught 'rodeo style,' rope 'em and deliver 'em medicine, while nurses are taught to obey, tinker and follow a patient through.

Sure, I may not know about the latest and greatest cardiac drugs etc. that an CICU RN is familiar with... but, we typically shame nurses (and doctors) during Critical Care, ACLS and PALS classes and we mostly top nurses in critical thinking/decision making skills... yet, post graduation, the "licensed" RN goes forth to make from 8 to 20 dollars more an hour than the "certified or licensed" Paramedic. My only satisfaction comes when I catch an arrogant nurse spouting off. Then I can kindly remind him/her, "yeah... but we can EJ, RSI and/or surgical cric, and make decisions without having to contact a doctor first." [rant off]
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Old 09-26-2007, 02:59   #6
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I say trukee, that is the best disposition of our gripes I've ever seen. Here in Alabama they are trying to make the paramedic level a degree level but ambulance companies refuse to pay more than 8-9 dollars an hour so Alabama is in a severe shortage of EMTs for several years due to this.
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Old 09-26-2007, 06:19   #7
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Just so you know, even doctors licenses aren't forever. They have to attend continuing education and re-license every two years in MD also.

As far as the respect issue, apparently there were issues between nurses and paramedics as to who was in charge. It is my understanding that nurses asserted authority on the basis that they were licensed and paramedics were not. As I was not practicing ALS under that system, that is the best of my understanding.

And you will be getting a PM on where I work, you should be familiar....
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Old 09-26-2007, 17:59   #8
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Quote:
Originally posted by FirNaTine
Just so you know, even doctors licenses aren't forever. They have to attend continuing education and re-license every two years in MD also.

As far as the respect issue, apparently there were issues between nurses and paramedics as to who was in charge. It is my understanding that nurses asserted authority on the basis that they were licensed and paramedics were not. As I was not practicing ALS under that system, that is the best of my understanding.

And you will be getting a PM on where I work, you should be familiar....
FirNaTine,
First, thank you for your PMs. Truly nice to talk with someone concerning an old friend that I've lost touch with.

Also, when I stepped into the doors of an ED, and post conducting a transfer-of-care brief with a nurse, then, and only then, did I (we) consider the nurse to be 'in charge' of anything. If they wished, they could have their own concepts of at what point they were in charge... but, we did not give a dang about their 'opinion.' I've stood in the halls of AA General (etc.) and listened as nurses barked orders... only to smile and ignore them... much to their dismay too! Several nurses did try to call us on the carpet for this, but we always prevailed (because medics are smarter lol). AaaH, the good ole days.

Next, I understand that other professionals are required to attend "CE." My father was one of those professionals and had to do likewise... but, his encompassed a scheduled eight hours every two years. Much less than required of 'us'... and, from what I -knew- of such gatherings, they amounted to a "good ole boy club; HarDeeHarHar" type of meeting/setting.

Although most consider 'Medic CE' to not be much more than a formality farce, the "CE" that top, licensed, professionals receive is much more informal... and usually involves a few beers. Maybe we should try that approach?

G21FAN,
Thanks for your kudos... that situation just gripes at me for some reason. I think that EMTs are becoming scarce across the country. Some markets are flooded, and they're usually the ones with medic schools operating in proximity. But in general, I think that we're a dying breed as being a medic is no longer a solid career, unless coupled with the fire service, and then serving only as an adjunct to one's FD career.

I am an example, I only hang on to ALS as a tertiary means because it's a fall-back job and the FD remains within my blood. But as for a career stronghold or goal, I dumped my concentrated EMT efforts when I left the FD.

Another thing, and I'll try to be brief with my own hijack. In 1985, I wrote a research paper concerning the role-reversals of Medics and RNs. I saw a trend developing that is in its full-swinging glory today. I still recall the sinking feeling I had when OEMS regulations amended to allow RNs to ride AIC during facility transfers... I knew right then, that my prediction was coming full force.

RNs are now in the field, on ambulances, on helicopters, shoving medics out of 'our' arena and scope of specialty. And, medics are going into the clinical settings, working as ED techs, lab techs etc. The industries can charge more when an RN is on the ambulance... and pay less when a medic is replacing the RN inside an ED.

As with every walk, follow the dollar and you shall see where you land. I despise this... but again, there is vindication for us lowly medics. I've seen CC ambulances end up staffed with a driver and one or two RNs. For one reason or another, the medic is not available to ride. That ambulance can only respond BLS in the field without the medic on-board (interfacility transfers not withstanding). Don't think that I miss the opportunity to gig 'em Almighty RNs when this situation occurs {all in good fun, of course}.
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Old 09-26-2007, 21:14   #9
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Quote:
Originally posted by Truckee

I find that I get more 'respect' when I arrive on an ambulance wearing turnouts, than I do when I arrive wearing a 'private' uniform. Something about being identified as an "FD" provider subconsciously adds to others perceptions of my skill level. Riding aeromedical also gains that reaction... same medic divided by different uniform and/or ambulance = different reaction from clinical personnel and the GP alike.
This is a very insightful observation.

They all have been. This is a very thought provoking read- my gears are churning- which is really amazing here on the tail end of a 72!
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Old 09-27-2007, 00:44   #10
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I was certified as an EMT and I'm Licensed as a Paramedic. The only difference (practically speaking) was who the issuing authority was. The County EMS Agency certified me and/or recognized my cert from another county. The State EMS Authority Licensed me... and anywhere I go in this state, I'm automatically deemed an EMT-1 or EMT-2 without any further testing. Each EMS system "accredits" me to function as a Paramedic in their system with their protocols. Each system has a slightly different scope of practice. Some lean more towards "Mother May I" and others lean more towards "off-line" stuff and only want you to call in when you've reached the end of the protocol.

When I am working, I can easily count on one hand the personnel that can take control of my patient. An MICN is NOT one of them...

As far as training goes, I am a specialist in field care. I was trained as an Athletic Trainer and later as a Paramedic. I have skills that I would not be able to use as a Paramedic or as an RN, yet knowing the anatomy as well as I do can make a difference.
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Old 09-27-2007, 01:02   #11
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Quote:
Originally posted by D25
This is a very insightful observation.

They all have been. This is a very thought provoking read- my gears are churning- which is really amazing here on the tail end of a 72!
I partially agree. A Flight Medic uniform tends to get some respect. Flight Medics get an education that most RN's never get. Out here, the ED's are used to seeing Paramedics wearing turnouts OR Private uniforms. I have seen outstanding FD medics and some not so good ones... (EMT-P to be hired as a FF) and I have seen some outstanding Private company Paramedics and some bone heads.

I've met a lot of RN's. Some are outstanding. Some I am just amazed that they're RN's. Sometimes both worked in the same department...

My experience shows that eventually you personally become known to the EDs you go to most often. Then it doesn't matter who you work for. The EDs know how good you are as a care provider and expect that level from you anyway.

This is not, however, the case when you are in a location where they're not familiar with you. They can be completely biased against you because of who you work for (private/FD). I just make them pay attention to what I have to say. If I say it like I KNOW what I am talking about, that gets me more respect than the uniform itself.

When receiving patients from facilities, I always asked the nurses to give me a report as if they were giving report to another nurse. It usually puts them at ease because then they're using a format they're comfortable with and the more skeptical nurses always are surprised when I talk with them in their language... and demonstrate that I understand what they said...
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Old 09-27-2007, 08:01   #12
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D25,

I'm so glad that we could knock your cobwebs loose! Now, go brush your teefs and get some rest. Thanks for posting. {eta} Love your signature line too!

akulahawk,

You bring to light one aspect of licensure that I've not considered. That being crossing protocol area boundaries.

In VA., the state is broken into "EMS Council" areas. A provider can operate at the BLS level across the state without much hassle. However, to operate at the ALS level, a provider must register with the local council and be 'evaluated and approved' prior to being allowed to practice ALS skills. Possibly 'licensure' would ease this situation, but that's doubtful.

As for RNs, I know that I've sounded harsh toward them. But, don't misunderstand, I LOVE nurses I simply detest the way our industries handle and manipulate both of the professions. I also despise the misconceptions other medical professionals hold about medics. Yes, with every walk of life, there are exceptional people and then there are boobs.

When I mention respect based on appearance, I was making a testament to immediate reactions from professionals and the GP alike. You're dipping deeper by clarifying perceptions of others based upon a relationship built over time. I agree that once hospital personnel, other agencies/providers etc. gain a working grasp on an individual provider's abilities and personality, that a respectful relationship will evolve, or not.

As someone whom has operated both as a big fish in a little sea, and as a little fish in a big sea... and as someone whom is prone to study 'people,' I can say that serious prejudices exist simply based upon affiliation. The hospitals/settings that I frequent, the respect level exists and has evolved over time. In settings where my face gets forgotten before I show again or the faces change... pop in or show up wearing turnouts or a flight suit and the waters part as if Moses walked up. Stroll in wearing any other get-up, and the interactions change... boob or not. Walk in wearing tattered jeans, flip-flops and a ragged T with "RN" on its collar and the reactions and respect remain fairly consistent.

Quote:
When receiving patients from facilities, I always asked the nurses to give me a report as if they were giving report to another nurse. It usually puts them at ease because then they're using a format they're comfortable with and the more skeptical nurses always are surprised when I talk with them in their language... and demonstrate that I understand what they said...
Transition-of-care briefs are fairly standard in Virginia; I always conduct one. One large health care system in my area has a "Hand-Off" policy in place. Regardless of who is assuming custody of a patient, a transition brief must be conducted.

However, I've had nurses, both inside that system and outside, look at me with a sneer and say, "you can read it as well as I can, it's all right there (referencing patient's documentation)." That conduct says nothing more than, "you're a lowly ambulance driver and I've not the time for you." I've even had nurses refuse to give a patient's chart or information to me, saying that violates HIPPA. WTF ever...ever! No, don't fret, none of that ever flies with me. But, I'm sure they get away with such things with other providers.
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