In Which States is a Paramedic Certified vs. Licensed?

gotbeerz001

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Nevada is a certification. Once you get a job you apply for an "Ambulance Attendant's License" at your appropriate level and cannot work on an ambulance, or volunteer for that matter, without an AAL.

To clarify my clarification, in CA you need:
- school and NREMT for certification;
- certification to apply for State license;
- County accreditation to work under license;
- Ambulance Certificate from DMV to drive;
- Medical Exam/Clearance to get ambo cert.

... Have I forgotten anything?
 
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To clarify my clarification, in CA you need:
- school and NREMT for certification;
- certification to apply for State license;
- County accreditation to work under license;
- Ambulance Certificate from DMV to drive;
- Medical Exam/Clearance to get ambo cert.

... Have I forgotten anything?

You forgot the $ part that our lovely state is charging is for all of this... LOL.
 

Jason

Medic
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In VA:
We are certified, not licensed. And it is taught that here it is a big difference. From the responses it seems there is a lot of differences from state to state.
Remi makes some good points (as usual). I have had a similar explanation given to me. I have also heard people speak of EMS providers and use the terms license and certified interchangeably, or wrongly.
In VA we are certified, to show knowledge and skills. However, we "practice" medicine under the license of our OMD. Without our OMD, we are "practicing without a license". We do not have our own license to practice under.
RNs on the other hand are licensed and do not "practice" under a physician, and are held separately responsible for their care of the patient.
Also, some perspective should be observed in the roles of Paramedics and RNs. We as paramedics are trained for field work and an environment that is different than an RN's. RNs are trained for a hospital environment with a different level of care and expectation. I try not to look at it as who is a higher level of Provider, but who is educated to do the most good in or out of the hospital. Here, RNs have very little to stand on if providing care outside the walls of a hospital (unless employed by an agency or company that uses RNs for certain types of Critical Care Transport runs).
 

MrJones

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...In VA we are certified, to show knowledge and skills. However, we "practice" medicine under the license of our OMD. Without our OMD, we are "practicing without a license". We do not have our own license to practice under....
At the risk of opening yet another big-ol' can of worms, state EMS boards that perpetuate that way of thinking are one of the elements holding us back as a profession. I do not practice under my Medical Directors license; I practice under my license with his supervision. How do I know? I know because my Medical Director doesn't lose his license if I make an egregious error - I lose mine and he goes on his merry way.

The longer we meekly accept the perpetuation of the "we operate under a Doctor's license" myth the harder it will be to reverse that erroneous perception.

/soapbox
 

Medic496

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To clarify, CA has 3 steps:

Your schooling and passing the NREMT certifies you.

Your certification allows you to apply for licensure through state EMSA.

While you are then a licensed paramedic, you still need to become accredited with your L(ocal)EMSA before you can begin working. The process of accreditation cannot begin until you have a sponsoring agency (employer).

(I know you know this DesertEMT)
Actually, the NREMT provides a pass fail option on their validated exam and provides national REGISTRATION if successful. In CA, EMSA then licenses and the LEMSA accredits. A person holding NRP is a "Nationally Registered Paramedic".

It is also irrelevant to maintain once licensed in CA, but provides a "passport" for reciprocity across most State lines.
 

Jason

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At the risk of opening yet another big-ol' can of worms, state EMS boards that perpetuate that way of thinking are one of the elements holding us back as a profession. I do not practice under my Medical Directors license; I practice under my license with his supervision. How do I know? I know because my Medical Director doesn't lose his license if I make an egregious error - I lose mine and he goes on his merry way.

The longer we meekly accept the perpetuation of the "we operate under a Doctor's license" myth the harder it will be to reverse that erroneous perception.

/soapbox

I agree, "state EMS boards that perpetuate that way of thinking are one of the elements holding us back as a profession", however it's the current issue we are having to live with.
:(
 

MrJones

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I agree, "state EMS boards that perpetuate that way of thinking are one of the elements holding us back as a profession", however it's the current issue we are having to live with.
:(
But it's also up to us - through our own efforts and the efforts of our professional organizations - to change the status quo in this regard.
 

Carlos Danger

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But it's also up to us - through our own efforts and the efforts of our professional organizations - to change the status quo in this regard.

This is true, for sure.

But I hear paramedics make statements to this effect all the time, and yet I've known very few paramedics who were actively involved in trying to make changes.

Everyone who would like to see the profession change, how many times have you:

  • Renewed your membership to your state or a national advocacy association
  • Donated money to a state or national advocacy association
  • Done a literature search to gather evidence for your position, and written a proposal based on such evidence
  • Scheduled a meeting with folks from the state EMS board to discuss the issues
  • Spoken with medical directors about whether the state medical director's office is likely to offer support for what you are trying to do
  • Communicated with local EMS educational leaders about issues surrounding education
  • Visited (not emailed) a state legislator to explain the issue and ask for their support
 
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Rick Tresnak

Rick Tresnak

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I'm curious in what type of scenarios do RN's attempt to exert "authority" over a paramedic?



Actually, there is no difference at all. The terms are often used interchangeably because, as they apply to EMS, they are interchangeable.

Here's how it was explained to me by an attorney years ago:

  • The term "certification" traditionally refers to a verification by an educational or credentialing body that one has completed an educational program or somehow proven a competency. That piece of paper that you get from your EMT or paramedic program that proves you successfully completed the program is a "certification"; so is the piece of paper you get when you pass the NREMT or FP-C exams. They certify that you successfully completed the program or passed the exam, but they don't authorize you to practice....you still have to apply to the state in order to gain authorization to practice.
  • A "license" is a legal authorization by a governmental authority to practice. Often, in order to apply for a license to practice (get your state EMT card, or your plumber's license or your medical license), you first have to obtain a certification - that piece of paper that says you completed EMT school or plumbing school or medical training.
  • Here's why the confusion arises: most states refer to the authorization that they grant EMTs and paramedics to practice as a certification, when traditionally that authorization would be referred to as a license. This is of course inconsistent with the way states typically refer to other occupational licenses (a plumber or hairdresser is "licensed" by the state, not "certified").
  • Here's why states use different terminology for EMS licensure: The states do this because early on, it was the opinion of some that the requirement to practice under the supervision of another professional (a physician) meant that one was not truly licensed to practice in the same way that other licensees are. This was based largely on the misconception that EMT's and paramedics would be legally shielded (by the physician) from the same types of legal responsibility and liability that other licensed professionals have.
  • Here's the bottom line: none of this matters all. Whether your state refers to your authorization or practice as a certification or a license is absolutely meaningless. Either way, your legal and professional responsibilities and liabilities are exactly the same. Either way, you have to be supervised by a physician to perform ALS interventions.
There is a misconception among many that if paramedics were just "licensed" rather than "certified", that it would have all sorts of important implications and would somehow make all sorts of positive difference in the way paramedics are viewed and in the things they are allowed to do. This is untrue, as is proven by the states where paramedics are "licensed" rather than "certified". In CA, for instance, paramedics are "licensed" yet have probably the most restrictions on their practice of all the states. In TX, paramedics can be either "licensed" or "certified", and there is zero difference between the two.
Many places use the certification card as a way to create hierarchy.
What I mean by this is that I go to one facility and work in the ER. I can do everything the RN does and actually more. The next one says that is only a nursing responsibility. I can't give acls drugs, Tylenol etc.

Because of the confusion the State tried to get our EMS certification changed to a License. The board of nursing made quite a stink and we couldn't change.

The thing is there shouldn't be a difference in certification and licensure. We both have two years of college. In iowa we need more con ed and we can work under protocols.

It made me wonder what other states did.
 
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Rick Tresnak

Rick Tresnak

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This is true, for sure.

But I hear paramedics make statements to this effect all the time, and yet I've known very few paramedics who were actively involved in trying to make changes.

Everyone who would like to see the profession change, how many times have you:

  • Renewed your membership to your state or a national advocacy association
  • Donated money to a state or national advocacy association
  • Done a literature search to gather evidence for your position, and written a proposal based on such evidence
  • Scheduled a meeting with folks from the state EMS board to discuss the issues
  • Spoken with medical directors about whether the state medical director's office is likely to offer support for what you are trying to do
  • Communicated with local EMS educational leaders about issues surrounding education
  • Visited (not emailed) a state legislator to explain the issue and ask for their support
I have been very active in these rolls. All but met with the state EMS boards. (I am not sure who that would be in my state)

I really wish the profession had a more unified approach. I am a member of several associations. But we certainly lack a unified approach.
 

Carlos Danger

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Many places use the certification card as a way to create hierarchy.
What I mean by this is that I go to one facility and work in the ER. I can do everything the RN does and actually more. The next one says that is only a nursing responsibility. I can't give acls drugs, Tylenol etc.

There's no doubt that in some cases, this is simple protectionism - nursing leadership just doesn't want anyone doing anything that is traditionally a nursing responsibility. In that case, the people who say "you can't do that because paramedics aren't licensed" may be using that simply as an excuse.

On the other hand, there are regulatory and accreditation-related reasons why facilities want or need to delineate nursing responsibilities vs. non-nursing ones. Basically, every admitted patient needs to be assigned an RN, who is responsible for completing regular nursing assessments, among other things. So the thing is, as long as a patient has an RN assigned, it may make sense for reasons of consistency and continuity that only the RN administers meds or does certain other functions.

The reason you hear people say things like "you can't do that - you aren't licensed" is likely because the regulations that delineate nursing vs. non-nursing responsibilities often refer to RN's as "licensed personnel" and LPN's or techs as "unlicensed personnel". So when they hear about a paramedic being "certified" rather than "licensed", it may be significant in their minds, but it's really only terminology. If you were licensed, it probably wouldn't change much. They would just find another reason to not let you do what they don't want you to do.
 

Tigger

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There are a few services (AMR in CO Springs for example) that have a system so all medics can do some, but only some that are specially certified by the medical director can do others. Credentialing is the correct term for it.
That whole deal was started by the medical director for AMR and a whole bunch of other agencies in El Paso and the surrounding counties including my own. He authorized (his words) medics personally for RSI, and issued his own cards for it. Aside from that, if you worked under him you could perform every skill in the protocol book, including the waivered ones (surgical crics, nitro drips for the more outlying agencies, etc).

He recently retired and I am not sure what the new procedure will be. All providers still get tested by one of the physician advisers yearly at all the paid agencies. If you don't get tested, you don't work.
 

Mtnmedic

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You forgot the $ part that our lovely state is charging is for all of this... LOL.
Like you're that hysterical lady in "Airplane"...only you're saying: "Thank you. Please sir, may I have another?"
 

Mtnmedic

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In Oregon ALL levels of EMS providers are licensed, including EMRs. Most notably, EMRs (formerly First Responders) were "certified" until that was changed a little while ago.

Furthermore, ALL Paramedics in the State of Oregon are required to possess an AA (or better) degree -of any kind- in order to become licensed by the state. There are a few conditional exceptions.
 

joshrunkle35

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In Oregon ALL levels of EMS providers are licensed, including EMRs. Most notably, EMRs (formerly First Responders) were "certified" until that was changed a little while ago.

Furthermore, ALL Paramedics in the State of Oregon are required to possess an AA (or better) degree -of any kind- in order to become licensed by the state. There are a few conditional exceptions.

That's pretty freakin' awesome! I wish my state (Ohio) had degree requirements as well.
 

TransportJockey

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In Oregon ALL levels of EMS providers are licensed, including EMRs. Most notably, EMRs (formerly First Responders) were "certified" until that was changed a little while ago.

Furthermore, ALL Paramedics in the State of Oregon are required to possess an AA (or better) degree -of any kind- in order to become licensed by the state. There are a few conditional exceptions.
I thought there was a five year experience requirement that could be used in place of the degree?
 

Mtnmedic

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I thought there was a five year experience requirement that could be used in place of the degree?

Here is the whole enchilada, right from the Oregon Revised Statutes:

333-265-0050
EMS Provider Licensure by Reciprocity

(1) A person registered with the National Registry of EMTs as an EMR, first responder, EMT, EMT-Basic, advanced EMT, EMT-Intermediate I-99, EMT-Intermediate I-85, Paramedic, or EMT-Paramedic may apply to the Authority for licensure by reciprocity until January 1, 2015 at which time only National Registry EMR, EMT, advanced EMT, and Paramedic will be accepted for reciprocity.
(a) A National Registry EMT-Intermediate I-99 may apply for an Oregon EMT-Intermediate licensure by reciprocity until January 1, 2015 at which time National Registry EMT-Intermediate I-99 will no longer be accepted for reciprocity.
(b) A National Registry EMT-Intermediate I-85 may apply for an EMT licensure by reciprocity until January 1, 2015 at which time National Registry EMT-Intermediate I-85 will no longer be accepted for reciprocity.
(2) A person applying for Oregon EMS provider licensure by reciprocity shall:
(a) Submit a completed application on a form prescribed by the Authority along with the applicable nonrefundable fee;
(b) Submit documentation of the EMS provider training which meets or exceeds the requirements for Oregon EMS provider licensure at the level of licensure for which the person is applying;
(c) If applying for Paramedic licensure by reciprocity, submit proof of having received an associate’s degree or higher from an accredited institution of higher learning or submit proof of having worked for at least three years out of the last five years as a Paramedic in either another state or in the United States military at the National Registry Paramedic level.
(d) Be in good standing with the applicant’s current licensing agency and with the National Registry of EMTs; and
(e) Consent to a criminal background check in accordance with OAR 333-265-0025(3).
(3) The Authority shall review an application for licensure by reciprocity and shall conduct a criminal background check.
(4) If there are no issues that arise during the review of the application and the applicant meets all the applicable requirements of ORS chapter 682 and these rules, the Authority shall grant the applicant a license by reciprocity.
(5) If the applicant does not meet the standards for licensure, or there are criminal history or personal history issues that call into question the ability of the applicant to perform the duties of a licensed EMS provider, in accordance with ORS chapter 682 or these rules, the Authority may deny the application on the basis of the information provided, or conduct an additional investigation in accordance with OAR 333-265-0085. Following such an investigation the Authority may take any action as specified in OAR 333-265-0040(4).
(6) The Authority shall be the sole agency authorized to determine equivalency of EMS provider course work presented from an out-of-state accredited institution of higher learning.
(7) The Authority shall be the sole agency authorized to determine equivalency of work experience in lieu of the associate degree requirement for Paramedics.
(8) The Authority shall return any application that is incomplete, or cannot be verified.
Stat. Auth.: ORS 682.017, 682.216
Stats. Implemented: ORS 682.017, 682.216
Hist.: HD 63, f. 6-6-74, ef. 6-25-74; HD 1-1981, f. & ef. 1-14-81; Renumbered from 333-023-0620; HD 19-1984, f. & ef. 9-10-84; HD 16-1986, f. & ef. 9-9-86; HD 18-1990(Temp), f. & cert. ef. 6-19-90; HD 19-1991, f. & cert. ef. 10-18-91; HD 8-1993, f. 6-22-93, cert. ef. 7-1-93; HD 18-1994, 6-30-94, cert. ef. 7-1-94, Renumbered from 333-028-0020; HD 8-1995, f. & cert. ef. 11-6-95; OHD 9-2001, f. & cert. ef. 4-24-01; PH 10-2008, f. & cert. ef. 6-16-08; PH 13-2010, f. 6-30-10, cert. ef. 7-1-10; PH 1-2011, f. & cert. ef. 1-6-11; PH 15-2011, f. 12-28-11, cert. ef. 1-1-12; PH 1-2013, f. & cert. ef. 1-25-13
333-265-0060
Paramedic Provisional Licensure

(1) As authorized by ORS 682.216, the Authority may issue a provisional Paramedic license to an out-of-state licensed Paramedic who meets the requirements in OAR 333-265-0050, except for the educational requirements in OAR 333-265-0050(3)(a) and is in the process of obtaining an associate’s degree or higher from an accredited institution for higher learning.
(2) A provisional license shall only be provided in the event that the associate’s degree or higher is obtainable within two years.
(3) An applicant shall comply with the application requirements in OAR 333-265-0050 and shall submit:
(a) A letter of recommendation from the applicant’s most recent medical director;
(b) A letter from an Oregon EMS agency specifying that the person shall be immediately employed or has a conditional offer of employment, whether in a paid or volunteer capacity; and
(c) A letter from the applicant’s prospective EMS medical director stating that the EMS medical director will serve as his or her EMS medical director while being provisionally licensed.
(4) The Authority may return any application that is incomplete, cannot be verified, or is not accompanied by the appropriate fee.
(5) A Paramedic with a provisional license issued under these rules shall enter into an agreement with the Authority and shall submit quarterly reports to the Authority describing the license holder’s progress in obtaining an associate’s degree or higher from an accredited institution for higher learning.
(6) A Paramedic provisional license shall be revoked if the person:
(a) Ceases active involvement in emergency medical services;
(b) Fails to meet the conditions set forth in the agreement;
(c) Fails to cooperate or actively participate in a request from the Authority in order to obtain more information or required materials;
(d) Has his or her EMS provider scope of practice revoked or restricted by his or her EMS medical director; or
(e) Does not submit written documentation of the successful completion of any of the educational requirements set out in this rule
Stat. Auth.: ORS 682.017, 682.216
Stats. Implemented: ORS 682.017, 682.216
Hist.: HD 18-1994, 6-30-94, cert. ef. 7-1-94; OHD 9-2001, f. & cert. ef. 4-24-01; PH 10-2008, f. & cert. ef. 6-16-08; PH 13-2010, f. 6-30-10, cert. ef. 7-1-10; PH 15-2011, f. 12-28-11, cert. ef. 1-1-12; PH 1-2013, f. & cert. ef. 1-25-13
 

Mtnmedic

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That's pretty freakin' awesome! I wish my state (Ohio) had degree requirements as well.
Actually, at the risk of someone calling me an old-school stalwart…

IMHO I find it annoying, inconvenient and in some cases prohibitively expensive in terms of time and money. All to achieve a staffing standard that, in some places, is already difficult to achieve as it is. We can thank AMR NW for that. A Fortune 500 company has all the power, money and resources it needs to do whatever it wants, dictate whatever it desires, crank up personnel requirements and flush out/replace people easily in order to thump their chests when it comes to bidding for huge contracts. Not so with the average EMS outfit.

The degree requirement does NOT mandate any course content that would have any kind of specific EMS professional skill- or prehospital care skill-enhancing education. In other words, it can be a degree in ANYTHING, even general studies. Even from an accredited online-only school. Yep. I confirmed this with the Oregon Health Authority EMS and Trauma Systems. They don't care WHAT it is so long as it's a degree in SOMETHING. What good is that, really? One could argue that having an art degree, engineering degree, automotive degree, or some other kind of unrelated degree doesn't necessarily make you a better Paramedic than a similarly trained, similarly experienced Paramedic without a degree working in the same system using the same treatment protocols. Now if it was a degree in EMS management or Paramedicine, etc., heck even Fire Science, sure...I can see its practical application.

I'm not even going to get into the discussion of how a degree mandate for Paramedic licensure makes it harder for rural EMS teams-paid or volunteer- to get and retain ALS-qualified providers in areas where they are needed the most.

Now, I hear some people want states to mandate degrees for EMTs. Are you kidding me? It's ridiculous. Just.....STOP. In most states, the vast majority of EMTs are VOLUNTEERS and those who are paid are mainly treated as "ambulance drivers" paid at a sub-par rate. Who in the world would go through the time, expense and trouble of getting a degree just to be certified (or licensed) as an EMT in either of those capacities? Think of all the rural communities whose volunteers are folks in town often in their 30s and 40s or older that already have jobs and just want to help out because there just simply is nothing else out there to provide aid. I can absolutely guarantee that if legislation came to pass right now requiring EMTs to have a degree in order to get certification/licensure, a LOT of volunteer EMS workers are going to walk off and more considering becoming volunteers or entry-level ambulance attendants will think twice about the extra commitment. That could seriously hurt a lot of communities. Maybe some paid EMTs will stick around because they’re in Paramedic/Firefighter school or it’s on the horizon or that they’re in some job where a degree would be of immediate benefit, etc.

Don't get me wrong: I think having a degree is a good idea. Mandating it for certification or licensure is not. At least for a while.
 

joshrunkle35

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The degree requirement does NOT mandate any course content that would have any kind of specific EMS professional skill- or prehospital care skill-enhancing education. In other words, it can be a degree in ANYTHING, even general studies. Even from an accredited online-only school. Yep. I confirmed this with the Oregon Health Authority EMS and Trauma Systems. They don't care WHAT it is so long as it's a degree in SOMETHING. What good is that, really?

Well, for me, I view my ALS skills as something far secondary in importance to my communication and diagnostic skills. Knowing what questions to ask, how and when to ask them are, in my opinion, more useful than correct treatment. How can you treat if you don't know what to treat? Asking the patient, patient's family or bystanders what happened is really, really helpful.

Unfortunately, many EMS personnel that I have come in contact with have the vocabulary and communication skills of an eighth grader. Some of these are people I work with, some I've met at conferences, some have even taught CE classes that I sat in on. It happens frequently and is very pervasive in EMS. This hurts EMS on a few different levels. First, the lack of standards prohibits and prevents professionalism. We will not be seen as professionals by others who may provide a similar level of care in an emergency. Secondly, the patient(s) may view us as unprofessional...this hurts the image of EMS in general. Third, the patient may lose faith in our ability to treat them, even if we are doing everything right, simply because the service appears uneducated and unprofessional. (Which doctor do you want, the one in dress clothes and lab coat, or the one in their pajama's who just rolled out of bed? Obviously, the info in their head and their treatment is the same, but simple appearance goes a long way) The lack of faith a patient has in our ability could lead to poor patient care and outcome, as a result of a nocebo effect.

I realize that it won't do much to change the technical skills that are being performed, but technical skills are such a small part of patient care, and a degree, or similar standards would definitely translate to better patient care overall, when you factor in what a huge role communication skills (verbal and non-verbal) play in patient care.
 
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