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Provisional certification: What if it weren’t just an emergency measure?

A bold proposal to change the way we educate and certify EMS providers

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provisional certification could also serve as a test bed for changing the way we educate and credential EMS providers in this country.

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On Mar. 19, 2020, in response to social distancing guidelines during the COVID-19 pandemic, the National Registry of EMTs gave emergency approval to add a provisional certification.

A provisionally certified provider has graduated from an EMS education program and passed the NREMT cognitive exam, but due to travel restrictions, bans on large gatherings, and social distancing guidelines, has not yet had the opportunity to take the psychomotor exam.

When those restrictions are lifted and psychomotor exams are reinstated, provisionally certified providers will have a window of several months to take and pass the psychomotor exam. Once passed, the provider automatically transitions to fully certified.

It’s a good deal for students, and a much-needed aid to agencies strapped for qualified personnel. A number of our students have obtained their provisional certification and are practicing as EMTs and advanced EMTs now. NREMT has cited Dec. 31, 2021, as the date this window will close, and as there is no mechanism to recertify as a provisional provider, it most certainly won’t extend beyond Mar. 31, 2022.

But what if it did?

NREMT’s guidance to state EMS offices is that provisionally certified providers should be paired with an experienced, fully certified provider as a mentor, but that is impossible to police. Realistically, some of these provisionally certified providers are going to be paired with an inexperienced, ink-still-wet-on-their-card paramedic, or a burnout with one year of experience repeated 25 times, who is more cautionary tale than mentor. EMS agencies need meat in the seat, period. Many of them are not going to care about the distinction between provisional and actual certification.

But provisional certification could also serve as a test bed for changing the way we educate and credential EMS providers in this country.

A skilled trade approach to EMS

My good friend EMS Artifact has long advocated that EMS adopt the same approach to education as the skilled trades: apprentice, journeyman and master.

Now, NREMT has proposed nothing officially on this matter, so this is just the cabin fever and beer-fueled musings of a longtime paramedic and educator, but here’s how such a system might look, with provisional certification as a jumping-off point.

Apprentice Paramedic. Requirements would be graduation from a COAEMSP-accredited program. The educational program would have compiled a paramedic portfolio adhering to the NREMT required documentation of a paramedic’s skills. Once the candidate passes the NREMT Paramedic Cognitive Exam, he or she would be granted certification as an Apprentice Paramedic.

Apprentice Paramedics would have a slightly restricted scope of practice, able only to function under standing orders to the level of, say, the old Intermediate-99 curriculum. The I-99 curriculum was essentially “paramedic lite;” an I-99 had a much broader scope of practice than the current AEMT, and with the exception of a handful of drugs and procedures, could perform most of the bread-and-butter work of a paramedic.

An Apprentice Paramedic would have to spend 1-2 years under the tutelage of a Journeyman or Master responsible for directly supervising the performance of any skills not included in the scope of practice of the apprentice. Successful completion of the NREMT psychomotor exam would be the entry threshold to Journeyman Paramedic.

Journeyman Paramedic. With passage of the NREMT psychomotor exam, the Journeyman Paramedic would be able to perform the full scope of practice of the current NRP, under both direct and offline medical control. Journeyman Paramedics would spend time perfecting their craft and obtaining the various specialty certifications, such as FP-C, CCP-C or CP-C.

Low-frequency, high-acuity skills, such as RSI/DSI, central venous cannulation and others would require the supervision of a Master Paramedic, perhaps in the role of a shift supervisor who would respond to scene calls with ambulance crews. Journeyman Paramedics would have 2 years to obtain, at minimum, an associate’s degree as one of the entry requirements for Master Paramedic licensure.

Master Paramedic. The Master Paramedic would possess an associate’s degree, at minimum, along with at least one specialty certification and certification as an EMS instructor. They’d utilize the full paramedic scope of practice, be skilled in various specialty areas, such as lab interpretation, ventilatory management, sonography, wound closure, and so on, and be able to operate autonomously (off-line protocols, not necessarily an independent practitioner). Senior supervisory line personnel or educational program faculty would have to be Master Paramedics.

Granted, it’s a bold proposal, and one with no small number of obstacles to implementation. There would be many hurdles to clear, but before you say it’s impossible, consider many of the things we’re doing now that most of us considered impractical or impossible just a few months ago.

What do you think?

Read next: Degree requirements, Pink Floyd, and a seat at the adults’ table columnist Kelly Grayson, is a paramedic ER tech in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. Kelly is the author of the book Life, Death and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.