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Flights Between States


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#1 medic18lt

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Posted 12 November 2009 - 02:02 AM

What is your companies policy for flights between states ie based in ohio taking a flight in kentucky to say west virginia. Is your crew licensed in all states or just state you are based in?
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#2 skysix

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Posted 13 November 2009 - 06:14 AM

For nurses it depends if all the states involved are part of the compact and how often this happens, although generally you must be licensed in the state that you pick up in, otherwise, and maybe required to be licensed in the other states involved. ( It can get very expensive)
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#3 old school

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Posted 13 November 2009 - 06:47 PM

If you are talking about FW interfacility runs, there should be no issue at all. The legal reason was explained to me before and I don't remember it in detail, but it made good sense when I heard it B). It is something about the referring and receiving facilities and physicians basically assuming responsibility for ensuring that the transport service is appropriate, personnel and equipment wise. I know that the program I work for routinely does 4-point transports throughout every state in the Eastern US (and sometimes out west and to Central America and the Caribbean), and licensure is never brought into question in any way for either our RN's or RRT's.

With RW it can get much trickier, especially when you talk about scene flights, because then you have to satisfy the requirements of the EMS board of each state involved. The rules vary from state to state of course. Most of the states that I am familiar with have no problem with out-of-state services flying in to mutual aid on a scene call, and will then require that the patient be transported to the closest level I or II, regardless of which state it is in. But some of those same states will only allow an out-state-service to respond if requested by an in-state HEMS service. The state I work in now, curiously enough, will allow an out-of-state RW service to respond, but then the patient MUST be taken out of state, unless the requestor was an in-state HEMS service, in which case the patient can be transport to an in-state facility. And in none of these scenarios is state certification or licensure an issue, UNLESS the out-of-state service markets and routinely responds in our state. Clear as mud? And then RW interfacilities are completely different still....
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bring it in for the real thing

#4 dghokie0139

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Posted 14 November 2009 - 04:15 PM

For RW flights our service had both RNs and PMs licensed in MD, DC, VA and DE. We went into WV and PA regularly, but weren't licensed there. I expect that the PA and WV laws allowed this since only one end of the patient leg was in that state. My understanding is that many states allow unlicensed transfers if you aren't regularly going into that state.
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#5 Macgyver

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Posted 15 November 2009 - 02:43 AM

If you are talking about FW interfacility runs, there should be no issue at all. The legal reason was explained to me before and I don't remember it in detail, but it made good sense when I heard it B). It is something about the referring and receiving facilities and physicians basically assuming responsibility for ensuring that the transport service is appropriate, personnel and equipment wise. I know that the program I work for routinely does 4-point transports throughout every state in the Eastern US (and sometimes out west and to Central America and the Caribbean), and licensure is never brought into question in any way for either our RN's or RRT's.


Depends on the states involved. The law when flying OVER a jurisdiction is slightly grey but likely not an issue under most state nursing/EMS boards. Not so much if you pickup or drop off in states you're not licensed in. Some allow it if infrequent, some only care if you are picking up, some don't care either way. Most however have an issue if you regularly pick up and drop off in the same state and it's not one you're licensed in. A lot depends on the knowledge level of any lawyers involved. And they usually are only involved after a complaint or suit is filed.

As a (purely hypothetical of course) example, a RN/PM team pick up a pt in their base jurisdiction (lets call it BOB) to drop in a neighboring one (lets call it JANE). The first bag of a blood transfusion is running started by the sending. A second bag (from a different donor) is hung in-flight. The charting does not show who physically hung/connected the bag but does have both co-signing the transfusion forms. The law in BOB allows the medic to initiate transfusions under a physician's delegated medical authority. The law in JANE does not and limits the paramedic scope of practice to maintaining infusions already established by another licensed provider.

An ICU nurse/medic at the receiving gets shorts in a knot and files a professional misconduct complaint alleging the medic practiced out of scope and in so doing also was practicing medicine without a license. Case all hinged on exactly who did what and when. As it turns out the RN was charting and the medic was the one who switched bags. Fortunately for the medic the times in the charts and the flight logs from the company proved the 2nd bag was hung BEFORE entering JANES airspace.

So then it became a jurisdictional issue / turf war:

(1) Did JANE's EMS board have any legal authority to disciple a medic not licensed by them for something that was out of scope for him to do while on JANE's turf? (They do - but not the case in the complaint)

(2) Did JANE's EMS board have any legal authority to disciple a medic licensed by their EMS board for something that was out of scope for him to do while on JANE's turf but that was actually done while legally practicing in BOB's turf? (in other words did their scope limit the medic to practice within it globally - or only while on their turf)

Saner heads eventually prevailed and it was dropped - unfortunately leaving the technicality questions still up in the air (so to speak) and unresolved (in a legal sense). However the legal concensus supported the rights of both BOB and JANE to regulate the scope of a medic WHILE PLAYING IN / ON / ABOVE THEIR TURF (basically extending the jurisdictional boundaries up into space) but that if no part of the flight (including fuel stops) was in their jurisdiction they had no authority at all (right of passage or something from airline law).

Note that this only addressed the question of where their authority extended to - EVERYONE I spoke with agreed that if the entire flight was done in JANE's backyard, simply being from and licensed in BOB and doing only an occasional flight within JANE was no defense or exemption.

So back to the real world: Some states require anyone doing Air Ambulance flights that originate within their state to have an EMS license for that state no matter where they are from. The license conditions often require registration within that state. While the EMS/Air Ambulance boards MAY allow a drop-off - the technical language of the RN act often has verbage that forbids unregistered individuals from practicing nursing (a HUGELY broad definition) or holding themselves out to be RN's as violations of the law (So when giving report to the receiving RN don't claim to be a RN!). That makes pickups a virtual legal impossibility as the sending MD has to be able to verify transfer of care to an appropriately trained and licensed provider...

2 lessons...

Most important: Don't pi$$ off the RN's at either end, be humble and have a good attitude

Don't believe everything told you in training about what/where you can practice - verify with the RN/EMS boards of the jurisdictions involved AND GET IT IN WRITING ON LETTERHEAD!
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Ken BHSc, RN, REMT-P

#6 emsrn

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Posted 16 November 2009 - 05:24 PM

Depends on the states involved. The law when flying OVER a jurisdiction is slightly grey but likely not an issue under most state nursing/EMS boards. Not so much if you pickup or drop off in states you're not licensed in. Some allow it if infrequent, some only care if you are picking up, some don't care either way. Most however have an issue if you regularly pick up and drop off in the same state and it's not one you're licensed in. A lot depends on the knowledge level of any lawyers involved. And they usually are only involved after a complaint or suit is filed.

As a (purely hypothetical of course) example, a RN/PM team pick up a pt in their base jurisdiction (lets call it BOB) to drop in a neighboring one (lets call it JANE). The first bag of a blood transfusion is running started by the sending. A second bag (from a different donor) is hung in-flight. The charting does not show who physically hung/connected the bag but does have both co-signing the transfusion forms. The law in BOB allows the medic to initiate transfusions under a physician's delegated medical authority. The law in JANE does not and limits the paramedic scope of practice to maintaining infusions already established by another licensed provider.

An ICU nurse/medic at the receiving gets shorts in a knot and files a professional misconduct complaint alleging the medic practiced out of scope and in so doing also was practicing medicine without a license. Case all hinged on exactly who did what and when. As it turns out the RN was charting and the medic was the one who switched bags. Fortunately for the medic the times in the charts and the flight logs from the company proved the 2nd bag was hung BEFORE entering JANES airspace.

So then it became a jurisdictional issue / turf war:

(1) Did JANE's EMS board have any legal authority to disciple a medic not licensed by them for something that was out of scope for him to do while on JANE's turf? (They do - but not the case in the complaint)

(2) Did JANE's EMS board have any legal authority to disciple a medic licensed by their EMS board for something that was out of scope for him to do while on JANE's turf but that was actually done while legally practicing in BOB's turf? (in other words did their scope limit the medic to practice within it globally - or only while on their turf)

Saner heads eventually prevailed and it was dropped - unfortunately leaving the technicality questions still up in the air (so to speak) and unresolved (in a legal sense). However the legal concensus supported the rights of both BOB and JANE to regulate the scope of a medic WHILE PLAYING IN / ON / ABOVE THEIR TURF (basically extending the jurisdictional boundaries up into space) but that if no part of the flight (including fuel stops) was in their jurisdiction they had no authority at all (right of passage or something from airline law).

Note that this only addressed the question of where their authority extended to - EVERYONE I spoke with agreed that if the entire flight was done in JANE's backyard, simply being from and licensed in BOB and doing only an occasional flight within JANE was no defense or exemption.

So back to the real world: Some states require anyone doing Air Ambulance flights that originate within their state to have an EMS license for that state no matter where they are from. The license conditions often require registration within that state. While the EMS/Air Ambulance boards MAY allow a drop-off - the technical language of the RN act often has verbage that forbids unregistered individuals from practicing nursing (a HUGELY broad definition) or holding themselves out to be RN's as violations of the law (So when giving report to the receiving RN don't claim to be a RN!). That makes pickups a virtual legal impossibility as the sending MD has to be able to verify transfer of care to an appropriately trained and licensed provider...

2 lessons...

Most important: Don't pi$$ off the RN's at either end, be humble and have a good attitude

Don't believe everything told you in training about what/where you can practice - verify with the RN/EMS boards of the jurisdictions involved AND GET IT IN WRITING ON LETTERHEAD!



That sounds like it was a nightmare. All I can say is thank goodness for the RN compact, and flying within those states so far. Primary state of licensure is based on residence, so my primary license isn't even where I am based. On case you presented, was RN delegation not even considered? If I'm willing to verify competency, I can delegate the pilot to physically change the blood (he might have the easiest access in an A-Star and a femoral line [just a point, not a real option]), as that is mere mechanics and I maintain full responsibility.
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#7 LearRRT-CCEMTP

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Posted 20 November 2009 - 08:34 PM

The Airline Deregulation Act covers this and I believe I noticed a while back that AAMS addressed it on their website. Essentially, state laws cannot interfere with nor prevent transport across state lines. Several expensive attorneys explained it to me that this law basically protects you as long as you are crossing state lines with the patient. The moment you fly into another state and do a point-to-point transport within that state's boarders then you fall under that state's laws. What ever they require of programs operating in that state is required of you! Take home point is if you are based in and fly from state A into state B for a patient, then make sure you take that patient back to state A or to state C or D! If you take them to a hospital in state B then you MUST follow that state's rules!
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#8 Macgyver

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Posted 21 November 2009 - 06:52 AM

The Airline Deregulation Act covers this and I believe I noticed a while back that AAMS addressed it on their website. Essentially, state laws cannot interfere with nor prevent transport across state lines.


Agree - but that law does not remove the right of a nursing or EMS board to set conditions on those who are registered with them - or who practice in protected areas of medicine in the manner of, or holding themselves out to be, a RN or REMT-P. And the jurisdiction is not only on the ground - although I agree also that most will not pursue the issue and it is a legal grey zone as few precedents exist. Simply pretending there is no issue may not be enough to save you if a lawyer or complainant with deep pockets decides to force the point.

As someone who routinely flies over multiple states etc I am sure you are comforted by the opinion you have been given - and the reality of it is that you are unlikely to ever find out otherwise (unless you really have a bad outcome or P off someone) but I have yet to see a precedent that states that a State RN board has NO authority over an individual practicing nursing in the air above their state...
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Ken BHSc, RN, REMT-P

#9 Macgyver

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Posted 21 November 2009 - 06:56 AM

The Airline Deregulation Act covers this and I believe I noticed a while back that AAMS addressed it on their website.


I think actually that what AAMS is referring to on their website is the authority of a state to allow or prevent an operator from setting up a base / accepting flights (the whole CON argument). Not whether or not the medical providers need to follow the states licensing regs and scope of medical practice...
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Ken BHSc, RN, REMT-P

#10 Macgyver

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Posted 21 November 2009 - 07:02 AM

On case you presented, was RN delegation not even considered? If I'm willing to verify competency, I can delegate the pilot to physically change the blood (he might have the easiest access in an A-Star and a femoral line [just a point, not a real option]), as that is mere mechanics and I maintain full responsibility.


Yes - the RN can delegate to someone who is trained and capable of performing the delegated act (so long as that act is not prohibited by a scope of practice issue - which it wouldn't be for the pilot but was for the medic).

However to ask a layperson to initiate a blood transfusion would be far outside the intent and language. Possibly abandonment actually to allow it. Not saying it makes sense, just that technically even though it is a continuation of existing therapy each unit is regarded as a separate transfusion. And a jury might be easily convinced that were they to be asked to safely and correctly change a blood unit including documentation etc and safe technique - that this was not what a reasonable lay person could be expected to do.

And exactly how would one go about "verifying competency" of a non-medical individual to the satisfaction of the CDC etc (or whoever regulates the use of blood products and sets the required policies / training etc)?
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Ken BHSc, RN, REMT-P