Each state and local jurisdiction may vary in the implementation, either by standing orders or requiring medical consult for both the administration of medications and the implementation of various procedures. These requirements change from year to year, depending on the latest medical information and the success or failure of pilot studies. In our jurisdiction all BLS treatments are by standing order. Most ALS skills and medication are by standing order, but not all, i.e. morphine administration, paramedics can administer morphine to isolated injuries such as burns, extremity fractures without consult. But for suspected myocardial infarctions (MI’s, heart attacks), after certain standing order meds. like oxygen, nitroglycerin and aspirin, we must consult with the hospital/medical direction to administer morphine. What I mean by “cutting loose”; in Maryland each county has a BLS and ALS Medical Director. Even though as a paramedic, I am licensed by the state, we still operate under the Medical Director’s medical license, similar to Physician Assistants, who are license by the state, they still work under the medical license of the physician for whom they work. In the case of ALS, each County Medical Director can establish additional requirements over and above the state requirements, since we operate under their license. Our Medical Director requires new paramedics or ones transferring into our jurisdiction to be precepted by an experienced paramedic for at least 15+ calls, when the senior paramedic feels the individual is capable of operating independently, the new paramedic meets with the Medical Director, he will interview and present certain scenarios for the candidate to handle, if the Medical Director determines the individual has the maturity, skills and knowledge to handle calls independently he/she “cuts them loose” to start to run calls independently. The Medical Director may determine the individual still requires to be monitored for additional time, the individual then simply runs additional calls with a preceptor until such time the senior paramedic feels any deficiencies or concerns have been addressed, the individual them meets again with the Medical Director for evaluation. As far as who pays or sponsors the program; for EMT-B, Maryland Fire and Rescue Institute, which is part of the University of Maryland (MFRI), puts on the EMT-BLS program, several times a year at local fire companies. The Maryland Institute for Emergency Medical Services (MIEMS) is the agency that tests, certifies and licenses. For EMT-P/ALS, the local college has a two-year program, the University of Maryland – Baltimore Campus has a four-year college program. As with most college programs, the individual has to pay or sign an agreement of post educational employment. Pete