Emergency medical technician – intermediate

Advanced Emergency Medical Technician (AEMT) is a mid-level provider of prehospital emergency medical services in the United States; a transition to this level of training from the Emergency Medical Technician-Intermediate (EMT-I), which had somewhat less training, began in 2013 and has been implemented by most states at this point. The AEMT is not intended to deliver definitive medical care in most cases, but rather to augment prehospital critical care and provide rapid on-scene treatment. AEMTs are most usually employed in ambulance services, working in conjunction with EMTs and Paramedics, however are also commonly found in fire departments as non-transporting first responders. The AEMT is authorized to provide advanced life support, which is beyond the scope of an EMT.

Education and training

AEMTs must be certified as EMTs prior to seeking certification, which involves a class lasting about six months, the curriculum for which is largely outlined by the NAEMT but can vary slightly from state to state. Along with the classroom time, the AEMT student is required to complete many hours of clinical experiences in the operating room, emergency department, other hospital units and advanced life support ambulances. During these clinical hours, the AEMT student must successfully demonstrate full practical knowledge of skills learned. Upon completion of all classroom and practical skills hours, AEMT students must successfully pass a standardized psychomotor and cognitive assessment before they can be certified.

EMT-I/85

EMT-I/85 is a level of EMT-I training formulated by the National Registry of Emergency Medical Technicians in 1985. This training level includes more invasive procedures than are covered at the EMT-Basic level, including IV therapy, the use of advanced airway devices, and provides for advanced assessment skills. The EMT-I/85 typically administered the same medications as an EMT-B (oxygen, oral glucose, activated charcoal, epinephrine auto-injectors (Epi-Pens), nitroglycerin, and metered-dose inhalers such as albuterol). However, in some states they were also allowed to administer Narcan, D50, glucagon. Like all other EMT levels, their scope of practice was governed by the State and/or their Medical Director.

EMT-I/99

The EMT-I/99 level was the closest level of certification to Paramedic, and allowed many techniques not available to the EMT-I/85 or EMT-Basic. These techniques included needle decompression of a tension pneumothorax, endotracheal intubation, nasogastric tube placement, use of cardiac event monitors/ECGs and medication administration to control certain cardiac Arrhythmias.

Advanced EMT

The Advanced EMT or AEMT is the new mid-level EMS provider that has been introduced at the national level according to the new national EMS scope of practice model.^[1] The AEMT replaced the EMT-I/85 and EMT-I/99, however some states have continued to teach similar levels, but they are not nationally recognized. The new scope consists of all EMT level skills, basic airway management and the insertion of supraglottic airways, suctioning of an already intubated patient, usage of a CPAP device, initiation of peripheral intravenous therapy, pediatric and adult intraosseus placement, needle decompression of a tension pneumothorax, and several pharmacological interventions beyond the EMT level.^[1] These pharmacological interventions include administering non medicated intravenous fluids such as 0.9% saline solution, administering nitroglycerine by the sublingual route, administering epinephrine 1:1,000 for anaphylaxis and 1:10,000 for cardiac arrest, administering Dextrose 50%, 25% and glucagon for diabetics, administering naloxone for opioid overdoses, administering nitrous oxide for pain management and administration of inhaled beta agonist medications such as albuterol and ipratropium for respiratory emergencies caused by asthma, COPD, etc.^[1] Other states may use different names for the above and often have a scope of practice beyond the minimal national standards.The EMT-I/99 had a total of three re-certification cycles to meet the requirements to transition to the Paramedic level, while the EMT-I/85 had two re-certification cycles to transition to the AEMT.^[2]

Scope of practice

In addition to the standards established by the United States Department of Transportation (DOT), some states issue licenses for more specialized levels of training. The minimal psychomotor scope of practice at the national level for an AEMT includes

Alaska has an EMT-II, which is very similar to the I/85 standard, and the EMT-III, which is closer to the I/99 standard. A sponsoring physician can broaden the scope of an EMT-III beyond state-defined protocols by providing additional training and quality control measures.^[3] This means that additional drugs and procedures (including wound suturing) can be accomplished by an appropriately trained EMT-III. The EMT-III program is a short upgrade program, and does not generally receive reciprocity with other states.^[4]

California uses an EMT designation which is equivalent to the National EMT-Basic, and Advanced EMT, which is the intermediate level or limited advanced life support, followed by Paramedic, ALS level.

Iowa EMT-Basics can administer Epi-pen per protocol, insert a Combitube, and set up and maintain (but not start) an IV that is non-medicated as well as all other basic skills. EMT-Intermediates can establish an IV in addition to the EMT-Basic skills. An Iowa Paramedic is a NREMT-Intermediate/99 and is not the highest level of care in Iowa. This allows them to insert ET tubes and perform needle decompression, manual defibrillation and medication administration. The Iowa Paramedic Specialist is the NREMT-Paramedic. Iowa also has a Critical Care endorsement for Paramedic Specialists.

Massachusetts recognizes the DOT levels of EMT-B, AEMT and EMT-P. EMT-Intermediates in Massachusetts followed the same protocol as the EMT-Basic, but were allowed to start IVs, perform fluid resuscitation, perform an ALS assessment and insert advanced airways such as endotracheal tubes, Combitubes and laryngeal mask airways. The Intermediate level in Massachusetts has been phased out and replaced by the EMT-Advanced, however most of the scope of practice remained the same.

Maine recognizes three levels, EMT Basic, EMT-Advanced, and EMT-Paramedic. EMT-Advanced in the state of Maine can provide many different treatments including IV therapy, EKG Monitoring, 12 Lead EKG placement, Dextrose (D50), Glucagon, and other medication. Advanced level EMTs can also place laryngeal mask airway devices and use CPAP when needed. Some treatments and medications require consultation with online medical direction.^[5]

Michigan uses the National Registry AEMT examination, but does not require continued national registration when an AEMT renews.^[6]

New York State has an AEMT-CC (Advanced EMT - Critical Care) certification, which is unique to New York, but almost identical in curriculum set by the national standard EMT-Intermediate/99. In addition to the national scope of practice, New York also authorizes its AEMTs to intubate patients and is considering the implementation of four lead ECG monitoring. However, no advanced EMT certifications are recognized in New York City. One either functions as an EMT-B or a Paramedic.^[7]

Oklahoma recognized an EMT-Cardiac level until recently. However, that level has been phased out and providers in Oklahoma at the EMT-Cardiac level have since been trained and certified to the paramedic level or downgraded to EMT-I.

Pennsylvania uses the National Registry AEMT examination, but does not require continued national registration when an AEMT renews. However, the PA Bureau of EMS has not define a scope of practice and protocols as of Sept. 2014. ^[8] PA is new to this level of certification. As Sept, 19, 2014, there are 6 PA certified AEMTs in the Commonwealth.

Rhode Island's first-level ALS provider is EMT-Cardiac, which is unique to Rhode Island and Virginia. (Virginia has recently phased out the Cardiac Tech program.) The EMT-C is a certification between the EMT-I and EMT-P, allowing the use of more cardiac drugs than the EMT-I, but fewer than the EMT-P. The time and cost of an EMT-C program is generally less than one third that of an EMT-P program. EMT-C or higher licensure may be required by Rhode Island fire departments, who provide emergency medical services in the majority of the state.^[9][10]

Tennessee EMTs are licensed at either the EMT-IV (Intravenous Therapy) Level or the EMT-Paramedic Level. EMT-IVs are trained to the NREMT-B standard in accordance with DOT regulations, as well as receive additional training in advanced airway management, administration of epinephrine 1:1000 in anaphylaxis, administration of nebulized and aerosolized Beta-2 agonists such as Xopenex and albuterol, administration of D50W and D25W, IV therapy and access, and trauma life support including the use of MAST trousers. EMT-IVs can also administer nitroglycerin and aspirin in the event of cardiac emergencies, and can give glucagon. EMT-IVs can also administer the Mark 1 autoinjector kit for Organophospate poisoning and suspected nerve gas exposure. The State of TN Board of EMS is currently evaluating allowing EMT-IVs to administer Narcan and nitrous oxide as well. The board has accepted the new levels of EMR, EMT, EMT-Advanced, and Paramedic. Gap analysis has been completed by the state and the board has moved to allow up to 4 years for the EMT-IV to transition to EMT-Advanced by way of an eight-hour course, choosing to let all EMT-IV's and Paramedics under the current standard be renewed as usual for this cycle.^[11]

In Virginia, the first level of ALS is EMT-Enhanced (previously Shock Trauma), which is unique to Virginia. It is essentially equivalent to the EMT-I/85. The EMT-Enhanced can start IV lines, perform dual-lumen airway insertion, and administer some medications such as D50W, glucagon, albuterol/Atrovent, epinephrine and sometimes narcotics. They cannot, however, administer any cardiac medications. The next level of ALS is EMT-Intermediate, which is equivalent to the I/99 level of certification. In most counties, the EMT-I operates under the same protocols as EMT-Paramedics. There are a few procedures that EMT-Is can't perform, that paramedics can including rapid sequence intubation, surgical cricothyroidotomy, and needle cricothyroidotomy. (Virginia phased out its Cardiac Tech level and replaced it with its Intermediate level.)

In Washington State, EMT-Basic protocols are similar to those in Iowa. Certified EMT-B personnel can administer Epi-pen per state protocols and can insert a Combi-Tube. The Washington EMT-B can set up and maintain an IV that is non-medicated, but EMT-I certification is required to start the IV.WA Office of Emergency Medical and Trauma System (May 2009) Some county protocols (such as Jefferson) accept an EMT/ILS Tech which, in addition to all EMT-I and EMT-B skills, can administer D50W, Narcan, albuterol, and can now draw up epinephrine in addition to using the Epi-Pen.

Wisconsin offers an EMT-IV-Technician certification for the EMT-Basic, allowing them to start basic IV lines, treat for hypovolemic shock, and administer Narcan, D5W, and a limited number of other medications. This level of training is often used in non-urban areas where hospitals may be sparse and advanced life support intercepts or aeromedical transports can take a great deal of time. Additionally, some private ambulance companies employ EMT-IV Technicians for interfacility transports which only require IV therapy and do not necessitate the specialized advanced care of a paramedic.

See also

• Emergency medical responder levels by state
• National Registry of Emergency Medical Technicians
• National Association of Emergency Medical Technicians
• Emergency Medical Services in the United States
• Wilderness emergency medical technician
• Medic
• Combat medic
• Corpsman
• 68W
• Rescue squad
• Pararescue

References

External links

• National Registry of Emergency Medical Technicians
• National Association of Emergency Medical Technicians
• National EMS Memorial Service
• National Highway Traffic Safety Agency, Office of Emergency Medical Services
• The Difference Between an EMT and a Paramedic
• EMT City, large community for EMTs and Paramedics