What’s the Point of Advanced EMTs and Intermediates?

Happy Medic and I share a hatred of the terms “basic” and “advanced” in relation to EMS provider and unit capabilities.  He writes about this in his post “The End of the EMT-Basic?”

When I worked in Buffalo, EMT-Intermediates were primarily credentialed to start IV’s and intubate. When I worked in Virginia, EMT-Intermediates were credentialed to do the same skills as paramedics, though after much less education and clinical time.  You just needed to know how to do those things, not why you should do them.  Or so I was told.

In an attept to implement nation-wide standards for EMS certification, NHTSA published a Scope of Practice Model in 2007.  It dropped the dreaded “basic” after EMT.  Unfortunately it kept an “Advanced” EMT level that is below a Paramedic.

For many communities, Advanced Emergency Medical Technicians provide an option to provide high benefit, lower risk advanced skills for systems that cannot support or justify Paramedic level care.

I do not believe this level is necessary, and that it only creates confusion.  If an AEMT and paramedic are on scene, who should the patient think is in charge?

I believe that the SOP authors overestimated the benefits of AEMT interventions.  The true life-saving skills are the basic ones done well.  I also believe that they underestimated the risks of the AEMT interventions.  I envision a brain storming session where the authors asked “how can they screw up Narcan?”   Under-educated and poorly overseen paramedics screw it up all the time, so it is unreasonable to expect less-educated AEMTs to do any better. When those AEMTs work in rural areas and only see a few patients – and even fewer critical ones –  advanced skills are a recipe for disaster.

On Happy Medic’s post, Skip Kirkwood commented:

How about a single standard? If you’re going to have plumbers, let’s have a single standard – somebody who can go on a 911 call and handle everything they run in to with state-of-the-art, evidence-based medicine.

Why do we in the US have the lowest standards of any first-world, English speaking nations? Because we, alone amongst those nations, allow the volunteers to dictate the minimum standard, rather than allowing the profession to set the standard and allowing the volunteers to meet them if they wish.

I would submit that what we call a paramedic should be the entry level professional standard for those who would provide EMERGENCY medical services (meaning, respond to 911 emergency medical calls as the primary, transport capable responder). Call it something else for non-emergency medical transportation, inter-facility or discharge (non-critical care) transportation, etc.

To which The EMS Professional replied:

I love you!!

I’m not ready to go as far as love, but will say that I strongly agree.

For the safety of our patients, invasive skills are a privilege that must be earned.  Lets focus our energy on making EMTs and paramedics better, and to scrap the AEMT.


  1. I think the AEMT (and the previous EMT-I) level was created for areas where they did not want to pay for a paramedic. Since living in Kentucky, I have learned that we pay our paramedics at such a low rate in the rural areas, it should be easy to buy a few more. Why are we allowing volunteer agencies set the standard? There are many more volunteer fire departments in the country, and the career and combination departments still pay well.

    I am a paramedic. I am not a volunteer. I think placing the blame on the volunteer system solely would be a mistake. If Mr. Kirkwood thinks that only paramedic level personnel should staff emergency ambulances, then let him hire only paramedics and get rid of the EMTs in his system. He doesn’t need a change in the state licensing system or an act of congress to achieve this, he already has paramedics and advanced practice paramedics working for him.

    It will not be the volunteers that prevent Mr. Kirkwood from hiring only paramedics. It’s his budget that limits his staffing paramedics only ambulances. Change the entire model for billing in EMS. Enough of this taxi style service where the rates are exorbitantly high and the agencies only receive 66% of the total money billed. There will always be a need for volunteers in rural areas. Go to the small towns in any state, and ask them if they can afford to pay a living wage for an ambulance crew to be staffed 24/7, I bet you find they cannot.

    I like Skip Kirkwood, he has a lot of good ideas. I would like to see him implement these in his own agency, and then we would have some real data to see if his ideas work.

    • emspatientperspective says:

      Thanks RM, I believe (and hope he corrects me if I am wrong) that Mr. Kirkwood has at least one paramedic on every ambulance. Most of them are staffed with a paramedic and EMT, and advanced practice paramedics respond to patients on both ends of the critical and sub-acute bell curve. Mr. Kirkwood’s community is willing to pay for that. I’ve written before why I belive a paramedic should be on every call, mostly to deliver pain medication and to asses for vague life threats. If communities are unwilling to pay for that, so be it. It’s a bargain until anyone needs them.

      My point with this post, however, was that I see no benefit to an advanced EMT or intermediate level. Instead of throwing a few “advanced” skills at people with a limited knowledge base about why they should be performed, I wish they would concentrate on performing the basic interventions better.

  2. Scott Matheson says:

    I think the Intermediate level fills a much needed role. I do think that instead of having three levels there should only be two, EMT and Paramedic. EMT should be basic and advanced/intermediate combined. Also if your worried about skills being performed wrong that can be solved through training. To say that all EMT I or Advanced are bad providers is wrong. In my 20 plus years I have never had a patient care complaint or a protocol violation. With any skill based job you only get out what you put in.

    • emspatientperspective says:

      Thanks Scott, you hit the nail on the head with saying you get what you pit into it. We make providers put in much less than ones in any other First World country. The lowest commondenominator in the US is much lower than the one in Canada. How much clinical time was included in your EMT-I training? How much supervised practice did you get? I want to raise the minimum competency requirements for all levels, and see no clinical advantage to an intermediate skill set over BLS.

  3. A little background: I’m a full-time software engineer and a volunteer EMT-B in a volunteer/paid hybrid system located in Pennsylvania. It’s a shift-staffed system, so if I want to volunteer, it’s for a full shift (no respond from home). All of our units are ALS, crewed with typically one EMT-B, one Paramedic.

    I am eagerly awaiting the introduction of the AEMT program in Pennsylvania because I have an interest in wilderness medicine. In these cases, the training and permission to provide IVs and (hopefully) pain medication will be invaluable. However, becoming a full-on Paramedic isn’t practical. Sure, I could take the course, but keeping proficiency with the higher-risk skills such as heart medications or intubation is hard to do with my ~25h/month I put in. Also, I’m not going to be humping a 12-lead heart monitor up the side of a mountain, so I wouldn’t be using those skills where I’d like to be, anyways.

    For this particular application, the AEMT program is exactly what I’m looking for.

    • emspatientperspective says:

      Thanks Garrett, I’m happy that you wish to further your EMS education, and believe you are doing it for the right reasons. My criticism about the AEMT level is that the clinical benefit of the minimum interventions listed under the NHTSA Scope of Practice model (not sure about Pennsylvania’s) is largely unproven, and more is known about the risks of those interventions than when the document was published. Narcan is not a benign drug. NTG may kill someone with a right-side MI, and is not proven to help the other types. The only analgesia listed is Nitrous Oxide, which is not practical for the wilderness.

      For comparison, look at the minimum education standards for BLS in Canada here. Why do they require a two-year college degree, and we require a 150 hour class? Is it reasonable to expect AEMT’s in the US to competently perform more advanced interventions with a fraction of the education hours? I would argue no.

      • I’m originally from Ontario, so I’m familiar with the higher standard for training. However, it isn’t necessarily as great as you might suspect.
        First, let’s look at a sample curriculum (first found in Google Search):

        This 4-semester program includes mandatory courses such as:
        * College Reading and Writing Skills
        * An Introduction to Arts and Sciences
        * Fitness Appreciation
        * General Education Electives (x2)
        * Driver Education

        I’ll be the last person to argue that general education is a bad thing. However, I will argue that it isn’t necessary in order to be an effective EMS provider, and that good life experience is probably more valuable than taking a convenient art course.

        Next, speaking of my experience in PA, emergency vehicle driver training was a separate course. This allows people to operate in a non-driver role, either as 3rd person on an ambulance or at a fixed location.

        This program also has coverage of materials which I was expected to develop on the job, notably trip sheet writing and radio communications.

        So, some of the material is either not directly connected to the job or is possible to learn outside of the classroom. I’m not arguing that one is necessarily better than the other, but more that the difference isn’t nearly as clear-cut.

        Then we need to look at how ambulance reimbursement works as well.
        Ontario has a government-provided health insurance system. This is enforced by law. Here are the payment rules:
        Note that if a doctor doesn’t deem the transport medically necessary, the patient is responsible for the whole cost of the transport. This differs from the US where medical necessity is determined in advance of transport. In practice, this results in fewer people calling for an ambulance unless it is serious as they don’t want to have to pay for the cost.

        Finally, EMS is operated as a municipal service with operational payment covered by both the municipality as well as the province. When you don’t have to worry about billing and getting paid less for lower levels of service it is much easier to justify staffing an ambulance with higher levels of providers at all times.

  4. Ill keep this short and simple. The AEMT is a VERY vital spot… what % of calls are medic level? 10? what about AEMT/EMT-I? maybe 20? Im only an EMT and like 70% of the calls I go on are basic level… I plan to take an AEMT Class in the future, Its a step towards my goal of being a medic, but I dont want to jump right into paramedic school, I think its idiotic to even think about taking away the AEMT level…Thats just my 10 cents worth.

    • emspatientperspective says:

      Thanks James, sorry this took so long to reply to. In NREMT’s last newsletter, they actually described problems with the knowledge base of the AEMT curriculum being inadequate for the minimum skill set. I believe that the risk of harm caused by the AEMT skill set, including nitro, Narcan, and IV fluids, outweighs the benefit. Other procedures are done at the BLS level now that have a proven benefit, and less risk of harm, such as transmitted 12-leads, CPAP, and supraglottic airways. There is no “intermediate” or “advanced BLS” provider level in other countries, either. Instead of investing a lot of energy in a separate provider level, I would rather see a more rigorous EMT curriculum.

  5. I know I am late to this discussion, that said, to follow this logic, we should ask “what’s the point of Paramedics?” After all, they are less trained / experienced than the ER RN to which they turn over patients. Ergo, let’s staff ambulances with only ER qualified / experienced RN’s. Before you dismiss this comment, there are systems that are lobbying precisely for this. Further, and as research is demonstrating (you can google it), there is a growing body of evidence that Paramedics that get wrapped up in “stay and play” are actually having less positive outcomes than their lesser trained AEMT and EMT basic colleagues. Finally, in AEMT training / testing, NREMT is emphasizing more reliance on basic protocols than advanced invasive protocols.

  6. I will have to say that I take exception to someone saying that ” the volunteers are dictating what skill level should be allowed”. I started as an EMT at 16 years old and moved on through shock-Trauma tech, cardiac tech and finally NREMT-P that I obtained through George Washington University. I can tell you that as a volunteer paramedic I never felt that as volunteers we should or do get to obtain less CEU’s or score lower on our state or National registry exam and practical stations. It’s not the volunteers who set the standards it’s the OEMS. I am in a county where we have both paid and volunteers. I can tell you that if it weren’t for our volunteer system the community would suffer greatly. I can tell you that there are many EMT-Intermediates and paramedics that are volunteer and have skills and knowledge that far outweigh some of the paid staff. We are all educated in EMS at the sane level and ALL have to pass the same standards of testing whether we are volunteer or paid.

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