Emergency medical technician – intermediate

Emergency Medical Technician-Intermediate (EMT-I) is a mid-level provider of prehospital emergency medical services in the United States; a transition of this level of training to Advanced Emergency Medical Technician (AEMT), which has somewhat greater training, is in progress. The EMT-I is not intended to deliver definitive medical care, but rather to augment prehospital critical care and provide rapid on-scene treatment. EMT-Is are most commonly employed in ambulance services, working in conjunction with EMTs and Paramedics. The EMT-Intermediate or AEMT is typically authorized to provide more advanced medical treatment than the EMT and is typically authorized to provide advanced life support.

Education and Training

Typical training for the EMT-I involves a class, which can range from a couple of months to a year, with the length often depending on state requirements. Along with the classroom time, the EMT-I 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 EMT-I must successfully demonstrate full practical knowledge of skills learned.


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 administers 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 are also allowed to administer Narcan, D50, glucagon, thiamine, and atropine. Like all other EMT levels, their scope of practice is governed by the State and/or their Medical Director.


The EMT-I/99 level is the closest level of certification to Paramedic, and allows many techniques not available to the EMT-I/85 or EMT-Basic. These techniques include needle decompression of 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 will replace the EMT-I/85 and EMT-I/99. The EMT-I/99 will have a total of three re-certification cycles to meet the requirements to transition to the Paramedic level, while the EMT-I/85 will have 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 all EMT level skills, basic airway management and the insertion of supraglottic airways, suctioning of an already intubated patient, patient assessment, and several pharmacological interventions beyond the EMT level.[1] These pharmacological interventions include peripheral intravenous therapy, pediatric intraosseus placement, administering non medicated intravenous fluids such as 0.9% saline solution, administering nitroglycerine by the sublingual route, administering epinephrine 1:1,000, administering Dextrose 50%, administering glucagon, administering naloxone, administering nitrous oxide and administering inhaled beta agonist medications such as albuterol.[1] Other states may use different names for the above and may have a scope of practice beyond the minimal national standards.

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, EMT-I/85 and EMT-P. EMT-Intermediates in Massachusetts follow the same protocol as the EMT-Basic, but are allowed to start IVs, perform fluid resuscitation, perform an ALS assessment and insert advanced airways such as endotracheal tubes, Combitubes and laryngeal mask airways. Some medical directors and jurisdictions allow the EMT-I (or even EMT-B) to administer intranasal Narcan and nebulized albuterol. The EMT-I program is slightly longer than the Basic and requires both clinical and field time. The Intermediate level in Massachusetts is being phased out and replaced by the EMT-Advanced.

Maine recognizes three levels, EMT Basic, EMT-Intermediate, and EMT-Paramedic. Intermediates 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. Intermediate 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 recognizes the DOT levels of EMT-B, EMT-I/85, and EMT-P, however they refer to an EMT-I/85 as an EMT-S (Specialist). Since standards for EMT-Basic are nearing the EMT-Paramedic level, the EMT-Specialist is slowly being phased out.

New York State has an AEMT-CC (Advanced EMT - Critical Care) certification, which is unique to New York, but almost identical in curriculum to the national standard EMT-Intermediate/99. Part of the reason why New York possesses this level is that it also has an AEMT-I (Advanced EMT-Intermediate) certification which is at the same level as the national standard for EMT-I/85. However, no advanced EMT certifications are recognized in New York City. One either functions as an EMT-B or a Paramedic.[6]

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.

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.[7][8]

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.[9]

Vermont's first level of ALS provider is the EMT-I '03, which is unique to the state. EMT-I '03's have an expanded scope of practice which falls above an EMT-I/85 but below an EMT-I/99. In addition to providing IV therapy, EMT-I '03's are allowed to administer albuterol, aspirin, D50W, epinephrine 1:1000, glucagon, naloxone (Narcan), nitroglycerin and thiamine, in addition to EMT-B level medications.

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 few procedures that EMT-Is can't perform, that paramedics can. Some of these procedures include rapid sequence intubation, surgical cricothyroidotomy, and needle cricothyroidotomy. (Virginia has recently phased out its Cardiac Tech program and replaced it with Intermediate.)

In Washington State, EMT-Basic protocols are similar to those in 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.

References and notes

See also

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

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