EMT-Intermediates: A Concept That Never "Took Off"?

[x635 4,066]

In NYS, EMT-I's really are underutilized or obsolete, depending on how you want to look at things. In most agencies, they don't use EMT-I's.

I personally feel that every ALS ambulance should be double medic, and if not, at least an EMT-I to help with the skills. I know CT has a similar EMT-I program, but I can't remember how it is utilized.

I reccomend the class to any EMT who's not immediately planning to go to medic school. It's great to have the extra knowledge and skills, even if you're just working at the BLS level.

FAC911 was in the class with me as well, and only a few others. I believed we were allowed to use our skills under the direct supervision of a paramedic, but couldn't use the skills independtly. FAC, you remember anything about this? Also, I believe Yorktown VAC had an EMT-I program, but I don't know about that program, it's terms, or if it's still around.

WCREMSCO and NYS DOH has the structure in place for EMT-I's, but the concept has never really taken root.

I took my EMT-Intermediate class at Phelps in 1999 with Barry Nechis in the sub basement of Phelps. Was an AWESOME class, Barry was a great instructor and made lthe coursework fun. Not only did he teach us EMT-I skills, but also helped us to sharpen our EMT skills. It was also a great "primer" for Paramedic School, and really helped me while in the field as well. I remember the fun tabletop MCI excercise-that was the best! I've applied lessons from his teachings multiple times. If Phelps Hospital and Barry Nechis were to have offered a Paramedic class, I would have definetly taken it there.

[Remember585 815]

The big problem with the EMT-I's that I always see is that most times you have a Medic on location that wants to ensure everything for the patient is done, and done right. And, many times, the Medic may not know the capabilities of an EMT-I so they don't use them.

Additionally, many times when you have a "Tube job," the Medic wants to do it because they don't get to do it that often and want / need to get it. I don't blame them, but it sucks for the I's.

I also took the EMT-I class with Barry at OVAC in either 1999 or 2000. I had to drop the course because I started a new job that didn't allow me the time to finish it out. Looking back at it now, I am kind of glad I didn't waste my time. It is a good program, but in my area the EMT-I's don't get to use their skills as often as they would like.

And Seth you are right - Captain Nechis is a great instructor whom I have taken a few EMS and Fire classes with.

Barry - are you still teaching anything up here at the WCFTC?

[ex-commish 490]

My " I " expired last August and I did not re-new it. Not enough exposure to maintain skills. Most medics allowed me to do sticks but that was rare being most calls I ran were bls or I was stuck driving. I will say the class made me a much better emt and learned alot more on shock and trauma.

[Goose 188]

Last i heard the State was looking to melt the B and I program together, doing away with intubation altogether and replacing that with less advanced airways like the combi-tube. Now, as far as what would happen with IV therapy and cardiac monitoring, i don't know. The biggest problem with this potential plan is i don't know how you can expect volunteers to maintain those advanced skills - whatever they may be (hence why I'm not really sure if i beleive the state will ever melt the two programs together...)

At one point i had considered the "I" program but was told by many to not bother and if i was that passionate to learn and advance my skills, go to medic school. But as others have already stated, keeping up with those ALS skills is what is going to kill you. If you have a good relationship with your partner maybe that wont be a problem as he would let you get the tube or grab and IV...but i think for the program as a whole it would be far more difficult.

Likewise, the biggest downfall of the "I" program is the hard-on (pardon the term) many agencies have with paramedics. Couple that with the hoards of shoddy EMTs out there and you've got a recipe for disaster. Likewise, I'm not sure how the MDs feel about the "I" program...most of the protocols out there seem to barely take advantage of those that are "I" certified.

Personally, i wish the State did away with the B program altogether and had EMT-I as the base standard. It would not only up the initial level of care but would also filter out many of those who simply do not belong on the street.

Edited January 13, 2008 by Goose

[JJB531 652]

Personally, i wish the State did away with the B program altogether and had EMT-I as the base standard. It would not only up the initial level of care but would also filter out many of those who simply do not belong on the street.

I personally don't think that raising the standard will do anything in terms of filtering out individuals who don't belong on the street. Although it sounds like a reasonable concept, there are EMT and medic programs out there that just push people through these courses and graduate individuals who have absolutely no business whatsoever practicing prehospital medicine. Programs want high graduation rates.... and the more students these programs get, the more money they make. It's like anything else, certain programs are more interested in making the almighty dollar then they are graduating quality EMT's and Paramedics.

I personally am not impressed with many of the programs that are out there. Not knocking the instructors, because there are many talented EMS instructors, but I don't feel that the training is realistic enough to give new EMS providers, especially new EMT's who have no street experience, a feeling for what it's really like on the streets. When firefighters train in auto extrication, they're out there ripping apart cars. When they train in fire suppression, they're putting out real fires in a simulator. So why is it that when we teach EMT students on the use of a KED and removal from a vehicle, do certain programs put two chairs next to eachother in a classroom to simulate the front/passenger seats of a motor vehicle?

Sometimes I think that certain programs are all about the state practical exam and not preparing students for reality, and I think that's one reason why so many programs graduate weak EMT's. Obviously nothing beats real life experience and working alongside a seasoned, experience, and competant EMT or paramedic. But with the state of EMS, alot of times that is a luxury that an agency can not afford, and many are thrown right into the mix to learn on their own which carries a lot of inherent danger. Personally, unless I know you well enough, and trust you, there is no way I'm going to let someone start an IV for me. The ultimate responsibility for and EMT-I's actions falls on my shoulders and I'm not willing to jeopardize my medic card because of a mistake made by someone else.

[Engfire 0]

Here locally in OH I's are allowed to push 17 drugs that include morphine, but it is to only be used for pain management. I's can place a Pt on a monitor but are limited what they can do. In this area we are P heavy and only have a handful of I's floating around. The biggest problem we becomming and I and then becomming a medic is that very few medic programs give you and credit towards medics.

Quick question of you NYS guys is your I program 200+hrs or more like the 400+hrs program.

[GM911 0]

Quick question of you NYS guys is your I program 200+hrs or more like the 400+hrs program.

According to NYS DOH, regarding the EMT-I curriculum:

"...It is estimated that the “average” program, with “average” students, will achieve “average”

results in approximately 160-200 total hours of instruction (60-80 classroom/practical

laboratory, 50-60 clinical, 50-60 field internship)..."

http://www.health.state.ny.us/nysdoh/ems/pdf/emtioguide.pdf

[Guest alsfirefighter]

JJB...awesome post and insight as always brother! The EMT-I was an idea I wanted to toss around my department to upgrade our BLS guys but skill maintenance was an issue.

I personally feel that every ALS ambulance should be double medic, and if not, at least an EMT-I to help with the skills

I've never been a big fan of the 1 plus 1 system, meaning double medics. I've ridden in a system that utilized that concept and to me it didn't equate to much of a difference in patient care and in some cases I noticed that it allowed some weaker medics with poor skills to hide within the system. Throw in the fact that sooner or later you still have 1 in the back that has to drive, some extended scene times on occassion because both are working and lose track of on scene time instead of getting up there and drive.

I do also see some of the benefits of having them as well, but as a person who is always by themselves generally, I have no efficiency issues and the majority of my co-workers and colleagues do not either.

As far as having an EMT-I help with skills? What is it that they are going to do for a Paramedic that a EMT cannot do if someone takes the time to show them? Any newer emt of even attendant that has ridden with me knows I've always taken the time to show them how to spike a bag, where equipment is, setting up the monitor, holding cric pressure, holding the tube properly when asked and so on. This continues when you have something you find assessment wise to allow them to see something they haven't yet or for experienced members that they might not have seen for quite some time.

The "I" concept didn't take off for numerous reasons. In my area staffing is an issue and I often had the line done by the time they arrived. Some also have to understand the system they are in and call volume and such. I wasn't keen to letting all my sticks go by when all medics need to stay in practice. Intubation...rarely would I give one up unless it was in a string where I was catching a lot of them...and then what happens? This might not sound PC but there were EMT-I's that I wasn't impressed with their EMT-B skills or mannerisms. So then what I'm going to be comfortable with allowing them to do what I considered basic but essential skills at critical times? Some of these were providers that couldn't adminster Albuterol correctly or at the right time. I had issues with that occassionally, or the EMT-I who would rather set up their IV equipment before even asking anything other then a question to hear a complaint they deemed ALS. Or the ones who would walk in as I'm just about ready to stick and they would hover over you like a hyena waiting for you to get off the prey you just caught. Ask me...I'm open and I'll either say yes or no. Then there was issues where "I's" were starting lines on calls that we would often BLS. It created frustration for many of us.

I often also asked a simple question to "I's" when they asked me or I offerred a stick to them or tube. "Are you going to be able to get it?" Your answer was often how I judged how you may be. I never wanted to hear "I hope so." or "I'm gonna try." I want to hear "Yes" or "I'm fairly confident." Even if you gave me one of those answers and missed, I love the confidence and aggressiveness.

For airway I think it was great. But I believe EMT-B's should be able to use Combitubes. Its not rocket science NYS...its effective and it works and with great success with many other states. IV access...in some cases OK its fairly important...but normal saline doesn't cure anything.

Paramedic programs can't weed out many bad EMT-B's, hence they become "P's". So upgrading to EMT-I only curriculum does nothing. If you have shoddy EMT's you work with, or with agencies you have to work with, if you don't take the steps to fix some of the issues you are part of the problem. Any agency Captain out there that I have to deal with as transport agencies know I come to them with issues, both of personal and with skills/operations. Do they always do something with it, no, which is a seperate issue, but I can tell you I work with and am personal friends with 2 of them and they do take it in, digest it and see what is going on and in many cases with 1 if he sees a pattern its addressed in the office or through training.

If you don't try to fix the problems...you are part of the problem!!!!

[Bnechis 3,961]

In NYS, EMT-I's really are underutilized or obsolete, depending on how you want to look at things. In most agencies, they don't use EMT-I's. I personally feel that every ALS ambulance should be double medic, and if not, at least an EMT-I to help with the skills.

I reccomend the class to any EMT who's not immediately planning to go to medic school. It's great to have the extra knowledge and skills, even if you're just working at the BLS level.

I agree, but your never going to see 2 medics in most cases due to cost and availability.

I also feel the basic EMT does not give enough, but I dont want to see it longer. I like the idea of being an EMT for a while then upgrading. You have a better sence of it and hopefully your skills are sharper then.

FAC911 was in the class with me as well, and only a few others. I believed we were allowed to use our skills under the direct supervision of a paramedic, but couldn't use the skills independtly. FAC, you remember anything about this? Also, I believe Yorktown VAC had an EMT-I program, but I don't know about that program, it's terms, or if it's still around.

WCREMSCO and NYS DOH has the structure in place for EMT-I's, but the concept has never really taken root.

You can use them under both direct & indirect (if the agency is an "I"). It would be useful, but the paid system is unwilling to pay for it and the vollie side never took interest.

I took my EMT-Intermediate class at Phelps in 1999 with Barry Nechis in the sub basement of Phelps. Was an AWESOME class, Barry was a great instructor and made lthe coursework fun. Not only did he teach us EMT-I skills, but also helped us to sharpen our EMT skills. It was also a great "primer" for Paramedic School, and really helped me while in the field as well. I remember the fun tabletop MCI excercise-that was the best! I've applied lessons from his teachings multiple times. If Phelps Hospital and Barry Nechis were to have offered a Paramedic class, I would have definetly taken it there.

Thank for the compliment. Nice to see it in writing.

My intention always was to make it a pre-medic. Some just want that far and decided it was as far as they wanted to go, others used it as the prep to being a better medic.

[Bnechis 3,961]

And Seth you are right - Captain Nechis is a great instructor whom I have taken a few EMS and Fire classes with.

Barry - are you still teaching anything up here at the WCFTC?

Thanks

Not much, too busy in NR.

I am on the DOH regional faculty so I do teach in the CLI & CIC program. I also taught all of the Decon Trailer Programs.

[Bnechis 3,961]

Last i heard the State was looking to melt the B and I program together, doing away with intubation altogether and replacing that with less advanced airways like the combi-tube. Now, as far as what would happen with IV therapy and cardiac monitoring, i don't know. The biggest problem with this potential plan is i don't know how you can expect volunteers to maintain those advanced skills - whatever they may be (hence why I'm not really sure if i beleive the state will ever melt the two programs together...)

I've heard that rumor for almost 20 years....I don't see it coming anytime soon.

Personally, i wish the State did away with the B program altogether and had EMT-I as the base standard. It would not only up the initial level of care but would also filter out many of those who simply do not belong on the street.

Georgia did that, some say with the intention of eliminating vollunteers.

The interesting issue is in NYS you need 120+ hours of training to "treat" a life and death issue, but you need over 1,000 hours to cut my hair.

[helicopper 1,050]

Paramedic programs can't weed out many bad EMT-B's, hence they become "P's". So upgrading to EMT-I only curriculum does nothing.

If you don't try to fix the problems...you are part of the problem!!!!

Paramedic programs CAN weed out bad EMT's... if they choose to. JJB hit the nail on the head. They're receive funding based on graduates so they're inclined to maintain a lower standard than I think most of us would like so they can make the most $$$. If they raised the standard and remediated average EMT's to make them excellent EMT's before starting the medic program we'd all be better off. There should also be a stronger screening process so an EMT with no experience can't just jump into the medic program. When I took my medic class, I was interviewed and my experience was evaluated before I was allowed to enter. Do we do that anymore?

I agree, but your never going to see 2 medics in most cases due to cost and availability.

Not exactly true... Rockland Paramedics! Every unit (except Tuxedo and that's only because of volume) is two medics. They have the ability to work together to expedite treatment or split to cover secondary calls in their area. I'd really like to see Putnam go to two medic units especially on the east side where they're always relocating to cover due to multiple calls.

The expense is there but if they're in the same truck you're offsetting some of the cost.

Seth, the EMT-I idea never took off for a couple of reasons - one someone already hit on and that's the EMT-I not being able to perform skills because the medic needs to keep his/her skills sharp. That's a problem in low volume systems.

The other is that EMT's in volunteer systems already have a hard time with all the demands for their time and adding several hundred hours of training for "I" is a major commitment. Some will make it, many will not. In paid systems, there's very little return on the investment so why spend all that time/money to use EMT-I's when you can use EMT-B's.

[OoO 24]

How exactly does an EMT-I compare to a medic?

Edited January 13, 2008 by OoO

[Guest alsfirefighter]

Paramedic programs CAN weed out bad EMT's

Chris....I do agree with you, that's why I put that they can't weed out "many" poor EMT-B's. Some always fall through the cracks or do well enough education wise. While I wasn't interviewed based on my experience in my class, I felt comfortable at the time I entered based on my BLS experience, which as you know Chris you and several other medics in the area I rode in contributed too a ton. I can say when I went through the standards were a bit higher being the full regular A & P 1 and 2 courses got rid of some non-hackers and those that I called the "fun" and "cool" seekers who are there because "being a medic looks fun or cool." Then as we went along there were those who couldn't maintain the schedule, cardiology always tends to cause a few to go running or drop out as well. With colleges performing the courses, it won't be about experience but in some cases money and I have been involved in several other conversations where there are many that believe that with the right curriculum/degree program, BLS street experience prior to paramedic classes aren't necessary. I see both sides as valid and many use the example that doctors aren't paramedics, who become nurses who become doctors. It is also used to discuss the Paramedic shortage issue, which funny enough I think licensing paramedics could assist in many capacities to help the nursing shortage.

OoO...I do not know all the intimate details of the curriculums...however EMT-I's from what I know can intubate and start IV's and I believe manually defibrillate. Any additional skills some that have been there would have to elaborate. I'm not sure if they can do needle cric's or chest decompressions or not.

[ny10570 745]

ALS and others really covered this pretty well, but the one thing I wanted to emphasize is that Excellent BLS is much more important than so-so ALS. From my experience EMT-I's tend to be cookbook techs. They see a problem, administer treatments A, B, and C and transport. Often they don't really understand what they are doing and why. Its not their fault, its a lack of training. A greater emphasis on BLS in Westchester would make such a big difference. Get response times down and get some more medics getting the EMT's involved in patient care. Teach them assessment and show them not just what you're doing but explain to them why.

[ex-commish 490]

OoO...I do not know all the intimate details of the curriculums...however EMT-I's from what I know can intubate and start IV's and I believe manually defibrillate. Any additional skills some that have been there would have to elaborate. I'm not sure if they can do needle cric's or chest decompressions or not.

No chest decompressions allthough we were showed how to do them. Sticks and tubes under direct supevision of the medic. Only tubes I did were in the OR during rotations. And also manual de-fib.

[NYMedic37 22]

Does Ossining EMS still use EMT-I's? Any other EMS agency in Westchester use EMT-I's? I have a friend that is interested in the EMT-I program. Thanks

[JJB531 652]

Does Ossining EMS still use EMT-I's? Any other EMS agency in Westchester use EMT-I's? I have a friend that is interested in the EMT-I program. Thanks

The Ossining ambulances are all staffed with medics... an EMT-I could possibly practice skills with Ossining if the medic is comfortable enough to allow them to.

[IzzyEng4 427]

CT still has the EMT-I level and it is used alot in my area of the state. However, a few yeas ago they were looking to get rid of the EMT-I level and decided against it. Unfortunately, the New Haven Sponsor Hospital Program (Yale and St. Rapheal's) eliminated EMT-Is from their protocols thus only recognizeing MRTs, EMT-B and Paramedics. The rest of the sponsor hospital regions kept the EMT-I levels still. As of right now I am not certain what teh state is planing now.

[GAW6 66]

I am currently an EMT-I (since 1998) expiring in September and probably going to go back to being a Basic. As HFD219 said, we do not get many chances to use the skills. We end up driving the fly car to the hospital for the Medic the majority of the time. At least taking the course gave me the extra knowledge, and for that I am grateful.

[NYMedic37 22]

I am currently an EMT-I (since 1998) expiring in September and probably going to go back to being a Basic. As HFD219 said, we do not get many chances to use the skills. We end up driving the fly car to the hospital for the Medic the majority of the time. At least taking the course gave me the extra knowledge, and for that I am grateful.

My friend who is an EMT-I is looking to recertify her EMT-I but is having trouble locating an EMT-I refresher class. Where can she go?

[NYMedic37 22]

The Ossining ambulances are all staffed with medics... an EMT-I could possibly practice skills with Ossining if the medic is comfortable enough to allow them to.

Thanks

[NWFDMedic 58]

The EMT-I course is still around and I'd like to see it as a trial class for potential medic students. I took my EMT-I class in either 1997 or 1998, having 4 or 5 years as an EMT under my belt. I don't know if the class is taught similarly statewide, but my class was very intense and it taught a lot of the "why" behind the "what" that you learn in EMT class. I felt that the class was more valuable for the knowledge and assessment proficiency than the skills. If you don't like the EMT-I class, you probably shouldn't be thinking about medic school and wasting thousands of dollars.

In the Hudson Valley Region, an EMT-I can only operate within a paramedic system. Loosely translated, the EMT-I can only operate independently if the paramedic resource is not available. I had a couple of instances in multiple patient situations where I was allowed to operate independently as an EMT-I, including a flight job in a remote area where the next paramedic ambulance was going to be forever and a day away.

After I went to medic school, I joined a volunteer agency that was operating at the EMT-I level at the time with a mutual aid agreement from a commercial paramedic service. I found the EMT-I system to be more problematic than helpful, but that was largely due to the providers, not the system. When you give EMT-I's a few new tools, they like to use them, sometimes to a fault, causing delayed scene times with patients that needed an ER or a paramedic. I kept trying to stress that IV's don't save lives or improve patient condition, but we still had many providers that would sit on scene to get the stick.

On the good side, I thought the volunteer agency had some of the best patient technicians in the area. Also, at the time, the volunteer agency did not bill, so if it was a patient that only needed an IV and monitoring into the hospital, you would still meet with the medic, but the paramedic service did not bill if they did not treat. I'm sure that made a lot of seniors in the community happy.

So to end my long rant, I could really care less about the EMT-I skills. An IV isn't going to save a life and neither is an ET tube except in a few extreme cases. Where I think the state needs to move is toward the assessment level for an "ambulance attendant" to be at the current EMT-I level. Providers need to know a little bit more about patient care than an EMT class teaches if they are going to be entrusted with a patient's care to the hospital. The current EMT level is great for a first response agency, but I think the ambulance service needs something more. (I'm not knocking EMT's here, there are tons of EMT's out there that have the clinical experience and do a great job every day, but I don't think we prepare students in EMT class to go out there and assess treat patients.)