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EMT-B, EMT-A and Paramedic what's the difference?

Discussion in 'First Aid Station' started by smellypaddler, Nov 14, 2010.

    smellypaddler Loaded Pockets

    Hi Guys,

    I live in Australia where we don't have EMT's so I was wondering what the role, responsibilities and clinical skills for EMT's are.

    Where I live all Ambulances are crewed by 2 paramedics. Paramedic training is now a university degree course only and takes 3 years to complete. You then have a period of clinical probation when you gain employment with the ambulance service.

    We also have Mobile Intensive Care Ambulance (MICA) paramedics who have performed further study and training and work as a single unit to assist the 2 person road crews.

    Paramedics can administer various drugs and MICAs can perform chest decompressions and cric's.

    I'm intersted to know what it is like in the USA.
    MedicInTraining likes this.

    Rukus Empty Pockets

    It's been over 5yrs since I was certified, but EMT-B(asic) is the lowest level of certification.

    I'm not too sure about the EMT-A I think it stands for advanced , but the paramedics are the ones that can administer meds (IV's)

    My EMT-B cert was taken over the course of one school semester (16 weeks) and there was a test to be certified within my state only, or a more advanced national test as well.

    xneverwasx Empty Pockets

    I'm in the same boat as Rukus (lapsed EMT-B cert), but there are two levels of Intermediate EMTs: EMT-I85 (IV Technician) and EMT-I99. EMT-I99s can administer certain IV meds, administer/interpret EKGs, and perform more advanced airway techniques than EMT-:censored: (Paramedics generally have more advanced techniques/interventions than EMTs). The way things are out here (northern Wisconsin--Woods in BFE :p), almost all the Fire/EMS services are volunteer and don't have funding for full Paramedic-level care, so we make do with what we've got. Hope that helps. If you wanted more info, you can go to nremt.org, the governing organization for EMT/Paramedics in the States.

    lexmedic157 Loaded Pockets

    EMT-A was the old curriculum that is now EMT-B. EMT-A has since been phased out into First Responder (basic first aid, CPR, etc), EMT-B (all the first plus immobilization), EMT-I (intermediate, IV's, cardiac monitor rhythm recognition, and most meds), and EMT-P (paramedic, top EMS responder, some surgical techniques, med admin, and critical care interventions)

    Flight-ER-Doc Loaded Pockets

    Not quite.

    EMT-A or Advanced is the intermediate level of skill and training. EMT-B usually requires around 120 hours of classroom and practical training, EMT-A around 250 hours (more or less) and EMT-P (Paramedic) requires 800 hours or more of classroom and practical training.

    EMT-A and -P must be on duty (in most jurisdictions) to use their skills, because they must have medical control (a licensed physician who is responsible for their actions). EMT-B can perform their scope of practice at any time, but it does not generally include any invasive procedures (no IV's, drugs, advanced airway interventions).


    Hi lexmedic157,

    In Fla EMT -B is basic EMT -A is advanced. I have been an Emergency Medical Technician Advanced level for over 35 years first in NY now in Fla. The only issues that currently face advanced level EMT's in Florida is that we cant utilize some of our skills without a medical director. Years ago Fla used to also certify EMT-D (Driver), for this cert I had to maintain my EVOC (Emergency Vehicle Operators Course), Shakane, Slalom and Skid pad training. Since very few EMT's had access to all the training this cert was dropped.

    An example of this is that endotrachael intubation is now covered in Emergency Medical Technician Advanced training, however EMT's cannot perform this skil without a doctors orders. If anything, Basic has been all but phased out, as they now include all the advanced level training in the basic EMT classes and you get an EMT -A certification upon graduation.

    Advanced now includes a few minor skills like AED, ET intubation EPI pen etc... I just recertified for another 2 years through my work, I think I will recert until I cant do chest compressions anymore, then it will be my time to get ready to get them instead of giving them LOL.

    lexmedic157 Loaded Pockets

    Ok, let me preface this, EMT-A was the old curriculum for Virginia.

    smellypaddler Loaded Pockets

    Thanks for the replies. If you are sick or injured who are you most likely to have attend EMT-A, EMT-B or Paramedic?
    Also the doctors orders bit is a little confusing. If say you are certified to perform a procedure and your patient requires it what do you do? Do you have to get on the radio and clear it with a doctor first? How does this effect patient care and outcomes?

    On another note - who pays for the service provided by immediate responders? In my state you pay for ambulance insurance at $60 per year which covers you for all emergency and non-emergency ambulance services including helicopter rescue etc. I let mine expire once and required an ambulance and the bill was $1000. A friend of mine had a skiing accident a few years ago and his helicopter rescue and road transport was $9000

    medic2807 Loaded Pockets

    It really depends on where your injury happens, oddly. I think I have been at every level of the US EMS hierarchy (first responder, EMT-B, EMT-B with manual defibrillation (back in the day before AEDs. I'm dating myself there), EMT-Intermediate, and EMT-Paramedic. In rural areas, many EMS systems provide the basic level care. Most "larger" towns (ie, towns with a hospital) usually have a paramedic or paramedics. A lot of interfacility transfers require a paramedic to manage and maintain medications enroute. Big cities always have paramedic level care. Also, smaller EMT-basic ambulance services will often intercept or rendezvous with an advanced life support (paramedic level) service if the patient is unstable and requires more care, or call lifelight which provides advanced care. Ironically, a lot of your inner-city EMS systems have pretty simple advanced protocols. Hennipen County EMS (Minneapolis, MN) comes to mind. Also, Houston, TX and NYC EMS. They have a level one trauma center on every corner so there is no need to stay and play. Typically, your rural EMS systems have pretty advanced protocols because you might end up going out an hour to get a patient. I worked as a paramedic in a town of about 100,000 that did a lot of rural calls and interfacility transfers. If we were backed up next to an urban truck, their truck looked pretty empty, but well used.
    As far as medical orders from a doctor, again, depends on where you are. There is a wide breadth of skills that a paramedic can perform. The medical director (or committee) picks and chooses what the paramedic can do and how they do it. The level of medical oversight is variable as well. When I did my training, I interned with services in Iowa, Kansas, Minnesota and some services had very liberal protocols and didn't have to call med comm unless they had a question. Some services had to call for everything. Most protocols are written so that if there is a communication breakdown you can provide care up to your level of training. This could be technology related, weather related, or as simple as "Dr. Olsen is in with a critical patient (or bathroom) and can't take your call".
    Also, depending on the situation, your medical director may elect to dismiss the need to contact medical temporarily. When I went to the Gulf Coast after Hurricane Katrina, communications were non-existent. Plus, we were 2000 miles away from our hospital, so our already liberal protocols went completely cowboy.
    The shoe is on the opposite foot for me now. I am a physician assistant in a rural ER in North Dakota. Although I am not the medical director for the local ambulance service (only a physician can do that), I basically serve as the liaison (help with training, QA, etc.) due to that fact that I have been involved in EMS for a long time and the medical director is a family medicine doctor. And of course if I am covering ER, I am medical control. We don't require our teams to call for orders. They get the protocols pounded into their heads in ATLS, QA meetings, and during training so they have pretty liberal orders. And if you have to call for orders, things are going poorly usually, and calling is a pain. If things are really going sideways, they are always in contact anyway. I do have them call if they are on an interfacility transport that originated in my facility, particularly if they patient is vented, on drips, or is otherwise complex (chest tubes, etc.)

    As far as the helicopter issue, he was paying for the helicopter, not the responder. Those darn things are expensive to maintain.
    • In Omnia Paratus

    VinnyP Loaded Pockets

    In the UK we have Paramedics which is also a three year degree but they can also qualify via vocational workplace training and part time study. They can perform sugical procedures, IVs and administer certain meds. This is a protected title and you have to be registered with the HPC to call yourself a Paramedic. There will be at least one of these on any ambulance responding to an emergency these days. Additionally there are Ambulance Technicians who are being renamed to Emergency Care Assistants, these have a 6-9 week course followed by some on the job coaching. As the name suggests assist the Paramedic, monitor patients and deliver basic emergency care, this is the gateway occupation to being a paramedic via the vocational part time route. We don't have any prescriptive issues on who can do what and when (this includes lay people) and every case is looked at on an individual basis other than administering presciption meds which always has to be carried out by a clinician unless the meds are already prescribed for the patient.
    It's usually the other way around here, the courts will protect people who mess up trying to do good (No one has ever been succesfully sued or prosecuted for making a mistake when trying to save someone), but can be harsh if people don't do enough. Generally the more training you have the more you are expected to do and this can involve a duty of care.

    smellypaddler Loaded Pockets

    Medic2807, Thanks for the detailed reply that helps a lot with my understanding of the system over there. You are right in the fact that my friend was paying for the helicopter rather than the skills of the responder - he was charged by the minute for the chopper ride.

    I was wondering who pays for the ambulance in the USA if you need one?

    Looking at Flight-Er-Docs reply I was wondering if the 800 hours or more of training would be from start to finish or if it would be 800 hours plus the hours put into getting the EMT-B and/or EMT-A quals? I ask because the degree course here is 4 subjects per semester and each subject consists of 10 hours per week Uni and at home study. The three year course would consist of 2880 hours of study or approx 1300 hours of contact time study.

    lexmedic157 Loaded Pockets

    As far as I know most EMS providers are "certified" and not "licensed." The difference to me is that a certified provider has made the minimal requirements for the training. With this comes a pseudo "mother may I" approach where we act under the supervision of a medical director. This can be done by written protocols and online (telephone/radio) medical direction. Where I live we have pretty liberal protocols as they are regionalized (some may think it's crazy) and some agencies have long transports.

    Licensed providers may act in some circumstances under their own license but that allows the potential for medical malpractice suits. I think most providers are certified and are able to keep some of the lawsuits off of them. On a side note I know plenty of certified providers that carry malpractice insurance for a rainy day.

    Flight-ER-Doc Loaded Pockets

    It is a minimum. The US federal Department of Transportation (oddly enough) is the agency that writes the standards of training for prehospital providers, and they mandate the time, but it is modified (to increase the requirements) by state agencies and local education providers. Some require that you get an EMT-B cert and a year or two of experience before entering paramedic training, some don't. It doesn't make a lot of difference in the outcome, since the training is duplicative to some degree (CPR and bandaging are CPR and bandaging, after all). The fast programs that I know of usually take 6 months or so, full time, with 8 hours a day of classroom work and lots of home study, plus time spent in the hospital and usually 20 or so shifts as an intern with a paramedic unit in the field. Last time I checked (a few years now) the cost for these programs was in the range of $25,000 or so, but they are fairly easy to get into: Programs run through public colleges are harder to get into but cost far less. Here's one program in the Los Angeles, California area: http://www.mtsac.edu/instruction/tech-health/medical/emtparamedic.html. They don't charge a lot but require extensive experience first.

    There are college programs that offer a technical certification, 2-year or even 4-year college degree, and military programs that offer different add-on training opportunities.

    medic2807 Loaded Pockets

    One thing I forgot to mention is The National Registry of EMTs (NREMT). Many states (upward or 30 or 40) require paramedics to be nationally registered. You take their test and recertify to them. Most states (like here in North Dakota) require that, and then you send proof that you are nationally registered (certified) to the state to get a license. In Minnesota, however, you can get licensed by the state without being nationally registered (the reregistration requirement is easier that way). The nice thing about NREMT is with so many states participating, you have a chance to move around through reciprocity. I think all states have reciprocity if you are NREMT certified-correct me if I am wrong. Individual services may have other requirements to work. It gets complicated in some area. I know in California, cities, counties and municipalities all have their own rules, so the level of care can vary greatly from city to city.

    Flight-ER-Doc Loaded Pockets

    Thats true, but to take the NREMT exams you have to at least graduate from a state-approved (somewhere) program.

    And while California has statewide scopes of practice for all levels, counties can and do modify them - mainly silly crap like the definition of post-partum hemorrhage (which is truly asinine, since virtually nobody but surgeons and emergency physicians can estimate blood lost on the floor).

    lexmedic157 Loaded Pockets

    You mean that was only 50cc? It looked like 5000cc!

    medic2807 Loaded Pockets

    Meh. Most of them do a poor job of it as well.

    smellypaddler Loaded Pockets

    OK, so I kind of understand the system now but I still don't understand who pays for it. If you require an ambulance and you call it for yourself who pays the bill?

    I'm sure there are probably different rules if an ambulance is called for you by someone else if for example you are involved in a motor vehicle accident.

    Flight-ER-Doc Loaded Pockets

    It depends but ultimately either the patient pays, their insurance pays, the federal government pays through medicare/medicaid insurance, or the EMS system/ambulance company pays by not being paid.

    Jurisdictions that operate government (as opposed to private) EMS systems either pay out of tax receipts, or they try and collect from the patient or his insurance company.

    It's similar to the way I get paid. I'm (the medical group I am part of) an independent contractor to the hospital I work in. For a variety of reasons, I don't get paid for my professional services by about 1/3 of the patients I see. A federal law (EMTALA) in the US mandates that I see people, without regard to their ability to pay, however the federal government didn't arrange payment. These are patients that don't have any form of insurance (private, or public).

    So, I get to spend my own money on trying to collect from these patients. Some of these people are truly destitute, most are simply deadbeats that dont pay. My groups second largest accounts payable category (after payroll to the partners and staff) is collection fees, and we don't recover a lot. Mainly what we recover is through getting people signed up for various public insurance programs (medicaid), and recovering their payments. Occasionally we get standup patients that actually want to pay, we love those guys.

    Obviously, we all want to be paid for our services. To make up the difference between the payment we get from patients, and the deadbeats, the hospital itself pays us a certain amount. The hospital then increases their cost recovery from everyone they can - which leads to charges like $10 for a couple of aspirin. In short, everyone pays.

    And few hospitals are financially secure. Many are losing money, many go out of business, many are bankrupt.

    Nice of the government to 'help' out the destitute. Those patients that want to actually pay their debts? We can't (legally, under federal law) give them any discounts below the reimbursement rate for medicare. Thats because by law, medicare gets the lowest fees we offer to anyone: If we were to donate services to a particularly needy family, say, that is considered offering a lower charge, medicare would demand that we charge them that - and we can't live on free services offered.

    Oh, and just the cherry on top: Those patients that don't pay (at all)? They can and do still sue us for whatever they feel slighted about. My hospital had one lawsuit filed against them by a deadbeat patient because their (free) sandwich we offered them was stale. A drug-seeker (these are deadbeat patients that come in and try and scam us to give them narcotics, which they can either take, or sell on the street) who doesnt get the drugs can sue for malpractice, and lawyers will take the case on contingency (they get 1/3 plus expenses, which can result in their getting all of any settlement). We can pay off and save the cost of the trial and legal defense, or fight and even if we win, we still have the cost of the legal defense (and all the time we spend in court proceedings, depositions, discovery, etc is cash in the lawyers pockets, and time we can't spend with paying patients).

    It's a great system. And Obamanation care will be worse.

    medic2807 Loaded Pockets

    Here, here. I have no idea how the Obama Admin. plans to "reform healthcare" without decreasing the amount of lawsuits though tort reform. But, they don't plan on doing that. So we will all continue to practice defensive medicine. I scanned another Medicaid patient's head last night when all she was looking for as a shot and a bucket of Vicodin. I have a tendency to be more aggressive from a medical standpoint with people who can't/won't pay than with those who can. Those who can pay don't sue because it will require them to miss work...