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By Dan Limmer

On July 1, 2024, the NREMT will implement its redesigned ALS exam. On this date, there will no longer be a psychomotor exam, the expanded scenario questions will move from pilot to live, and students will be required to complete student minimum competencies for skills, patient types, and team leads.

Are we ready for this transition? I don’t believe we are.

The AEMT level of certification has always been a series of contradictions. It is an ALS level that is rarely used to its full potential. Pass rates nationally are dismal. Educators frequently miss the target in content—especially in vital areas like pathophysiology, clinical content, critical thinking, and application of those advanced skills. In a way, we are stuck in the old EMT-I mentality. The AEMT certification level needs a significant jumpstart.

Is the ALS redesign enough to fix AEMT? No. But it’s a start.

We won’t have issues on the paramedic side of the ALS redesign. There is already an SMC (student minimum competency) and structure through accreditation. Whether you like accreditation or not, it has taken the paramedic level of certification and made it a tight ship. Voluntary accreditation for AEMT will begin in 2025.

Will we embrace accreditation for AEMT programs? I hope so.

The Problems with AEMT SMC

We are putting a lot of weight on the SMC for AEMTs. We have a few significant problems brewing—and I’m not sure anyone is paying attention. Consider the following:

  • The AEMT SMC, spearheaded by NASEMSO, hasn’t been released. It was approved by their education council earlier this year. EDIT: NASEMSO released the SMC in August. Review it here.
  • The NREMT is requesting feedback on adopting the AEMT SMC (23-Resolution-03) , due on August 8—and we haven’t seen NASEMSO’s SMC yet. (I provided this feedback officially to the NREMT.)
  • According to the information presented at the poorly attended AEMT accreditation session at Accreditcon, the AEMT SMC contains reasonable and specific skill and patient categories, allows some content to be achieved through simulation, and requires the student to have successful team leads. It will up the ante for many programs—and require more hours and coordination.

This article is written in early July 2023. Classes likely to require using the AEMT SMC will begin in about six months. Many programs will have to adjust clinical hours; this may involve changes in credit hours or presentations to colleges’ curricula or advisory committees. States, which it appears will ultimately be responsible for oversight of SMC adherence, haven’t created their SMCs and distributed policies. Some states will likely have to change rules or existing laws—which will take time. And time which is relatively short.

While the NASEMSO task force has created a consensus AEMT SMC, it also appears that the NREMT will allow states to make their own. As we learned from the paramedic accreditation for registry eligibility kerfuffle, some states want to take the easy way out. Word from state officials I spoke with indicates there is still some discussion within NASEMSO about the AEMT SMC.

Moving Forward with AEMT Accreditation

We have the opportunity to improve the AEMT level of certification. The SMC isn’t enough. We need higher standards in educators, education, exams, and record keeping. We need a tighter ship like we have at the paramedic level. I recommend the following:

  • The NREMT adopts the NASEMSO AEMT SMC as required. Don’t leave it up to the states. States can always require more. We are starting a process that makes AEMTs different from state to state, moving us farther from the progress of the EMS Compact.
  • The NREMT and States work together to begin the process of making accreditation at the AEMT level mandatory in 2030.
  • The CoA recognizes that AEMT accreditation differs from paramedic in scope, cost, and time. Keep the standards high. Keep the cost and the process reasonable.
  • We recognize there is much more to do to salvage and resuscitate the AEMT level to create the functioning (and passing) levels we need in EMS.

I can hear the cries now. We won’t be able to get AEMTs! The process is too much work!

I have news for you. The pass rate for the NRAEMT is barely above 50% for the first attempt. We aren’t getting AEMTs now—and many of the ones who pass still lack education and clinical experience. Our education is substandard for what we need and expect from these providers.

It’s time to recognize that we have a fundamental education-expectation mismatch, and we need to step up as a profession to fix that, even if it is painful.

Join the discussion 2 Comments

  • Michael Hunter says:

    Dan, I agree with most of your comments. I’m a Program Director of a CAAHEP accredited Paramedic program. I also think we need a voluntary accreditation of EMT as well, but that that’s another debate. I have never been a fan of a mid-level provider. I believe the AEMT was flawed from the beginning. If we want to make a change, we should consider the AEMT becoming the EMT level. But back to the subject. I’ve seen a draft NASEMSO SMC. I think the most difficult part of the SMC is the clinical and field internship portion. I already have difficulty placing my Paramedic students in clinical experience. The internship is problematic because at a Paramedic ambulance provider, the AEMT student will never truly be able to be the Team Leader because in many cases the Paramedic will need to take over care so they can provide Paramedic level of care. So the AEMT student is stuck “assisting” the Paramedic. I totally agree with your last statement in the article that there is an education/expectation mismatch. The current AEMT level lacks proper anatomy & physiology, pathophysiology, and pharmacology in the 2021 National EMS Education Standards (NES). The NES are mismatched to the skills listed in the 2019 Scope of Practice Model. Finally, the NREMT should not allow states to create standards that are less than a national SMC. The states are subject to the whims of politicians who think they know how to solve the workforce problems. I believe our workforce problems are rooted in the educational system that can potentially have 50 different iterations and no mandated national standard. Thanks for listening to my rant. 🙂

  • Klaus Reinhardt says:

    I’ve worked beside, first, EMT-Intermediates, then Advanced EMT’s, for longer than many people who read my writings are alive. In my opinion, the Advanced EMT level could not die a death, fast enough. I believe the Advanced EMT model is flawed, unless, some (actively) EMS Physician Supervised (education and provision of medical care) EMS operations have been able to demonstrate a meaningful purpose and use of Advanced EMT’s.

    By far, nearly every Advanced EMT who I have worked with is near-useless; there is nothing “Advanced” about them, other than they have a tool chest with interventions and therapies, that, collectively, between their flawed implementation by the Advanced EMT, and the alleged merits of the interventions and therapies, that, in my opinion, serve no useful purpose. What I routinely encounter (almost all of the time), are Advanced EMT’s who have awful assessment and critical decision-making skills, flawed decision making, and a sense of priority and technical skills that are equally flawed. I am yet to see an Advanced EMT perform an acceptable assessment, or history and physical. Instead, I watch these EMT Advanced “go in for the kill,” by rushing to perform “Advanced” interventions. Nearly every time that I have observed this, the Advanced EMT has gone to an Advanced Intervention, before they performed an adequate assessment. In my opinion, these people are frightening, and the public and community officials have been deceived that there is something useful about Advanced EMT’s, when in fact, they are “monkeys.” Clearly the “organized fire service (IAFF)),” has used the Advanced EMT position to leverage additional pay. I don’t know the specifics, but it seems that the private ambulance sector has found a way to bill the public and commercial payers a higher rate for an EMS encounter, in which the patient is “tended to” by an Advanced EMT. And, sadly, there are a large universe of so-called EMS Medical Directors who sign off on the deployment and operation of these Advanced EMT’s, and who do not adequately (medically) supervise them.

    In the state where I work, hospitals have been provided a menu by the State EMS Office, to enable them to determine what patients can be transferred between facilities by an EMT-Basic, Advanced EMT, Paramedic, or Critical Care Team, based NOT on the clinical knowledge and acumen of the crew, but by a menu of “skills that those personnel can perform.” Routinely, I see patients transferred between facilities by personnel who are grossly inadequate for the position they are in, and the patient that they are responsible for caring for. In the same state, the “Sending Physician,” who has responsibility for “their patient,” and the medical oversight of the “transferring ambulance crew,” do not care about the patient between facilities, and are not the least bit concerned about “their patient,” or the responsibility that they accept as the “Transferring Physician.” Finally, in the same state that I work, there is a fire department that has decided to replay the TV show “Emergency” in their wet dreams; their firefighter personnel race to the scene, to quickly perform Advanced EMT treatments, before they’ve even assessed their patient; rumor has it that there is a “financial bounty” for those non-transport fire personnel, for the Advanced EMT treatments that they perform. Those non-transport fire personnel are not medically supervised; they operate in No Man’s Land, in terms of medical oversight, or the (medical) efficacy of what they do or don’t do.

    Then there is the case of a former State EMS Director, turned politician, who advanced the EMT-Intermediate model, turned Advanced EMT model, under the false premise that these people do some good to patients. Any day, I’d take a competent, skilled EMT-Basic, over an Advanced EMT.

    As I said above, in my opinion, the Advanced EMT level of certification/licensure, could not die a death, quickly enough (hopefully, before the patients that these EMS “TECHNICIANS, ” NOT CLINICIANS, kill them (their patients)).

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