evaluating allowing emt-ivs to administer naloxone, nitrous oxide as well as intraosseous infusions (ios). 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 four years for the emt-iv to transition to emt-advanced by way of an eight-hour course, choosing to let all emt-ivs and paramedics under the current standard be renewed as usual for this cycle. texas has a five-tier system, consisting of emergency care attendant, emt-basic, advanced emt, emt-paramedic, and paramedic. in virginia, the first level of als is advanced emt. the aemt certification replaced the emt-enhanced, unique to virginia, starting in 2013 and fully replaced in the emt-e certification in 2016. the emt-e was essentially equivalent to the emt-i/85 and could start iv lines, perform dual-lumen airway insertion, and administer some medications such as d50w, glucagon, albuterol, epinephrine, and sometimes narcotics, but could not administer any cardiac medications. the next level of als is emt-intermediate, which replaced the emt-cardiac technician beginning in 2002, and is equivalent to the i/99 level of certification. in most jurisdictions, the emt-i operates under the same protocols as a paramedic. there are a few procedures that only emt-intermediates cannot perform, including rapid sequence intubation, surgical cricothyrotomy, and needle cricothyrotomy. in 2020, virginia began phasing out the emt-i. existing emt-intermediates may continue to practice and maintain their certifications indefinitely, but no new certifications are issued. als certifications are now limited to either aemt or paramedic. in the state of washington, emt-basic protocols are similar to those in iowa. certified emt-b personnel can administer epipen per state protocols and can insert a combitube. the washington emt-b can set up and maintain an iv that is non-medicated, but emt-i certification is required to start the iv.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, naloxone, albuterol, and can now draw up epinephrine in addition to using an epipen. wisconsin offers licensure at the advanced emt level. this allows providers to start peripheral iv lines, pediatric and adult io lines, treat for hypovolemic shock, and administer naloxone, d50, d25, normal saline, d5w, d10w, d15w, narcan, tordol, zofran, tylenol, aspirin, glucose, glucagon, epinephrine 1:1000, and albuterol. this level of training is often used in rural 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 advanced emts for interfacility transports which only require iv therapy and do not necessitate the specialized advanced care of a paramedic.