Is a New Federal Agency the Solution for What Ails EMS?

On the June morning this was written, two subcommittees held a hearing in Washington. The Subcommittee on Emergency Preparedness, Science and Technology and the Subcommittee on Management, Integration and Oversight are both part of the House of Representatives’ Homeland Security Committee. They came together to examine the subject of “The National Training Program: Is Anti-Terrorism Training for First Responders Efficient and Effective?”

Testifying at this hearing were representatives of law enforcement (New York Police Commissioner Raymond Kelly, National Sheriff’s Association WMD Committee Chair Patrick McGowan) and the fire service (the North American Fire Training Directors’ Steven Edwards, and National Fire Academy Board of Visitors member Jack Reall). The Congressional Research Service’s Government and Finance Division had a seat at the table. So did the VP of Research and Economic Development from the New Mexico Institute of Mining and Technology. Notice anyone missing?

Darn right you do. Last time we checked, EMS providers were first responders too. And they probably have some interesting and pertinent thoughts on whether antiterrorism training for first responders is efficient and effective.

This is just the latest instance of EMS being overlooked, even when the discussion is specifically about emergency response. It’s nothing new. We all know about the initial exclusion of nonfire EMS from the Assistance to Firefighters (FIRE Act) grants, and we’ve all heard that EMS got just 4% of the first responder funds awarded by the Department of Homeland Security in 2002–03. We’ve all heard the aggravating references to “police and fire” when political leaders or news media talk about the importance of emergency preparedness and response and those who protect our nation’s citizens. We’ve all felt the snub of being forgotten. Nobody likes it.But as far as changing the situation and gaining public recognition of the role of EMS, well, we haven’t got very far. For too many of the people in power, EMS is still painfully, infuriatingly, simply not on the radar screen.

Getting it there is imperative. If and when the next big one hits, the EMS providers who respond in those first critical moments will need state-of-the-art training and equipment just like their police and fire counterparts. Lives will hinge on their preparedness. And just ask them—they’re not prepared. When the Assistance to Firefighters grants were opened to nonaffiliated nonprofit EMS organizations this year, nearly 1,600 of them applied, seeking a total of $138.6 million—more than 10 times the $13 million available. These applications included $77.5 million for operations and safety programs and $61.1 million for vehicles.

And that’s just part of it. The needs go far beyond readiness for terrorism and major 9/11-style disasters. In many places, routine delivery of everyday medical care is in increasing jeopardy. Rising call volumes mix combustibly with provider shortages. Equipment and gear are lacking. Standards vary. Data to describe the scope of problems and point the way to possible solutions are insufficient. EMS, almost anyone will tell you, is in trouble.

So with all these problems, what do you do? How do you get the help you need? How do you raise the profile of EMS with leaders and decision-makers and prompt them to deliver the money, policies, nurturing and care necessary to fix what ails this vital industry?

Destination DHS?

The Homeland Security Policy Institute (HSPI) has an answer. In May, the HSPI, part of The George Washington University, released an issue brief titled Back to the Future: An Agenda for Federal Leadership of Emergency Medical Services that called for a reevaluation of how EMS is handled at the federal level. It suggested that the best solution is to transfer federal control of EMS from the National Highway Traffic Safety Administration (NHTSA) to a new EMS Administration to be created under the Department of Homeland Security (DHS).

“Without appropriate representation and integration into the federal government’s first responder activities,” the report’s authors concluded, “EMS issues will continue to go unaddressed, and lack of policy coherence and funding will continue unabated.”

The report was prepared by a pedigreed task force that included providers, chiefs and educators from a variety of services and institutions, supplemented by physicians, lawyers, emergency managers and emergency-response policy experts. (It is available at https://homelandsecurity.gwu.edu.)

Back to the Future follows previous high-profile efforts that reached similar conclusions. In its fifth and final report, completed in December 2003, the Congressional Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction (more commonly known as the Gilmore Commission) determined that a beefier federal office was needed to support EMS and help ensure its sustained funding by Congress. The Rand Corporation issued a comparable call that same month. A year before, Project USEMSA (U.S. EMS Administration), a task force aimed at achieving similar goals, was launched.

To many, the time for such a dramatic switch seems ripe, and DHS may even be open to it. Said Secretary Michael Chertoff in March: “Old categories, old jurisdictions, old turf will not define our objectives or the measure of our achievements. Bureaucratic structures and categories exist to serve our mission, not to drive it.”

Certainly, the HSPI report touched a lot of nerves. A storm of articles, press releases and commentary has followed, both pro and con, pushing the debate about how to best help EMS to levels rarely seen.

“Most important, what this has done is created a discussion on EMS issues that heretofore has not existed,” says HSPI Deputy Director Dan Kaniewski, cochair of the task force that produced the paper. “We’ve highlighted many issues that, as you can tell by the opinions on both sides, have been simmering for a long time.”

What Back to the Future proposed was two significant changes: One was moving EMS’s federal home. The other was enlarging the scope of federal involvement in EMS.

NHTSA’s involvement in EMS and its capacity for setting policy, as most readers know, is limited. Its EMS office is small and, by federal standards, not especially well-funded. This, to a lot of observers, is the key problem. NHTSA’s scope and charter just don’t allow it to give EMS the kind of federal help it needs.

“We’re 30 years into the system, and where are we at with federal support?” asks Paul Maniscalco, an adjunct assistant professor at GWU and past president of the National Association of Emergency Medical Technicians, who also cochaired the HSPI task force. “If something’s not working correctly in its current configuration, then it’s incumbent upon us to figure out how to fix it.”

Fixing EMS is a tricky business. Its mission is part healthcare, part public safety, even part public health. It’s certainly much more than traffic safety. So if NHTSA’s not the place best suited to tackling the whole varied range of problems facing EMS, the question becomes, what is?

Back to the Future cites the DHS’s mission to “minimize the damage from potential attacks and natural disasters.” DHS, it notes, developed and administers the National Incident Management System, which “emphasizes interoperability and prescribes the role of EMS in the incident response template.” EMS, it argues, is a vital component of homeland security, and DHS leads the nation’s first-responder efforts.

True, there hasn’t historically been a powerful medical component to DHS. But for a profession with the essential character of first responder, advocates say, that’s where it fits.

“If you look at the federal structure, the place where the discussions take place about how we’re going to deal with the scenes of major incidents is the Department of Homeland Security,” says Chris Callsen, a division commander with Austin-Travis County (TX) EMS, who was part of the HSPI task force. “When I go out tonight to do a street command shift, I’ll be seeing people at hospitals on and off. But I’m going to see police officers, firefighters and paramedics a lot more. When I’m responding to incidents, those are the people I interface with. That doesn’t lessen my linkage to the healthcare community, but I’m much more strongly tied, on a day-to-day basis, to the folks with whom I actually manage incidents on the scene.”

Callsen, who was also a leader of Project USEMSA, notes that there have been healthcare entities moved under DHS—for example, the National Disaster Medical System (NDMS) and Metropolitan Medical Response System (MMRS)—and also that the Department of Health and Human Services (HHS), which might seem a logical option for an EMS home, seems to have its hands full with hospital issues these days.

“The pre-facility management of casualties is no longer within HHS,” he says. “They seem to be focusing their efforts on things like surge capacity and facility issues. That’s not a bad idea, because there’s huge work to be done there, and that’s a different animal than prehospital management. There you’re talking some huge infrastructure issues and other things that are going to take a lot of time to solve.”

So if DHS is the right federal home for EMS, how does that translate to funding, equipment and other EMS needs?

Roughly put, proponents say, the answer is visibility. An EMS Administration would have to be funded each year by Congress. It would have a chief, comparable to the U.S. Fire Administrator, who would put a face on EMS and advocate for it in policy and funding discussions, articulating the needs of street providers. It would institutionalize EMS in the federal government in a more high-profile way than NHTSA has, and it would facilitate its integration into everything else DHS does (grants, planning, training, etc.). Basically, they say, it would prevent EMS from being ignored. Everyone in Congress wants to be seen as strong on homeland security; if you tie EMS to homeland security, the dollars—at least more than 4% of them—will theoretically follow.

The Patchwork Quilt

This is a reasonably easy idea to get one’s arms around, and in the few short weeks since the HSPI report was released, backing for it has been broad. Numerous state and national EMS organizations, including the National Association of EMTs (NAEMT), have endorsed it (see Table 1).

Support has not been universal, however. In fact, several major EMS players are pushing other plans (see Table 2).

Prominent among these are constituents of Advocates for EMS, the umbrella lobbying/education group representing such organizations as the National Association of State EMS Directors, National Association of EMS Physicians and National Association of EMS Educators. In a joint statement released two days after the HSPI report, those three groups agreed that EMS needs “high-level executive branch attention,” but said moving it to DHS is “the wrong solution to the problem.”

Instead, the Advocates groups proposed creating an EMS office in DHS and the passage of legislation to formalize and strengthen the Federal Interagency Committee on EMS (FICEMS).

“We think if they could put an EMS office in DHS, to provide the leadership on issues like homeland security and terrorism preparedness, that would be preferable,” says Advocates President Mary Hedges, executive director of the Minnesota EMS Regulatory Board. “At the same time, we would like to see better coordination among existing agencies, because there are so many that are already involved in EMS.”

Indeed, there are numerous agencies and organizations throughout the federal government that have fingers in the EMS pie. In HHS alone, you have the Centers for Medicare and Medicaid Services, the Health Resources and Services Administration (HRSA) and the Office of Rural Health. That’s also where the CDC resides. NHTSA, in cooperation with HRSA, is handling the National EMS Information System (NEMSIS) data-gathering project and supporting a National EMS Resource Center to help state and local systems with data collection and analysis. Would those efforts move if the office moved? And even if EMS weren’t under DHS, the U.S. Fire Administration and FEMA are, and they will remain inextricably linked to any equation through fire-based EMS and disaster planning and management.

“EMS has enjoyed a more-than-30-year history of multiple federal partners,” says Dia Gainor, Advocates’ secretary and director of the Idaho EMS Bureau. “We keep warm under the patchwork quilt of federal agencies that have an interest in developing and advancing EMS systems. We benefit as a result of myriad interests and issues those various federal agencies have, without dependence or reliance on a single lead agency.”

Wherever EMS goes, it’s surely important to keep all these people and programs connected and involved. And the plan for a stronger FICEMS to bind them all has the advantage of a head start in Congress: On June 22, the Emergency Medical Services Support Act, introduced by Sen. Susan Collins (R-ME), was approved by the Senate’s Homeland Security and Governmental Affairs Committee. If passed into law, it would formally establish FICEMS and mandate participation by NHTSA, the Office for Domestic Preparedness (or ODP, part of DHS), HRSA, the CDC, the USFA and more. Another recent report, from New York University’s Center for Catastrophe Preparedness and Response, supports this strategy.

“It’s the first time that FICEMS’s role will be defined, clarified and prioritized as an expectation of those federal agencies,” says Gainor, also a past president of the State EMS Directors. “I think it will elevate what we’re already experiencing from our various federal partners. It will give them a common table at which to reconcile their various interests, to ensure there aren’t competing priorities, to ensure there’s a complementary nature to grant programs, to ensure that states aren’t being pulled in different directions.”

Collins’ bill would also establish an advisory council, consisting of providers from “all sectors of the emergency medical services community,” to help guide FICEMS’s actions. A companion bill is in subcommittee in the House.

On the DHS side, Reps. Bill Pascrell (D-NJ) and Bennie Thompson (D-MS) offered an amendment to the Homeland Security appropriations bill in April that would have created an EMS administration in the department, but the idea was shelved pending additional research. However, Project BioShield II legislation currently in the Senate would create an Office of Medical Readiness and Response in the DHS, with an assistant secretary in charge. And in a reorganization plan for the department released in July, Chertoff created a new Chief Medical Officer position under the DHS’s Preparedness Directorate. This officer will coordinate the department’s reponse to biological events and serve as a liaison to other federal medical entities. It’s not particular to EMS, but it’s a significant addition of a formal medical component to Homeland Security—and interestingly, the position will be filled by NHTSA administrator Jeff Runge, MD.

Questions

Supporters of these respective plans have some questions about the alternatives. While acknowledging the homeland security aspect and funding problems facing EMS, opponents of the DHS administration idea wonder if important medical/healthcare aspects might suffer under a department with an essential charge of public safety.

“How much do we put under DHS, and how much do we leave where it is?” asks Hedges. “We’re not purely one discipline. One questions how well the DHS would be able to incorporate that health aspect.”

“If you asked ‘Are we healthcare, or are we public safety?’ I expect most people familiar with EMS would answer healthcare,” says Gainor. “Look at what happens at any emergency scene. If it’s a crime scene, the public safety aspect is handled by law enforcement. If there’s a threat to the environment because it’s a hazardous-materials incident, the fire department handles that aspect. EMS is focused on patient care. Yes, we interface with public safety, but ultimately, we’re a healthcare entity. We’re taking care of patients. I’d offer to those who believe the Department of Homeland Security is the right home for EMS, why not HHS? What about the Surgeon General? The U.S. Public Health Service?

“If it were the right place—organizationally, philosophically, culturally, procedurally—then we’d see the majority of state EMS offices based in their states’ equivalents of the Department of Homeland Security,” she adds. “They’re not. The vast majority are based in states’ departments of health.”

DHS proponents agree FICEMS would still be necessary even with a U.S. EMS Administration, but contend that it, alone, would be insufficient for solving EMS’s problems.

“I don’t think the idea of a FICEMS is bad, but there has to be somebody in the federal government who actually takes a leadership role in EMS and is accountable for it at the federal level,” says Callsen. “Right now no one’s accountable. It’s a small line item in everybody’s budget, and it certainly isn’t at the level of an assistant secretary or an administration chief anywhere. So while a concept like FICEMS can be effective, if nobody owns it, nobody’s going to take the lead, and what you end up with is a bunch of people sitting around with no direction.”

“The problem with FICEMS is that it’s not going to change anything for frontline providers,” says Kaniewski. “FICEMS is a coordinating mechanism. It is not, in any way, shape or form, a way to increase EMS stature at the federal level. It doesn’t have the resources. An advisory board is just that: It advises. It’s an interagency group that brings together leaders. But to think that’s going to have the same effect—the USFA has many advisory boards that advise the administrator, and the administrator carries those policies out with funding that the agency and Congress provide. Who’s going to carry out the policies FICEMS proposes? Who’s going to fund them? Who’s going to take ownership of that?”

The EMS Support Act specifies that NHTSA would provide administrative support to FICEMS, but doesn’t officially put it in charge. And having someone in charge does seem important—we’ve all seen good ideas languish and die without funding or implementation. On the other hand, merely having that person or agency in charge isn’t in itself an assurance of success. “Close examination will reveal that the U.S. Fire Administration has done little for the rank-and-file firefighter,” EMS journalist John Becknell suggested in a June column on www.MERGINET.com. “Tough police and fire unions have made a difference in those public services. Many of the issues facing EMS field providers…have resulted from a weak EMS labor movement, not a lack of representation in the federal government.”

A labor voice even half as strong as the IAFF does seem like it could benefit EMS. But that’s a story for another day.

Additional Options

While FICEMS and the DHS are the major options presently in play, there are some other notions about a federal home for EMS that haven’t received as much recent debate but merit at least a brief mention in any comprehensive discussion.

HHS seems a logical fit for any entity with a character that’s largely medical. A number of participants in various listservers and discussion groups have raised this as an option. But as previously noted, HHS’s prehospital involvement has been diminished with the move of programs like NDMS and MMRS to Homeland Security. HHS folks also have their hands full with hospital, Medicare/Medicaid and other issues.

A number of leading fire-service organizations responded to the HSPI report with a letter to Chertoff pointing out that the report did not include alternative proposals to a new agency, such as “working within the framework of the U.S. Fire Administration…to address EMS concerns.” Their letter didn’t specifically propose formally putting EMS under the USFA, but for many, especially in nonfire EMS, it raised the specter. And there’s no doubt that whatever is done with EMS, the fire service, which provides a lot of it, will have a say.

“EMS calls are becoming a greater percentage of fire departments’ mission, and we need to make sure that’s reflected in this discussion,” says Ken LaSala, director of government relations for the International Association of Fire Chiefs. “We’re not opposed to some kind of restructuring of the EMS system, but we want to make sure it’s done correctly. Things need to be looked at a lot more closely. We think some of the things in the GWU report are questionable. With the idea of a separate EMS agency, our chief concern is, how is that going to affect the voice of fire and EMS within the Department of Homeland Security? Just because you add another office doesn’t mean they’re going to end up, at the end of the day, with a greater voice for EMS. It may be that you end up minimizing it, because instead of having one voice, you have two. When the first-responder community, especially fire and EMS, can show a unified voice, it works better for Congress.”

At this point in the discussion, money really comes into play. The fire service seeks federal funds just like EMS does. It, too, says its needs aren’t being met. Would a U.S. EMS Administration necessarily come at the expense of the fire service?

“A big question for us is the private, for-profit EMS,” says LaSala. “Nobody wants to end up in a situation where the private folks take over that office, and all of a sudden federal money is being used to subsidize private EMS companies. That’s a big concern among a lot of our members. How is this going to affect us, and who’s going to end up influencing it? We want to make sure that whatever structure comes out of this represents all of EMS and doesn’t just end up as a voice for the for-profit companies.”

Supporters of the DHS plan are emphatic that they don’t want to carve their slice out of the fire service’s pie. Fund the fire service adequately, they say, but find the funds to take care of EMS too.

“Nobody wants the fire service’s money,” says Maniscalco. “The fire service fought long and hard for that money. If anyone involved in this were to say, ‘We’re going to take $100 million from the fire service,’ we’d say ‘no, that’s unacceptable.’ You’re never going to achieve national readiness if you’re always robbing Peter to pay Paul.”

Kaniewski points out that if EMS were taken from NHTSA and given to DHS, the operating budget that funds it, meager though it may be, would come along.

“The $3½ million EMS budget NHTSA has right now should be taken and placed into DHS, rather than forcing DHS to fund EMS out of its existing budget,” he says. And in the future, if DHS funds grants for EMS, fire-based systems should get their share. “If the fire service makes up about half of the EMS community,” Kaniewski adds, “they would be eligible for about half of any funds that come out of it. In my view, it’s an additional pot of money.”

There’s also the inescapable fact that many in fire-based EMS have historically felt like the proverbial redheaded stepchildren—that their mission is less valued than the fire mission, even as EMS calls soar and fire-suppression calls decline. Could the USFA effectively serve the EMS interests of not only combined departments, but also privates, third-services and volunteers?

For a lot of EMS folks, it would be a hard sell.

“Put this in the U.S. Fire Administration, and it’ll get a little bit of lip service for a couple of years, but eventually, the people running it won’t focus on EMS issues,” says Callsen. “They’ll focus on the issues that their primary and original mandate requires—and, frankly, that they have the most interest in—which are fire-suppression issues.”

Lest the debate here devolve into another round of “Should EMS be part of the fire service?” the HSPI authors emphasize that they’re not taking a position on how EMS is best delivered at the community level. A DHS administration, they say, would benefit EMS across the board—third-service, fire-based, private or volunteer.

“This isn’t about how EMS should be delivered at the local level; that’s a local decision,” says Maniscalco. “There are multiple models, and they can all work effectively if you do three things: value the mission, resource the operation and respect the people.”

Finally, what of NHTSA in all this? Opinions vary on how beneficial it has been for frontline providers.

“Coming from the state EMS office perspective, I see, regularly, the things that NHTSA’s doing,” says Hedges. “Granted, its EMS Division is small, but it’s been incredibly productive for its smallness. Many of us feel they’ve shown a lot of leadership and support. They’ll be establishing the new national database [NEMSIS] there in a few months, and they’ve worked with the folks at HRSA and the Department of Health and Human Services where EMS issues come up. That’s been incredibly productive.”

Still, as GWU adjunct associate professor Dan Gerard noted in a listserver discussion of the subject in May, NHTSA’s EMS Division has a staff and budget that are smaller than those of some cities. Congress and the Department of Transportation haven’t done much to enhance it either.

Says Callsen: “NHTSA and the DOT—and not the EMS folks at NHTSA, but the Administration as a whole—if they really thought EMS was a big priority, they could have been finding ways to increase its focus within their spheres of influence, if not before, then certainly post-9/11. But we haven’t seen much of a change. We haven’t seen people at the table talking about how we protect EMS providers, how much grant funding they’re getting, how they’re able to provide care for contaminated casualties. Haven’t heard word one.”

Could a bulked-up NHTSA, with more money, people and authority, solve some of EMS’s problems? The option hasn’t gotten much attention in the recent debate, but some wonder.

“If they funded it properly and gave it some new direction, NHTSA might work,” muses NAEMT President Ken Bouvier. “They’ve just been tucked away for so long, and that’s why people are saying we need a change. I agree that we need a change, but I don’t think that idea is going to come up, to be honest.”

“[NHTSA EMS chief] Drew Dawson is a good man, and he does outstanding work,” agreed Gerard in his listserve post. “I would like to see what would happen if we gave him a decent amount of money and staff to accomplish the job that needs to be done.”

Spokesperson Elly Martin said NHTSA officials believe their administration’s office has served EMS well, but that they had no comment on the HSPI report.

Open Ears?

An elephant-size variable in all of this is Congress. Any change in the way EMS is handled at the federal level will of course require the approval of senators, representatives and, barring an overridden veto, the president. So what are the prospects for change on the Hill?

Depends on whom you ask. Some say flatly that the major fire-service organizations—with their powerful voice and established Capitol connections—won’t let a separate DHS administration happen. Others aren’t so sure, and can even name influential lawmakers who purportedly have open ears to the plan.

“If this thing is a DOA,” one asks, “why are the people who aren’t involved on the street fighting it?”

“That [report of Congressional interest] is accurate,” says the IAFC’s LaSala. “We’ve heard from Congress that they’re interested in addressing the issue.”

Congressional Quarterly also reported in June that the spirited debate generated by the HSPI report had caught the attention of members of the House Homeland Security Committee, which may hold a hearing on the issue.

On the FICEMS front, Collins’ bill will now move on to consideration by the full Senate. Identical legislation she introduced last year also cleared committee before stalling.

Whichever option interested EMS folks prefer, this is the time for that old reminder about making your voices heard. If you want change, tell your elected representatives about it. Otherwise, it’ll be others deciding your fate.

From the Bottom Up

There’s a bit of a proletarian-feeling nature to the whole movement for a DHS administration. Its supporters believe it’s the best way to help Joe Field Provider, the neglected EMT on the street, and that’s where a lot of its support seems to come from.

Once the HSPI report came out, a number of employee associations quickly endorsed it, and Kaniewski says surveys have consistently shown support from frontline providers ranging between 75%–95%. In an unscientific Web poll conducted by this magazine (see Table 3), 61% of respondents agreed with it.

“I think the momentum is among folks who provide the prehospital phase of EMS, who actually provide services,” says Callsen. “For a long time, EMS personnel have felt like they were left out of the majority of the discussions about where the future of EMS was going. Even fairly far back—look at who was in the room in the 1970s talking about EMS. It was all either federal people or nurses or physicians; there was nobody in the room who actually represented the folks providing the service on the street. To a certain extent, I think we’re still in that same situation.”

The voice of the EMT and paramedic on the street is NAEMT, which, in a vote by its board of directors (some members of which were also on the HSPI task force), supported the idea of a single high-level federal EMS agency. That’s meant a bit of political stickiness for its leaders: NAEMT is also a constituent of Advocates, and other key Advocates members, with whom NAEMT works closely on many other issues, oppose the plan. But NAEMT, Bouvier says, took the position its members wanted.

“It’s a complex issue, and there are a lot of stakeholders,” he says, noting that the desirability of a stronger NHTSA is just a personal opinion. “A lot of our people feel that for the past 35 years, EMS has not got what it deserves, and that while NHTSA may have been the right place to house EMS many years ago, some people believe we’ve long outgrown that. They feel there’s a need for somebody to take the lead now and properly fund it. Right now, people are thinking that money will come out of the Department of Homeland Security.”

To get a more scientific grasp of what its members really want from a lead agency, NAEMT will hire an independent company to survey them. “What do we expect that federal agency to be able to do for us? That’s what our survey is going to try to capture,” Bouvier says.

Naturally, there are some street-level providers who don’t favor the DHS plan. But a lot of the early high-profile opposition, it seems, has come from those higher up: state directors, physicians, the big fire-service organizations, etc.

“There’s a perception,” says Callsen, “that there are groups out there that feel they have an ownership of EMS that is not reflective of the fact that they don’t provide the service. And it’s not that groups like the state directors, the educators and the physicians aren’t valuable. But I think what you’re seeing is that the folks who get up every day and get into the ambulance are saying, ‘You know what? We should have a voice in this too, and our voice should be pretty big, because we’re actually the folks doing the work.’”

That was the voice HSPI wanted to represent, Kaniewski says.

“Because EMS is made up of so many different constituencies, it’s difficult to have a consensus on big issues,” he says. “We realized going in that if we tried to involve all the EMS organizations and all the fire organizations and everyone else who wanted a seat at the table, we never would have come up with a solid recommendation. We were committed to having a true cross-section of the EMS community—fire-based, hospital-based, line providers, chiefs—so it’s not that we weren’t taking all of the perspectives into account. It’s just that these people represent not just EMS organizations, but the frontline EMS providers we consider to be the true experts. It’s a bottom-up, rather than a top-down approach.”

There’s certainly a lot of appeal to the notion of charting your own destiny. But as a state director, Hedges offers that maybe those higher-ups see a bigger picture that’s not readily apparent to the average EMT in the field.

“I understand that folks want more visibility for EMS at the federal level,” she says. “And the initial reaction from the person on the street when they hear about creating this in DHS is, ‘Oh, fantastic, this is what we need!’ It’s something that, on a gut level, you want to support. But then you get into the details, and you have to ask if it would eliminate some of the things that have been working. If you put it all into a public-safety and terrorism-preparedness type of agency, is that really going to benefit EMS?

“In some ways, EMS being in a lot of different places has strengthened it. We don’t want to overlook that richness of the variety of sources that come into play with EMS. We just need to make sure they’re talking to each other.”

Gainor also points out that EMS is much less standardized, from place to place, than law enforcement or the fire service. States handle EMS, and they handle it differently. In the quest for self-determination, she warns, beware a one-size-fits-all solution in which disparate creations are squeezed into the same box. What might be best for your agency, in other words, might not be best for everyone.

“Something that’s fundamentally different about EMS, as opposed to fire and law enforcement, is that it’s a healthcare system that’s regulated at the state level,” she says. “We’re a different creature by design, in the same way that states regulate hospitals and the practice of medicine. It’s a state-specific issue and a state’s prerogative to determine system evolution, standardization, policy initiatives and so forth.

“If there’s to be a regulatory component to a lead agency, that’s ground we would have to tread on very carefully, given the incredible diversity of the healthcare challenges faced by EMS systems. We’d face battles in Congress, as opposed to battles in state legislatures and decision-making at the local level that accounts for the idiosyncrasies we face at patient-care scenes.”

Conclusion

Reconciling the variety of interests and opinions expressed in this debate won’t be easy. Whatever happens, some people are going to end up unhappy. But nearly everyone agrees that one of the next steps needs to be geared toward getting folks at least closer to the same page.

“It would be amazing to get together some kind of national forum, and get the folks that have been most vocal into a room to start talking through these issues,” says Callsen. “Let’s lay them on the table and figure out how we can find common ground. Truthfully, I don’t think we’re all that far apart on what the goals are. I think people differ on how they think those goals can be reached.”

“We need to define the problem,” says Gainor, “because I’m not confident that the problems have been sufficiently identified to conclude that a single lead agency is the best solution for EMS systems nationally. Let’s get at a table, with all the partners who have spent all or part of the last 40 years working to improve EMS systems, to discuss, deliberate and prioritize the problems affecting EMS systems in this nation and then start strategically identifying solutions—one of which may or may not be a federal lead agency for EMS.”

Summits and forums and meetings have been tried before, of course, and here we are, still fractured and squabbling and poor. But at the very least, the tenor of the discussion has changed now. There are fairly concrete ideas on the table, and all of the best minds of EMS—at all levels—are engaged. In the long run, there has to be benefit to that.

“The thing that amazes me most about all this,” says Callsen, “is that no matter what happens, we’ve probably had more productive discussion about EMS issues at a national level in this country in the last six weeks than we’ve had in the last 10 years, if not more. People are actually engaged in the discussion. No matter what side of the issue you’re on, the discussion’s amazing. From my perspective, that can’t be anything but good. It raises awareness, it puts issues on the table that need to be resolved, and maybe it will help us craft a national direction for EMS.”