The Failure of EMS

The concept of an EMS system has failed. After 40 years, it is time to admit defeat. The concept of an EMS system has failed. After 40 years, it is time to admit defeat. While the idea of providing an organized system of advanced out-of-hospital care was a good one, internal and external forces have led to the imminent failure of the EMS system in America. I, for one, am glad, because the system as it is currently structured cannot work.

This collapse was about 20 years in coming. When I started EMS in the 1980s, there was a lot of hope for the industry. I grew up in an era when BLS ambulances were nearly 100% volunteer outside of large cities, when first aiders were transitioning into EMTs, and when statewide paramedic coverage was an almost-realized dream in New Jersey. It was also an era of mobile intensive care nurses (holy cow! a decently paid career track with options), a strong tradition of volunteer crew chiefs with a decade of experience mentoring new cadets, and a billing system that let paramedics bill enough to cover the costs of operating the paramedic system. It was far from perfect, but it seemed to be moving ahead.

Twenty-three years later, when I talk to colleagues from my era about their experiences, I hear a common refrain: "I thought being a paramedic was going to be a real job." Instead, we have regressed into an EMS system that is only interested in cost, not quality; that equates certification with competency, with no field training and supervision; EMS providers (both career and volunteer) who work an endless series of 60-hour work weeks; no upward career mobility; and McJobs (no pension, no benefits) instead of careers. How did things go so wrong? I have a few ideas. 

1. The public has never understood what we do.

Until we jettison the acronyms that mean nothing to the public (EMT, BLS, etc.) and focus on using the term "medic" for all ambulance providers, we will never have a consistent public image. A SWAT police officer is still called "officer." We also need to be the ones who talk to the press about accidents involving injuries and fatalities. The police are not the ones who cared for the patients--we are.

2. We let Medicare pay for calls, but not the EMS system.

When Medicare changed its payment rules seven years ago, we let them fundamentally change from paying for patients' pro rata share of system costs to paying for the actual cost of the transport, stranding a huge percentage of overhead costs if your agency has a normal level of utilization. We did not make it clear to our elected officials that they would need to pay the rest. We also accepted mandatory coverage from Medicare, which meant that systems had no reason to compete on quality, only cost, since their payment remained fixed.

3. We let other disciplines do our jobs.

Where I worked, I constantly heard the EMT crews complaining about the career fire department, yet on the scene, they always let the firefighter/EMTs carry the patient. I will say it in no uncertain terms: Do your own job. Fire takes care of fire and rescue, police take care of law enforcement. If it involves injury prevention, safety or health, it is EMS' job. Carrying patients, teaching injury-prevention programs in schools, installing child car seats and decontamination are all patient safety-related issues and clearly the role of EMS.

4. We never asserted control over emergency medical care.

It is great that your community firefighters and police are EMTs and respond quickly, but providing care is our profession and we have a right to regulate it. Generally, communities should have sufficient EMS resources to be able to respond anywhere in the community within minutes. But where EMS permits fire or police to provide emergency medical care, it should be only under our direct control for care, oversight and quality assurance.

5. We never stood up and said, "No more McJobs!"

In the Northeast, the volunteer EMS ethic is that "this job is so important, I'll do it for free," yet inexplicably, when they begin to transition to a career system, they do not think that EMS is important enough to pay career staff a fair living wage (with benefits and pension) to do it. To be fair, this is also prevalent in the private ambulance sector, but at least they can point to a profit motive. The reason paramedics have to work a 60-hour week is that you need 60 hours to pay your rent, and nobody in EMS thinks that's crazy. If we all quit our per-diem jobs tomorrow, salaries would correct themselves within six months.

6. We need to admit paramedics and EMTs are not the same.

EMTs are technicians with less than five weeks of full-time training (significantly less than the police or fire academy) who treat symptoms. Paramedics are professionals with at least 50 weeks of full-time training who treat a diagnosis. With the new curriculum, there is no longer even a continuum of education from EMT to paramedic. This is important for one key reason: It artificially depresses paramedic wages, because there are so many more EMTs in any bargaining group. This undermines a graduated pay scale that would pay paramedics significantly more and pay for their experience. Without it, how can we ever expect to retain good paramedics when their long-term wages are depressed by EMTs? The primary reason we lose so many great EMTs, who choose not to become paramedics, is because the money just isn't there in the long-term.

7. We abandoned the concept of the mobile intensive care nurse.

I've never understood why we created paramedics in the first place in an era that also saw the development of specialized critical-care nursing. In New Jersey, and in many states across the country, almost every paramedic program had nurse preceptors for years. Nurses specializing in out-of-hospital care were quite common until the early 1990s. I never actually saw a paramedic work in the field until I began my clinical rotations. If we shifted to a three-year community college MICN program, we could ensure both a decent wage scale and true career path for medics (and it would solve #6).

8. Volunteers are fine, but the year-to-year mind-set is not.

EMS is a complex business, with eight-minute response times within your community, a stock that is both critical and time- and temperature-based, burdensome regulatory requirements and continuing education for your staff. Who the hell told you that you can manage all this without a business plan? Without short- and long-term multi-year goals? Without strong management support for a volunteer labor force? Volunteer EMS organizations, even more than career organizations, need career managers with a multi-year business plan mind-set or your organization is going to fail. Even the Red Cross has career people who manage volunteer staff.

9. Regardless of our employer, when we do 9-1-1 response, we have not said that we are public safety.

After 9/11, I had the privilege of working with George Contreras and Richard Fox to try to secure federal line-of-duty Public Safety Officer Benefits for all of the municipal, hospital, private and volunteer paramedics and EMTs who died during that event. That experience really opened my eyes to the inequality faced by medics across the country. We are not public safety because of who our employer is; we are public safety because we respond to the public's calls to a public emergency number. That is a critically important distinction.

Summary

In summary, the problem is us. While we have become very good at blaming everybody else for our troubles, in our hearts, we must think that EMS is not all that important. If we did, we would be fighting like hell, working together and pounding our fists on the table.

As it stands now, most of the talented paramedics I started with 20 years ago are no longer paramedics. Some got hurt, some died, some burned out, and many of the rest work part time, because they love EMS, but need careers to make livings for their families. It is painful for me to say that EMS is not a career, but it is not. It is also painful to see the EMS system, which I do value and once had great hope for, collapse, but it is. While many of the problems I have identified have fixes that could be implemented now, I understand that most will only be implemented when the system collapses. And that can't happen too soon for me.

Scot Phelps, JD, MPH, EMT-P, CEM, CBCP, MEP, is an associate professor for the Emergency and Disaster Management MPA in the School of Public Affairs and Administration at Metropolitan College of New York. He has served as assistant commissioner for Emergency Management at the NYC Department of Health and Mental Hygiene, as a hospital emergency manager, and as a professor of emergency medicine at George Washington University School of Medicine.