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The Emperor's Clothes


For reasons I don't understand, I spent the past hour looking at comments on various online EMS lists and bulletin boards. Interestingly, I saw the same moaning and complaining that we did in the '70s and '80s. But as I looked at these entries, it became apparent that much of what we're still upset about are things that we have little possibility of changing.

A common theme was EMS system abuse. I agree that EMS system abuse is rampant and problematic. But it has been present since the dawn of EMS. There are no easy answers because the causes are complex -- poverty, ignorance, fear, substance abuse and the entitlement mentality that we have as Americans.

I've looked at numerous schemes to deal with EMS system abuse over the years, and none have worked. Such items as taxi vouchers, treat and release, telephone triage, and others are only Band-Aids on a hemorrhaging arterial bleed and certainly fodder for attorneys. The problem of EMS abuse will never be remedied until the root causes (poverty, ignorance, fear) are fixed -- and that won't happen until we have a Star Trek society. My advice in the meantime is to do the best you can with these people and move on.

Another common complaint was about volunteerism, and this isn't unique to EMS. The fire service is fighting over the same issue. There's a concern that volunteers restrict professional development in EMS and hold salaries down. I think there are faults in both arguments.

Professionalism isn't about pay but rather about behavior and ethics. I've seen many volunteer paramedics whose behavior was more "professional" than that of career paramedics. The argument that volunteers keep salaries down is also a reach. Volunteers generally do the work that a city or county government cannot afford to pay for. Stated another way, if not for volunteers, in some areas there would be no EMS at all. The jobs were never there and thus could never be taken. People assume that governmental entities can just open the books and find money. But these same people will rant about taxes when taxes are the primary source of government funding.

In addition, there's no way we can provide paid EMS and fire service across 100% of America. We have too much geography and too little money. Either we have volunteers or we have nothing. Which is best for humanity?

Also, when people talk about volunteerism in EMS, they forget about the attractions of the profession. EMS is exciting and rewarding, and many will do almost anything to get into the business (i.e., volunteer, take low-paying jobs, do dialysis center transfers). It's not the same in other professions. Nobody volunteers for yard work, but virtually everyone would volunteer to do something exciting.

Thus, again looking at the fundamental problem, as long as there are sparsely populated regions of the United State, non-paid EMS and fire (and police) will exist.

Ultimately, the root cause of the problems in EMS is reimbursement. Because EMS is somewhat new to many governmental entities, these entities haven't given it the same emphasis as fire, police and dog-catching. They try and farm it out to private companies and non-traditional funding schemes (PUMs) to get by. They don't want to pay for EMS because they see EMS as a part of the health-care system and people using the health-care system pay for it themselves (through insurance, Medicare, Medicaid or cash).

Most EMS people see EMS as public safety, but the governmental payers (Medicare and Medicaid) reimburse ambulances like health care -- not public safety. EMS agencies and companies can barely keep the doors open given the current reimbursement scheme. The same is true for emergency medicine. In many emergency departments, it would be cheaper to meet Medicaid patients at the door, give them a hundred bucks, and send them to some clinic (although it would be illegal and unethical). It really is that bad. And the same holds true for EMS.

While we all like to complain (it's our national pastime), talking about the issues we can't fix is akin to Hans Christian Anderson's fairy tale "The Emperor's New Clothes." The emperor is sold a new set of invisible clothes by two swindlers. When the emperor can't see the clothes, the swindlers tell him that people who are stupid can't see the clothes. Thus, being afraid of being stupid, the emperor wears his new clothes made from "invisible cloth" in a parade. It wasn't until a child pointed out that he was naked that he realized that he had been taken advantage of.

I'm not saying we're stupid. I'm saying that in EMS, we need to address the issue of the swindlers and not the clothes.


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