Over the past 30 years, EMS has evolved from a mostly volunteer offshoot of medicine to a comprehensive system of early emergency care that s based on science, state-of-the-art care and high-technology procedures and has saved tens of thousands of lives.
"With the advent of more science, things that we used to do are not proving to be effective, while things that we never thought about 30 years ago are actually becoming mainstream," says Bryan E. Bledsoe, DO, FACEP, EMT-P, clinical professor of emergency medicine at the University of Nevada, School of Medicine. "The original emphasis with EMS, when it was developed in the 60s and 70s, was on cardiac care. Now, it’s gone so much further beyond that to strokes and trauma. It’s truly become a subset of the general house of medicine."
But EMS is also under pressure today in ways it has never been before. The profession is grappling with low job satisfaction and salaries, slow career advancement, reduced reimbursement rates, and controversial mergers between EMS and the fire service all within a changing and uncertain health-care environment.
As JEMS recognizes 30 years of publication, we felt it was appropriate to not only look back at how EMS has evolved over the past three decades, but also reflect on and understand the current state of the profession and where it might be in another three decades.
Pending Health-Care Reform
"I don’t think anyone has any insight into what Congress is going to send up to the president to sign," says Edward Dickinson, MD, NREMT-P, JEMS medical editor and associate professor and director of field service operations for the Department of Emergency Medicine at the University of Pennsylvania. "I’m sure that whatever is going to happen will be difficult for everyone involved because having uninformed, uneducated legislators write health-care reform is problematic from the outset."
Although he may be right, health-care administrators like William K. Atkinson, PhD, EMT-P, CEO of WakeMed Health and Hospitals, feel that health reform has already happened. "A certain amount of the entire health-care system in America has changed in the past 12 months," he says. "I think a lot of people are seeing what’s coming and are voluntarily moving in that direction, and the genie is not going back in the bottle."
Most are anxiously waiting to see just how broadly health-care reform will impact EMS. "We’re waiting to see what the last bill is going to look like before it goes to the president s desk because the Senate and House versions are so different from each other," says Gary Ludwig, deputy fire chief for the Memphis Fire Department.
Others feel that no matter the reform, EMS may still get lost in the crush for federal dollars. "When you’re looking at something as massive as health care, EMS is barely a blip on the radar screen," says Bledsoe. "Right now in this country, EMS is so disjointed that there’s no unified voice. Who speaks for EMS at the federal level?"
But there will have to be both dollars and reform for EMS, because the current operational model is clearly fraying around the edges. "Ambulance services and fire departments are being constantly pushed to add new technology to meet customer demand, but the reimbursement scheme is so bad they can’t justify [the expense]," Bledsoe says. "Cities are cutting back and laying off firefighters and EMTs, but they’re still trying to hold on to the same standards in terms of response times and care. You can stretch a rubber band only so far before it breaks, and I think EMS is right at that breaking point."
Another area of uncertainty and much controversy surrounds the growing trend of merging EMS with fire services. The idea is gaining traction and converts in many cities across the country. For some, it’s an idea whose time has come. Others see fire-based EMS as a way to further reduce EMS impact and power.
"One of the things that the fire service has done very well over the past 30 years is fire prevention," says Jay Fitch, PhD, founding partner of Fitch & Associates. "[Now] there’s significant interest in expanding the role of fire service among firefighters in providing EMS."
Ludwig is one such supporter of the model. "As the chair of the EMS section of the International Association of Fire Chiefs, I believe that it’s an excellent model of delivering EMS," he says. "I will continue to support that, while at the same time, honoring communities that want to do their own self-rule and self-governance."
Bledsoe cautions, however, that fire-based EMS agencies will work only if fire departments see EMS as more than just a revenue stream. "Fire departments have to fully embrace the EMS role and do the necessary training and practices to provide as good a quality EMS as they provide in fire suppression," he says.
JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, agrees, adding, "If the internal culture in a fire department EMS system does not readily accept and endorse EMS as its mission, that’s clearly reflected, and almost palpable, in the care its members render in the field."
Ultimately, many feel it’s not the model but the delivery of care that should be emphasized. "It’s not the fire service that makes or breaks EMS; it’s the culture of patient care," says Dickinson. "That model can take place in the fire model, the private model or the third-service municipal model."
For Atkinson, a seasoned adminstrator, it’s not so much about which agency is responsible, as which agency is capable of the responsibility. "There’s never going to be a uniform system of health-care delivery in the nation. There s no way you can do that when you have massive inner-city environments, frontier environments, and everything in between," he says. "It’s not win or lose; it will be the capacity to provide the service."
Job Satisfaction & Educational Trends
As EMS providers feel greater pressure to deliver better care with fewer resources, the levels of career and salary satisfaction have been eroding. "EMS providers have real challenges in regard to career advancement and opportunity," says Dickinson. "If you look at them alongside their police and firefighter brothers, the chance for career opportunity and advancement is abysmal. And until there’s equity, there will continue to be dissatisfaction and attrition in EMS."
Bledsoe also points to harsh working conditions as another reason for low job satisfaction and attrition. "The abuse of ambulance providers, the overcrowding of emergency rooms, the fear of litigation, and the drive for customer satisfaction puts [EMTs] in an untenable situation," he says. "You get to a point where no matter how much you like your job, when you’re not getting paid adequately for it, and when the hassles start to counterbalance the initial perceived things that you liked about it, then job satisfaction goes down."
Conversely, Ludwig points out that the fire service has better pay and benefits than non-fire service EMS. "Our people are paid pretty well, and they have pretty good benefits," he says. However, he acknowledges that boosting pay for non-fire EMS, although warranted, is difficult. "What [EMS providers] do is so important, and they aren’t compensated for the responsibility that they’re given," he says. "And I don’t see that changing right now."
Most do agree that continuing education is one path to enhancing salaries, which should also begin to raise job satisfaction. "Our educational levels, certifications and accreditations will create the basis and foundation for truly establishing us as professionals," Ludwig added. "Once you have that professional status, then the pay will come."
Wages will have to increase if EMS hopes to keep its most prized and talented EMTs and paramedics. Many fear that the ongoing attrition will bleed the profession of good people and the much-needed experience and wisdom the field desperately needs.
"Rarely do you see many gray-haired paramedics," Bledsoe says. "When you go into a major fire department, you don’t have any problem finding people with 30 years on the job, but in EMS you just don’t see it. And when you do it’s the exception rather than the rule."
Fortunately, many are recognizing the need for higher pay, better educational standards and on-going leadership development. But paying for training and giving personnel the time needed to pursue in-service classes and higher education degrees is another matter. With many departments stretched thin in manpower, it can be difficult to keep shifts covered and allow for class time. Still, most agree that continuing education is important.
"The education for EMS has never really been on par with other health professions, and it s the big Achilles heel for us," Bledsoe says. "The emphasis on enhancing education hasn’t really changed in 30 years, and it continues to hold salaries down."
Atkinson agrees. "I think EMS still has pretty low expectations educationally of the people who are providing emergency services," he says. "If you want to know how to orchestrate systems, and you want to do something about being part of a much bigger coordination effort, you need to know a lot beyond just the core skills."
To offset the problem, EMS will have to start placing a greater emphasis on education, training and professional development.
"We have an obligation to our patients at all levels to keep ourselves current," says Dickinson. "Education is important in pushing us forward."
Enhancing Transport Protocols
Perhaps one of the greatest areas of focus in EMS today is in transportation, especially in transport protocols, ambulance safety and redesign, but more work needs to be done. "Ambulance crashes are still our biggest source of liability in EMS," says Dickinson. "[Riding in an ambulance] is inherently dangerous. You still have an open box in the back in which to tend to the patient, and it’s hard to be protected in a crash, but we are making inroads."
Fitch agreed. "We’re making some headway in developing a higher level of awareness of safety all around," he says. "But we need to improve the work environment and the whole idea of thinking about safety from a different perspective."
Where big improvements are really needed, however, is in helicopter safety, which has been a growing problem.
"In the same fashion that we’re trying to design our ambulances to better protect our people, we also need to look at why helicopters are crashing and what we can do about it," says Ludwig.
As in many aspects of safety, the federal government will have to step in at some point to regulate medical helicopter operations, according to Bledsoe. "Helicopter operators are seeing the handwriting on the wall in terms of decreasing reimbursement, and they’re taking helicopters out of service and changing to single engine and smaller aircraft," he says. "The system is so out of control that the only thing that s going to fix it is federal regulation." (Editor s note: For more on helicopter transport issues, read "Critical Decisions," p. 84.)
Atkinson also sees transport protocols changing in fundamental ways as agencies leave certain districts or merge with others. "As a result of reform, the medicine external to EMS is going to drive very different patterns of transport and treatment," he says. "You’re going to have to move a lot of equipment from district to district to cover [areas during] long transports, so we’re heading toward agencies having to interlock their hands in cooperation."
The Need for EMS Awareness
If EMS is to thrive, most agree that heightened awareness by, and communication with, stakeholders will need to be paramount. "We have to understand that part of the adversity we’re facing today, both financially and politically, has to do with the fact that we have let people think of us only when they re dialing 9-1-1," says Fitch. "That s a systemic as well as an organizational issue that has to be addressed in the coming years, or we will not exist."
Bledsoe agrees. "EMS is one of those things that people don’t think about until they need it," he says. "Then when they need it, they have expectations that a lot of times paramedics can’t meet."
Reaching out to the community in more effective ways, and better communicating the value of EMS, will enhance the profession as a whole and allow outsiders to see the real value that EMS brings to the table. And despite the challenges that EMS will face in the coming years, many EMS leaders are excited and hopeful for what the future may hold.
"There are people out there who are capable of making all of this work, and making it work for EMS," says Atkinson. "But we've got to put the fear aside. I think the opportunities for emergency-oriented people to get involved are greater than at any other time."
Ludwig echoes the sentiment. "What you have are truly dedicated people who are committed to helping others in their time of need," he says. "When I see people in EMS do what they do, it inspires me." JEMS