Energy, specifically energy from fossil fuels, is becoming increasingly scarce and expensive, and political and social pressures to constrain greenhouse gas emissions are intensifying. Energy scarcity, energy costs and emissions constraints are potential threats to all industries, enterprises, organizations and services—including healthcare.1 EMS is a vehicle-intense component of the healthcare sector and, as such, is particularly vulnerable to these interrelated threats.
Sustaining EMS systems doesn’t merely mean continuing to provide emergency services. Indeed, it’s unlikely that either economic or environmental pressures would lead to a complete shutdown of ambulance operations in any community. In this sense, sustaining EMS systems means continuing to provide both the quantity and quality of services necessary to meet the public health and medical care needs of the community.
Administrative activities, recruiting and hiring, professional development and education for clinicians, and equipment maintenance are just a few examples of non-patient care activities that might be viewed as “nonessential” and thus subjected to rationing as a result of constraints on energy consumption Yet, all of these activities, and others, are ultimately necessary to sustain the full spectrum of EMS activities, including the delivery of high-quality patient care.
Given the importance of EMS systems, it might be hard to imagine there would be any doubt about their sustainability; surely communities would always ensure the availability of necessary resources. Around the globe, however, the lay media regularly report cuts in public services, including police, fire and EMS departments. Nothing is sacrosanct!
This isn’t just fear-mongering. In 2008, delivery of diesel and gasoline to parts of the southeastern United States was interrupted, resulting in widespread fuel shortages. Although there were no published reports of disruptions to direct patient care services, some EMS operations were affected in other ways. In metropolitan Atlanta, ambulances had to source fuel from alternative suppliers;2 one system in North Carolina had to suspend community and employee educational programs.
EMS operations also continue to struggle with increasing fuel prices. For example, in British Columbia, Canada, price increases during 2008 added $6 million to the fuel costs of the ambulance service—a 50% increase that hadn’t been budgeted.3 In the U.S., one private corporation providing air medical services and aircraft resources in 44 states saw its earnings per share fall nearly 37% in part due to rising energy prices.4 Although neither of these operations ceased providing emergency services, financial resources had to be redirected from other activities to accommodate these fiscal insults. An Australian study of the operational impacts of rising energy prices found they were associated with distinct resource, performance and safety implications that potentially affect both EMS patients and personnel, including longer response times, decreased staffing and higher workplace injury rates.5
Concerned about these issues, a group of sustainability-minded medical and EMS professionals established the International Institute for Sustainability in Emergency Services (iiSES) in 2012. Currently, iiSES brings together representatives from Australia, the United Kingdom, Canada, the U.S., and the Republic of Ireland to promote sustainability initiatives.
According to Ian Blanchard, one of the founding board members from Calgary, Alberta, “A major goal of iiSES is to raise awareness of the issues in maintaining many of our ‘high performance’ systems in light of increasing population size, population aging, increasing coverage area size, congested road networks, unstable energy supplies and fuel prices, [and] increasing attention to carbon footprint.”
Recognizing that sustainability issues aren’t typically at the forefront of the day-to-day challenges facing most EMS systems, cofounder Seth Hawkins, an EMS physician from North Carolina, explains, “We aim to challenge the idea that short-term emergency services and long-term sustainability are incompatible or mutually irrelevant. In fact, sustainability might be the most important unifying concept for emergency services management in the 21st century.” More information about iiSES can be found at www.greenems.org.
What Do We Know?
There’s some data to help guide sustainability-minded EMS systems, but when discussing the energy burden and greenhouse gas emissions of EMS systems, some understanding of the terminology is helpful. Energy consumption and greenhouse gas emissions are often described in terms of “scopes.”
Scope 1 energy consumption and emissions refer to direct energy consumption, such as the burning of diesel in ambulances or natural gas in furnaces. Scope 2 energy consumption and emissions relate to purchased energy consumption, where the energy and emissions are generated remotely from the site of consumption, most notably electricity consumption. Scope 3 energy consumption and emissions relate to an organization’s or service’s upstream and downstream production, supply chain, and waste disposal processes. Finally, the “complete life cycle” represents the sum of scope 1, scope 2 and scope 3 energy consumption and emissions.6 Greenhouse gas emissions are measured in carbon dioxide equivalents (CO2e).
In North America, scope 1 and scope 2 greenhouse gas emissions for ground ambulance operations are estimated at 37 kg CO2e per response or 3.5 kg CO2e per-capita, with 75% of those emissions arising from scope 1 diesel or gasoline consumption. Air medical services are much more energy- and emissions-intense, with emissions of approximately 1 ton CO2e per flight. Although these figures might seem small on an individual response or per-capita basis, they do add up: Using population and ambulance response data for the U.S., this would total between 660,000 and 1.6 million tons of CO2e each year.7
Data for Australian ambulance services are remarkably similar to those for North American systems, with scope 1 and scope 2 greenhouse gas emissions of 35kg CO2e per response, and 5 kg CO2e per capita, with 60% of the emissions arising from the consumption of diesel fuel and gasoline. Of course, the Australian population is much smaller than that of the U.S., but aggregate emissions are still estimated at 110,000–120,000 tons of CO2e each year.8
Complete life cycle energy consumption and greenhouse gas emissions for EMS systems in North America haven’t been published, but in Australia they’re estimated at approximately 390,000 tons of CO2e each year.9 This is consistent with research from other service industries showing that scope 3 emissions often represent the majority of an organization’s environmental impact.
What Can We Do?
There are a number of strategies EMS agencies could adopt to reduce their energy consumption and greenhouse gas emissions and facilitate their adaptation to a lower carbon economy. These have been described in detail in a separate article,10 but are summarized here:
Reducing unnecessary ambulance responses and ambulance transports would be one possible strategy, as would limiting the use of air medical resources, whether rotor-wing or fixed-wing, to only those situations in which they’re demonstrated to provide some clinical benefit. The preferential transport of some patients to specialty centers could reduce secondary ambulance or air medical transports. More indirectly, prevention initiatives, such as those targeting heart disease and motor vehicle crashes, would have the dual benefits of improved public health and reduced demand for ambulance transport.
Modifying response time expectations would be another potential strategy. Meeting rigid response time standards for all emergency calls requires considerable resources in the form of vehicles, stations and personnel—even though very few emergencies actually benefit from rapid EMS response. Response time policies that allow responding to individual situations in the optimal amount of time, instead of all situations in a uniformly short amount of time, could reduce EMS system resource requirements, and thus energy consumption and emissions. Reducing driving speeds when transporting stable patients without life-threatening conditions to a hospital might also reduce energy consumption and emissions. Another strategy would be reducing ambulance idling at emergency scenes and hospitals, particularly given the extended off-load times confronting many EMS systems as a result of ED overcrowding.
A structural aspect of ambulance systems in particular need of research is the relative energy consumption and emissions profiles of fixed-station versus dynamic deployment staging strategies. While a fixed-station strategy has the added energy burden of stationhouses and usually longer response distances, a dynamic deployment strategy has the added fuel consumption of ambulances being constantly relocated to street-corner posts in order to minimize response distances and response times.
Technology-related strategies would include the use of hydrogen fuel cell, electric, or hybrid vehicles for administrative and support vehicle fleets. However, while hydrogen fuel cell and electric vehicles have lower scope 1 tailpipe emissions, their true environmental impact ultimately depends on local electricity generation processes. Similarly, the use of biodiesel would be a technology-related strategy, but biofuels aren’t universally carbon-neutral.
Reducing emissions from electricity consumption is another way in which ambulance services could reduce their environmental impact. Rooftop solar systems, adjusting thermostats in stationhouses and offices, ensuring lights and televisions are turned off while out of the station, and even reducing desktop printer idling are strategies that can significantly reduce consumption of electricity from the power grid. Advocating for “green” electricity generation, through solar, wind or hydroelectric generation, could have an even more profound indirect impact by reducing the emissions intensity of electricity production, and thus the life cycle energy consumption and emissions of EMS systems. Implementing environmentally friendly purchasing practices would further reduce ambulance system life cycle emissions.
It’s also important for EMS systems to evaluate any energy or environmental strategies they do implement. Energy and environmental conservation strategies that seem intuitive often don’t have the desired impact, and some can even make things worse—a phenomenon known as “rebound.” This is particularly true when considering the complete life cycle. For example, updating an entire ambulance fleet with high- efficiency vehicles might well reduce scope 1 diesel consumption and tailpipe emissions, but the scope 3 energy consumed and emissions created in the manufacturing, assembly and delivery of the vehicles can easily offset those gains.
Sustainability isn’t the most pressing issue facing EMS systems, but proactively addressing the energy and environmental burden of EMS agencies is the only way to ensure it never becomes the most pressing issue. Sustainability is not purely an environmental issue; there are financial implications to energy consumption that might be even more important for EMS systems. There are many strategies that EMS agencies can employ to reduce their energy dependence and environmental impact, but it’s important to evaluate those strategies after they’re implemented to ensure they have the desired effects.
1. Brown LH, Buettner PG, Canyon DV. The energy burden and environmental impact of health services. Am J Public Health. 2012;102(12):e76–e82.
2. Hess JJ, Greenberg LA. Fuel use in a large, dynamically deployed emergency medical services system. Prehosp Disaster Med. 2011;26(5):394–398.
3. Penner DE. (July 8, 2008). Rising fuel prices add millions to service costs. The Vancouver Sun. Retrieved Oct. 20, 2014, from www.canada.com/vancouversun/news/story.html?id=86254890-8f04-414a-8f92-43ad6cb3e40b.
4. Harlin K. (Sept. 18, 2009.) Air ambulance company rebounds from tragedies, high fuel prices. Investor’s Business Daily. Retrieved Dec. 7, 2013, from www.investors.com/NewsAndAnalysis/Article.aspx?id=506506.
5. Brown LH, Chaiechi T, Buettner PG, et al. Higher energy prices are associated with diminished resources, performance and safety in Australian ambulance systems. Aust N Z J Public Health. 2013;37(1):83–89.
6. Purman JR: Tracking Your Carbon Footprint: A step-by-step guide to understanding and inventorying greenhouse gas emissions. iUniverse Inc.: New York, N.Y., 2008.
7. Blanchard IE, Brown LH, North American EMS Emissions Study Group. Carbon footprinting of North American emergency medical services systems. Prehosp Emerg Care. 2011;15(1):23–29.
8. Brown LH, Canyon DV, Buettner PG, et al. The carbon footprint of Australian ambulance operations. Emerg Med Australas. 2012;24(6):657–662.
9. Brown LH, Canyon DV, Crawford JM, et al. Estimating the life cycle greenhouse gas emissions of Australian ambulance services. Journal of Cleaner Production. 2012;37:135–141.
10. Brown LH, Blanchard IE. Energy, emissions and emergency medical services: Policy matters. Energy Policy. 2012;46:585–593.