Administration and Leadership, Columns

Managing the Personnel Crisis in EMS

Issue 7 and Volume 42.

The future of EMS hangs in the balance and few seem to appreciate that the crisis is no longer looming-it’s arrived. Over the past several years, we’ve witnessed the convergence of workforce shortages, decreasing reimbursement, increasing bills associated with EMS transportation and worsening budget constraints which threaten the longevity of this “third” emergency service.

We’ve seen ad after ad for top-tier EMS systems in a perpetual hiring phase. Increased pay, sign-on bonuses and relocation support often help entice prospective paramedics to come to a new home.

Why do we continue to struggle to recruit and retain our workforce in this exciting field? Some will say that pay appropriate to the demands of the job remains lacking. Though many advocate for advancement of formal education requirements in order to justify significant salary increases for “clinician” paramedics, there’s also pressure to maintain the “technician” model of care.

The Challenge

Some arguments focus on ease of recruitment and affordability of a less skilled workforce. The workforce itself is divided on the issue, with some EMTs and paramedics focused on holding onto the public safety identity rather than accepting that the role of EMS is transitioning to one of healthcare delivery. The public safety model entices the workforce through the hope of advancements in administrative hierarchy, while the healthcare delivery model focuses on advancement of the clinical practice leading to increased responsibility and autonomy.

One of the key elements that we may be missing is that we’ve created one system and one path for entry into and advancement: Everyone enters the paramilitary-like EMS system as an EMT. During the indoctrination process, we stress the importance of the uniform, good driving, radio operations, stocking, cleaning and following the rules of the organization. We stress the importance of conformity while penalizing those who think independently. We work hard to quash those who buck the system and stray from the prescribed path. This stepwise approach of EMT to advanced EMT to paramedic has been the primary path of advancement so far, but it’s no longer effective at providing the workforce that our industry currently needs.

Without question, we need technicians within the EMS system and many of our personnel are well-suited for this essential role. Stations have to be managed, vehicles have to be stocked and cleaned, ambulances have to be driven by skilled professionals and clinical procedures have to be performed. We also have many medical emergencies that are suited to a highly protocolized, technician-based approach where procedural aptitude is critically important for success.

Technicians are critical to the operation of EMS agencies; however, we do expect them to transition to the role of a free-thinking clinician capable of managing complex situations and teams. Although a v fib cardiac arrest has a relatively straightforward algorithm, pulseless electrical activity and asystole arrests require significantly more evaluation, investigation and medical decision-making.

In that circumstance, we need clinical masters who can paint on a canvas that has no lines. The challenge is that the personality needed to be a master clinician is often not someone who’s tolerant of “arbitrary” rules. They often don’t respond well to task assignments that aren’t consistent with their level of aptitude.

The conflict between education, mindset and task assignment may be part of the stress that leads folks out of the industry and into other healthcare areas where independent thinking is welcome.

A New Approach

Perhaps the answer is to approach staffing with an aim to align roles and responsibilities with the personalities and skill sets of the individuals we recruit. We need folks who are focused on task completion in a rigid administrative framework. EMTs are focused on maintenance and management of the physical plant (i.e., ambulances and stations) while the paramedic is focused on maintenance and management of the patient and the clinical practice. When at the station, the EMT is focused on resupply, equipment maintenance and clinical skills training while the paramedic is focused on chart review, patient follow-up, review of medical literature and practice improvement.

This model is by no means exclusionary toward the advancement of technicians but like the military, perhaps we should consider that the technicians we enlist enter through a vocational route and clinician/paramedics enter through a collegiate route. Then, you have an alternate path that allows equipping technicians with the skills to become clinicians.

The future of the industry will be bleak if we continue to embrace only the technician model, which focuses on protocols directing our workforce to transport patients to the hospital while doing what you can along the way.

We need to embrace recruiting and educating clinicians who can be decision-makers with a medical education that goes beyond the current pattern recognition-based approach and diverges from the assumption that most patients will be transported. This realignment will allow us to recruit college-educated paramedics who can safely disposition patients, while we increase pay, increase autonomy and hopefully increase job satisfaction so that we can stem the hemorrhage of the EMS workforce.