Administration and Leadership

EMS Must Be Fixed with Bulldozers, Not Tweezers

A couple of years ago I was honored to give the closing keynote talk at the Texas EMS conference. Texas is my home and it’s always good to see old friends from my days in EMS. The topic was a presentation on my 40 years of experience in EMS.

After the talk, I had long conversations with many of my former EMS colleagues about EMS then and now. The conversation always seemed to come back to the fact that EMS has not really changed that much. Pay is still quite poor and the system is basically broken.

We went back and forth about various ideas to make EMS better but, in actuality, they were same ideas we talked about over pitchers of beer 30 years ago.

This spring, I gave the closing keynote for the EMS Administrators’ Association of California conference in San Diego. The topic was my perspective on the future of EMS. This talk contained many of the thoughts that I initially presented in Texas. I had many of the same conversations with conference attendees in San Diego that I had in Texas. The issues are universal.

EMS is at a crossroads as is the U.S. healthcare system. If we don’t make some drastic changes, EMS will not improve and, in many instances, may not survive. Anything and everything must be on the chopping block as we look at strategies to improve EMS in the United States and to improve the lives of EMS providers.

The EMS Response System Must Change

I started my EMS career in my hometown of Fort Worth, Texas—first as an EMT and later as a paramedic. At that time, in the late 1970s, there were only six emergency ambulances for the city of Fort Worth.

We worked 24 hours on duty, 24 hours off duty and 48 hours on duty every other weekend. We only did emergency calls and worked extraordinarily hard.

The fire department often helped on motor vehicle collisions and had a limited first response role in other situations. However, for the vast majority of my career, almost every EMS response was handled by myself and my partner with a single ambulance.

Since that time, several things have happened. First, fire departments in the United States have become almost obsolete. Better building and construction codes, strict and comprehensive fire prevention codes, sprinkler systems and safer materials have minimized fires.

As fire departments found less and less to do, they began to look for other ways to serve the community. Often, it was as a first responder assisting EMS crews with initial care.

In many communities, ambulance operations were eventually assigned to the fire department because private ambulances were unable to provide the necessary services. In some communities, fire departments operate ambulances but typically don’t transport patients. For example, in Las Vegas, a 9–1–1 response will result in a private ambulance, a fire department ambulance and often a fire engine or similar apparatus. There may be up to six or seven paramedics on scene. The private ambulance usually transports and the fire department apparatus returns to service.

Short of an MCI or cardiac arrest, it’s unlikely that six or seven paramedics are required on any given EMS scene. Sending a million dollars’ worth of emergency equipment to a sick call borders on the absurd—and happens almost exclusively in the United States.

Some have decided to respond to medical calls with paramedics on engines. There is no scientific evidence that this provides any benefit for the patient. It also places wear and tear on high cost vehicles and is expensive.

The duplication of resources in an EMS response is costly, ineffective and dangerous. With firefighting all but eliminated in many situations, one must look at the entire public safety response in order to determine how best to use resources and serve the community.

Perhaps it is time to radically change the concept of emergency response. Since the vast majority of calls are for EMS, the primary role of the agency should be EMS calls. Certainly, there must be constant readiness and preparation for other typical fire department roles including firefighting, rescue and similar endeavors, however the majority of training and work will involve emergency medical activities.

Perhaps it is time to totally abandon the separation of firefighting and ambulance work and simply call the agency “emergency services.” This would unify fire, EMS and rescue operations under one roof and would not have the current degree of emphasis on firefighting that exists in most fire departments.

This is certainly a controversial thought given the long and historic role of firefighting in the U.S. The reality is that, in the 21st century, firefighting is an infrequent endeavor while medical emergencies continue to increase in frequency. Fewer than 10% of fire department calls involve fires. Some may involve rescue situations but the vast majority are EMS calls.

Not Everybody Needs to be Transported

As an emergency physician who works in two significantly different EDs in two different states, I can say with confidence that the number of patients with nonemergency conditions who present to the ED for care has increased significantly. There are certainly multiple reasons for this. However, there are multiple reasons for this. Unfunded mandates such as the Emergency Medical Treatment and Labor Act (EMTALA) require hospitals that accept Medicare to see all patients who present to the ED requesting care.

In actuality, EMTALA does not require the hospital to treat the patient but does require a medical screening exam (MSE) to determine whether or not a medical emergency exists. Once you have gone to the trouble of obtaining an MSE you may as well go ahead and treat the patient.

Some hospitals have started referring patients to a non-emergency area or requesting copayment when an MSE has been completed and the condition is determined to be non-emergent. 

However, because healthcare is generally legally risk-averse, most emergency departments just treat all patients and do not try to sort out the emergency versus the non-emergency conditions.

Regardless of the patient’s acuity, it is an opportunity to bill and a possible revenue source. U.S. emergency departments are generally in a constant crisis mode—often due to patients with minor conditions who can easily be managed in a clinic or similar setting.

EMS does not fall under EMTALA in most instances. However, because of legal concerns or contractual issues, EMS providers are told to transport all patients who want to go to the hospital regardless of the acuity of their condition.

This approach is not without risk. First, it is contributing to the overload of already busy emergency departments—especially in urban and suburban settings. Second, it is taking needed emergency medical response capabilities away from the community just so a patient whose car is not operating can go to the hospital for a refill of their seizure medications.

It is time that we establish evidence-based criteria, validated by multiple professional entities, that will allow EMS providers to screen non-emergent patients and ask them to seek other methods of obtaining transport to healthcare.

These patients can also be directed to urgent care facilities and similar facilities where ambulances cannot typically transport. Ridesharing entities such as Lyft and Uber are certainly options. We cannot continue to overload the current EMS system with non-emergent patients.

The costs are greater than people think. There is certainly equipment wear and tear as ambulances are used more and transport longer distances, but there are other costs. There is also wear and tear on the physical and emotional status of EMS providers. These are individuals who have spent their lives preparing to care for patients with high acuity conditions. Suddenly they find themselves becoming glorified Uber drivers for patients who think that their ingrown toenail requires a trip to the ED at 3:00 AM on Sunday morning.

This will require some legislative change to protect EMS providers from the current legal threats that often are used as a reason to require ambulance transport of patients who request it.

We Probably Have Too Many Paramedics

Over the last few years, the media has been filled with articles about the looming shortage of paramedics across the United States. In actuality, there is a looming shortage of EMS personnel—not paramedics.

When the EMS system was developed in the 1960s and 1970s, it was never envisioned that each ambulance would be staffed by two paramedics. As the system was designed, the fundamental EMS provider was an emergency medical technician (EMT) who had training in common BLS techniques.

Over the years, additional skills have been given to EMT providers. In the overall scheme of things, most patients transported by EMS will do quite well with EMT-level care. This is particularly true with the inter-facility transport of patients. The exception of course would be critically ill or injured patients needing inter-facility transport.

If you examine the EMS system operated by the Seattle Fire Department, often cited as one of the best systems in the world, you will note that the Seattle Fire Department employs only 76 paramedics, yet has 981 EMTs.

Of the 77,752 EMS calls that the Seattle Fire Department responded to in 2015, 74% were handled by BLS units. Only 26% required ALS care from a paramedic. By limiting the number of paramedics, Seattle was able to enhance paramedic education and significantly add to their skill set.

The perceived need for paramedics and the eagerness of young EMS providers to obtain paramedic education has actually had a detrimental effect. In terms of personnel, the provision of EMS is based on supply and demand.

EMS is an attractive occupation for many who will do the job for minimal pay in order to get the experience and the satisfaction that goes with the work. However, after several years in the business, it soon becomes clear that a paramedic salary is not enough to raise a family or buy a house, and people begin to look elsewhere for income sources. For employers, there is always a ready source of eager paramedics willing to do the job for the current pay—no matter how poor it is. I have seen this cycle continue for almost 40 years.

Many of the best and brightest in EMS have left for nursing, medicine, or something with better pay and hours. Ultimately, this has kept EMS salaries and paramedic education requirements in the United States relatively low when compared to other industrialized nations.

As stated earlier, there is a looming shortage of potential EMS providers. This is something that is not going to be easily fixed. Unfortunately, it is generational. Millennials, also called Generation Y, are those people born between the mid-1980s through the early 2000s. They have a keen interest in technology and are highly idealistic. They are also non-materialistic and do not function well in highly structured environments—such as EMS.

They were raised by helicopter parents and have a general disdain for menial work. Unfortunately, the characteristics of millennials are almost diametrically opposed to the characteristics needed for success in EMS. This is one of the major reasons that fire departments, police departments, EMS agencies and the military are having trouble recruiting members from this generational group. There is nothing about EMS that is attractive to members of the Millennial generation. Certainly, there is no easy fix for this.

EMS Education is Too Brief

EMS providers want to be bona fide members of the healthcare system—and they should be. However, EMS education at all levels is significantly below that of nearly every allied health profession.

It is possible to obtain “boot camp” EMT education in two weeks or fewer. In some instances, paramedic education with subsequent certification can be obtained in less than a year. Critical care certification, which in the United States is very nebulous, can be obtained with a few classes.

If one looks at EMS education programs in other industrialized countries, most paramedics will have at least an associate’s degree and many have bachelor’s degrees. EMT training is often a year-long diploma program and includes considerably more than the typical U.S. program.

Critical care education in most countries is limited to those who meet certain entrance criteria and who have a potential job. It is often a year or more in length and very intense in terms of educational requirements and clinical training.

Minimal education hours and the lack of true licensure as a healthcare profession has kept EMS salaries down and has kept many EMS providers from advancing in the house of medicine.

EMS Needs to be Self-Governed

One of the attributes of a profession is self-governance and self-regulation. Medicine, law, dentistry, psychology, nursing, and most other professions are regulated at the state level by a board of peers who oversee licensure and regulation of the profession. Ultimately, a physician is responsible for the care provided. As the most highly-educated members of the healthcare team, that will always be the case.

EMS is regulated by various entities that vary significantly from state to state. Licensure and regulation of paramedics and EMS in general should occur through a nationwide, peer driven governing body. A change like this will help raise the image and standards of EMS and will make it easier for EMS personnel to move from state to state and from region to region without significant obstruction.

It will also improve the reimbursement process. In several Canadian provinces, the transition to self-governance is already underway, and the same is occurring in other countries.

Self-governance and self-licensure at a state level will open up numerous doors for EMS personnel including the potential for more advanced education and practice aside from the standard out of hospital environment. This will certainly take a legislative effort and significant legislative support to occur.

Unfortunately, EMS providers in the United States are so fragmented that there is no one voice that speaks for all of them. Most firefighter EMTs and paramedics identify as firefighters first, and are organized around their associations or unions. 

Few EMTs and paramedics are members of the National Association of EMTs (NAEMT) or similar organizations.1 There are few state EMS organizations that have thrived and been effective. My home state of Texas, certainly one of the more populous states in the country, has been through five different EMS organizations in my 40 years of being a Texas resident. There must be a unified voice. If there isn’t, EMS will be trampled by numerous other professions and entities.


This essay, bordering on a rant, was written to stimulate thought and help people to realize that we in EMS must be the ones to fix the profession. Typically, strategies to fix EMS have involved a conclave of stakeholders who come together to address the issue. But stakeholders by definition are persons with an interest or concern in something—especially a business. They are there to represent their stake (e.g., business, hospital, union, political entity) and many times the general goal of these conclaves is lost to these self-interests.

It is time for people to put aside their biases and preconceptions and map out a reasonable, efficient and sustainable EMS system. It is time to admit that the current model, much like the current health care system, has failed.


1.      Bureau of Labor Statistics. (n.d.) EMTs and Paramedics. Occupational Outlook Handbook. Retrieved July 25, 2017 from