There has been a great deal discussion, of late, related to a shortage of paramedics in the United States. It is often debated, and there are deniers, as well as believers. However, the data are clear in that fewer people are entering EMS when compared to a decade or two ago. The reasons are debatable but include such things as poor pay, working conditions, schedules, work type, and cultural changes in younger individuals and their belief systems. Many lament this but it may actually be the opportunity needed to drive EMS to the next level.

At a most fundamental level, the term “shortage” refers to a state or condition where something needed cannot be attained in sufficient amounts. From a business standpoint, it is the difference between supply and demand. A shortage can be rectified by increasing the supply of the necessary product. It can also be rectified by decreasing demand for that product. This is the basis of this discussion.

The evolution of EMS United States has been chaotic at best. Certain parts of the United States have had a very organized approach to the provision of EMS while others have appeared almost random. Initially, we would place one paramedic on an ambulance with an EMT. Later, two paramedics were placed on an ambulance. Then, for reasons that are unclear, we started placing paramedics on fire trucks and other non-transport vehicles. The concept behind this was that early advanced life support intervention would save lives. However, other than defibrillation, early advanced life support care has not been associated with increased survival (as demonstrated in the OPALS study and similar research). The push to put paramedics on virtually every emergency response vehicle has contributed to the decrease in the number of available paramedics for general emergency response.

Photo: National Highway Traffic Safety Administration

As I have written previously, the city of Seattle through their Seattle Fire Department has maintained a world-class EMS system with a limited number of paramedics. Most care provided to the citizens of Seattle by the Seattle Fire Department are provided by EMT-staffed ambulances. These are backed by a cadre of highly skilled paramedics who respond based on acuity and other indicators.

Perhaps it is time that we reevaluate the modern U.S. EMS system. The shortage of paramedics, whether real or imagined, is the best time to evaluate this. First, as much as I hate to admit it, we do not need as many paramedics as we have. Most ambulance transports can be accomplished without risk by two EMTs or an EMT and an AEMT. This is particularly true in urban areas where transport times are short and there are numerous hospitals and other receiving facilities. The enigma, however, is rural America. I have always said, as have others, that the further one lives from established healthcare facilities, the more sophisticated EMS must be. However, this concept has always been held back by the lack of funding, the limited availability of paramedic education, and the limited opportunities to perform higher-end skills in rural communities thus resulting in skill decay.

As we go forward, I think it is unreasonable to expect a paramedic on every ambulance in every community. As stated, most urban ambulance services can be staffed by EMTs or an EMT and AEMT. Paramedics should be available in every community but on a much more limited basis, similar to Seattle. Paramedics should be strategically placed based on prior usage data and geography and may simply respond in non-transport vehicles such as fly cars or in specially equipped ambulances that carry additional and more sophisticated equipment. They can respond to higher-acuity conditions on initial dispatch or can be summoned by EMT crews after initial contact. Paramedics would more be a part of the healthcare system, as occurs in some areas in New Jersey, and the EMTs would remain a part of the public safety system as currently common.

We would expect the next generation of paramedics to be well educated in healthcare and to hold a college degree. They would have an expanded skill set that would go beyond simple 911 response. They would have the ability to treat and release low-acuity patients without fear of legal recourse and provide healthcare on scene that would not necessarily require physician and hospital-based care. Such things as treating minor infections and repairing lacerations can be completed by the paramedic with subsequent referral for monitoring and follow-up. This would keep the paramedics busy performing healthcare and could conceivably decrease the patient load on already overburdened emergency departments. Routine transports and non-advanced life support care, which is majority of what occurs in EMS, would be handled by EMT providers and routine ambulances.

I would suggest the following:

  1. Paramedics would be health care providers with a very limited public safety role. They would have college degrees, have a diverse education and have a better understanding of the basic sciences. They would have an enhanced skill set and would be a part of a health care system more aligned with a hospital or similar facility. They would not be in a primary response role, except for previously defined calls where ALS skills are immediately needed.
  2. EMTs would be public safety providers who would handle the majority of EMS care and transport. We would abandon the current concept of basic life support and advanced life support and look specifically at the tasks needed for adequate care and then educate the EMT in those skills that may be beneficial, regardless of whether they were once considered BLS or ALS.
  3. Not every patient needs ambulance transport. We need to modify the legal and regulatory systems so that non-emergent patients can be evaluated by EMS providers. Those meeting non-emergent criteria can be given referrals to non-hospital-based care facilities or primary care providers. Alternate transport methods, including ride-sharing and similar modalities, can be used. This would serve to make ambulances more readily available and would decrease ED crowding.
  4. EMS would be empowered to take unique patient conditions to more appropriate facilities. Those with alcohol use disorders and other substance abuse issues could be routed to sobering facilities and/or substance abuse treatment centers instead of emergency departments. Homeless individuals can be an enormous burden on the EMS system as they tend to be a higher user of resources. They can be routed to facilities that aid the homeless. Psychiatric patients would be directed to predesignated psychiatric assessment and treatment facilities.
  5. Specialized treatment and transport systems (e.g., medical helicopters, critical transport vehicles, bariatric transport vehicles) would be an integrated part of the EMS system and strategically placed based upon demand and geography.
  6. Technologies without demonstrated benefit (e.g., stroke ambulances, paramedics on motorcycles, horses and bicycles) would only be utilized when there has been bona fide scientific evidence of benefit.

The mainstream media has now started to discuss the pending shortage of paramedics in the United States. While on the surface this may seem a crisis, I think it may be an opportunity to get the EMS system under control. It would take time to make the necessary changes but it would bolster the quality of care we provide on the streets of America and would give paramedics a true opportunity to be qualified and respected healthcare providers who also play a limited public safety role. The EMT would have an enhanced and important role in emergency care and transport. Opportunities such as this do not come up that often and we should use this to make necessary changes to improve both the work of EMS and the medical care and service it provides to the citizenry of the United States.