Why Solving Problems in EMS Is Difficult

When you read “wicked problem,” what comes to mind? Do you think it’s a problem that’s “wicked hard” to solve? In a sense that’s true–in fact, wicked problems can’t really be solved at all. As you read on, I hope you’ll come to appreciate that EMS can often be characterized as a wicked problem and, even though many of the problems and challenges of EMS can’t be solved, there are things we can do to tame the wickedness.

I first discovered the term “wicked problem” in an article titled “Strategy as a Wicked Problem” published in the May 2008 issue of Harvard Business Review.1 In his article, author John C. Camillus says that “when five characteristics are present in a strategyrelated issue, executives agree they have a wicked problem on their hands”–one where standard planning and problemsolving methods will be ineffective and may make things worse. The characteristics are:1

1.     The problem involves many stakeholders with different values and priorities;

2.     The issues roots are complex and tangled;

3.     The problem is difficult to come to grips with and changes with every attempt to address it;

4.     The challenge has no precedent; and

5.     There’s nothing to indicate the right answer to the problem.

What does this mean to EMS? How are these properties and characteristics reflective of our planning and policy issues? If we examine each of the five characteristics Camillus describes, we can clearly see they’re present in EMS at many levels.

Many stakeholders, different priorities: First, it’s clear there are many stakeholders in prehospital care: patients, ambulance companies, EMTs and paramedics, hospitals, physicians, health insurance companies, and others.

Tangled roots: Second, if we consider that the roots of modern EMS began in the mid-1960s, when the United States Department of Health funded the development of the first EMT curriculum and paramedics began springing up following the publication of Frank Pantridge’s influential paper published in The Lancet in 1967 that said sending care to people having a myocardial infarction rather than waiting for them to come to the hospital reduced morbidity and mortality, then consider the divergent evolution that followed leading to innumerable EMS delivery models. To say nothing of issues related to funding, it seems clear to me our roots are complex and tangled.

A difficult problem: Third, we have trouble trying to define what EMS actually is, because it isn’t simply one thing and there isn’t only one problem. We’re faced with numerous interrelated issues that reflect the complexity of the multiple systems that make up EMS and that interact in all kinds of ways.

No precedents: Fourth, since each EMS system is unique, the application of solutions attempted in other places is risky. Circumstances aren’t the same; the stakeholders, though seemingly similar, interact in different ways, creating unique situations without precedent.

No right answer: Fifth, because the numerous stakeholders have differing opinions on the nature of what EMS is and what EMS should do, and because there are many layers wherein problems are symptoms of other problems, nothing points the way to a right answer. We can try out a solution, but we won’t know if it was good or bad until we try it. It’s not like solving a math problem where two plus two always equals four, or diagnosing a problem with a car where, even though it’s complicated, there’s always an answer.


According to Camillus’s assertion that wicked problems have five characteristics, and considering that EMS displays all five, it follows that EMS is a wicked problem. The question that comes to mind now is, “What the heck can we do about this situation?” I’ll seek to answer that question in the next installment of this column in the November issue.


1. Camillus JC. (May 2008.) Strategy as a wicked problem. Harvard Business Review. Retrieved Aug. 18, 2015, from www.hbr.org/2008/05/strategy-as-a-wicked-problem.

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