I was fortunate to be involved in the formative years of EMS. I went to EMT school in 1974 and was in the first paramedic class in Tarrant County, Texas (Fort Worth) in 1975-1976. I spent quite a few years in the field working as a street provider. However, I was also able to meet and get to know many of the EMS leaders of the time. I spent a great deal of time with Jim Page, Alan Brunacini, and David Boyd, MD. I got to know Nancy Caroline, MD, Norman McSwain, MD, Red Duke, MD, and many others. I remember the formative years when the federal government was funding EMS program development in various regions of the United States—Fort Worth included, through the EMS Act of 1973. I listened to the discussions and arguments about what EMS in the United States should be. I remember these well. As I look back, one thing is clear, the EMS system we have today was never what the visionaries of the EMS developmental-era planned. We have taken multiple detours and encountered many dead ends and have ended up with an EMS system that is anything but a system.
It was never intended for the primary EMS provider to be a paramedic.
As the concept of bringing more sophisticated medical care to the prehospital setting was introduced, it quickly became clear that the number of paramedics needed was actually few. It was always intended that the principal level of EMS provider would be the emergency medical technician (EMT) that was initially called an EMT-Basic (EMT-B) or EMT-Ambulance (EMT-A). The model used in Los Angeles County and highlighted in the television show Emergency! placed paramedics primarily in a non-transport mode. While they did ride in the ambulance with the patient once paramedic care was initiated, their primary response vehicle was a non-transport utility truck. In Seattle, where paramedics do operate in a transport vehicle, the vast majority of EMS runs are adequately managed by EMTs with little or no paramedic involvement. In reality, and based upon evolving research, few EMS patients need paramedic-level care. Most only require basic comfort measures and horizontal transport to a hospital.
The television show Emergency! drove public demand for paramedics on every ambulance.
Jack Webb, Robert Cinader, Jim Page, and others went into the production of the “new paramedic show” Emergency! in 1972 with a desire to accurately reflect what paramedics could do. Prior to that, the lay public had no clue as to what a paramedic was. The show followed two humble and good-natured Los Angeles County Fire Department paramedics as they went through their education and work. There was no problem they could not solve. Lives were saved in every episode. In the end, the American public was still not sure what a paramedic was, but they wanted them in their community and they wanted them to respond to their emergency. Soon, the citizenry demanded paramedics and paramedic education programs started to develop and spread. Unfortunately, Emergency!, while usually technically accurate (thanks to Jim Page), did not reflect the reality of a typical ambulance shift in most communities. The breathtaking rescues and back-to-back cardiac arrest saves were a Hollywood phenomenon. Calls to nursing homes, bars, minor collisions, dialysis centers, and similar things were more common in mainstream America—and a whole lot less interesting than what was depicted on Emergency!
Few EMS Systems were as mature as what NBC depicted on television.
EMS of that era was a patchwork of various ambulance delivery models—all poorly funded. These included volunteer rescue squads/ambulances, funeral homes, private ambulance services, hospital-based systems and others. While the Los Angeles County program seen on television was funded by the California State Legislature, the vast majority of EMS/ambulance operations across the United States were poorly funded and many unfunded. The public began to push for paramedics in their community. However, there was never any clear way to fund it. The EMS Act of 1973 established and funded some “demonstration systems” across the country. But, when the federal seed money ran out, local government officials had no way (or desire) to continue to fund the operations.
The definition of “paramedic” was never defined.
The origin of the term “paramedic” is unclear. Historically, the word “paramedic” was used to represent military “combat medics” who accessed the battle zone by parachute. However, like many other EMS myths (e.g., MAST pants used in Vietnam, helicopters widely used in the Korean conflict), the truth is probably elsewhere. In 1975, when I enrolled in the first paramedic educational program in Fort Worth, there was no curriculum. The only guide we had was a mimeographed copy of Nancy Caroline’s manuscript that was prepared under a federal grant from the United States Department of Transportation (DOT) and supervised by Peter Safar, MD, from the University of Pittsburgh. The content of the course was speculative as there was no clear definition of what a paramedic was or would do. The class was long with a significant amount of clinical time (e.g., 40 hours of drawing blood in a hospital lab). Much of it was based upon the physician assistant (PA) program operated by the U.S. Army. The failure to define the role and education of a “paramedic” has been a constant obstacle.
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Following completion of our paramedic education, our skills were very restricted because of concerns about what “the ambulance drivers” were going to do. As with my hometown of Fort Worth, most of the early paramedic education programs varied significantly. I remember doing field internship rides with the Seattle Fire Department in 1976 where they were doing rapid sequence induction (RSI) with succinylcholine and central venous lines (without ultrasound). Meanwhile, in Dallas, paramedics were instructed by Biotel (medical control) to administer medicines based upon the color of the box that contained them. Phrases such as, “Give two red boxes (sodium bicarbonate) and one blue box (epinephrine)” were commonly heard on the Biotel radio. This was followed by the telemetry tone of the ECG being transmitted (as seen on every episode of Emergency!). The differences in EMS and paramedics across the country was striking. Eventually, the DOT defined the four levels of EMS education although significant regional differences persisted. Even to this day, there is significant variation in EMS education across the United States. We get constant feedback on our textbooks. Some complain that the text is too difficult or has too much detail while others complain that it is not detailed enough. There is no happy medium.
EMS was never functionally defined.
During the early years of EMS, prior to the EMS Act of 1973, the goals and scope of EMS varied significantly across the nation. In many areas (e.g., Seattle, Miami, Columbus), EMS was developed to treat cardiac emergencies. In others (e.g., Illinois), the driving force was trauma. When the federal government took over EMS oversight via the EMS Act of 1973, they were unsure as to which governmental agency would have oversight. Some argued that EMS was for trauma and should be placed under the DOT. Others argued that it was health care and should be placed under the then Department of Health, Education and Welfare (HEW). Ultimately, through a governmental paralysis of intellect, it was placed under the DOT. Because of this, there was initially a greater emphasis on trauma with care of medical emergencies secondary. Over the years it has morphed into the hodgepodge that EMS is today. It is truly an entity without a clear focus and goal.
EMS pay has always sucked.
Working as an EMS provider is very rewarding—emotionally and intellectually—but not financially. In my day, we worked 24-hours on, 24-hours off, and 48 hours every other weekend. Stated another way, we spent half of our life at work. The pay was horrible averaging $2.45 an hour (and we weren’t paid between 11:00 PM and 6:00 AM unless we got a call although if we were up for three hours or more, we got paid for the whole night). At that time there were only six emergency ambulances for the entire city of Fort Worth. It was not uncommon to run 20 or more 911 (although 911 was not yet available) in a 24-hour shift. The quality of the equipment varied. Crew quarters were somewhere between dilapidated and condemned. Heating and cooling were dicey. But we loved the work and stuck it out.
Regardless, on payday, we had to pay the bills (one service in Arlington was so bad that the first crews to get their pay check would rush to the bank to cash them because, if you waited until later, the banks would not cash the checks due to insufficient funds). Today, things are better but still inadequate. I remember talking with a nurse in the trauma center at the Alfred Hospital in Melbourne, Victoria, Australia. She was waiting for openings in the Victoria ambulance service because it paid better than hospital work. In the U.S., nursing school is a way out of EMS with better pay, benefits and lifestyle. Fire departments and government-operated EMS have paid better. But firefighters received little additional pay when they took on the massive responsibility of providing EMS.
Government reimbursement for EMS services drove increased use of paramedics and advanced procedures to enhance billing.
Ambulance reimbursement in the United States is uniformly horrible but became a little better when the ambulances were staffed by paramedics. Advanced Life Support (ALS) provision would allow a higher billing level if an IV was started or similar services provided. Soon, virtually every EMS patient arrived with an IV although studies at the time (and more recently) showed that most were never used for any therapeutic intervention. Soon, paramedics were on every ambulance including many who did non-emergency department transports. If one paramedic was good, two must be better. Even in Las Vegas, to this day, the private ambulance services are only allowed to staff ambulances with a paramedic and advanced EMT (AEMT) although EMTs can work standby events.
Fire departments saw EMS as a service line.
Fire department administrators were faced with a decreasing number of fires due to enhanced building codes, fire prevention, and other strategies. They had equipment and crews that had to stay busy and in the taxpayers’ field of view. The concept of having non-transport paramedics on various fire department equipment such as “paramedic engines” came into vogue. This contradicted the prevailing science, such as the Ontario Prehospital Advanced Life Support Studies (OPALS), that demonstrated that standard EMS basic life support skills were much more time-sensitive and effective than advanced life support skills (IVs, intubation, medications). The original EMS design, where most care was provided by EMTs with paramedics as a secondary resource, was lost in this.
Now, with the current paramedic shortage, many fire departments, such as Houston, are returning to the original tiered response model that has served Seattle and other Pacific Northwest communities well. It has now become again apparent that most EMS calls can be safely and efficiently handled by EMTs. However, this does not allow ALS billing and can result in less EMS reimbursement (of course, overall EMS reimbursement is horrible so the argument is academic). The whole thing has become absurd. When I was an EMS medical director in Las Vegas, I remember riding with a crew to a call on the Las Vegas Strip. The response included a fire engine with three paramedics and one EMT, a fire department ambulance (that rarely transports) with two paramedics, and a MedicWest American Medical Response ambulance with a paramedic and advanced EMT. Overall, six paramedics responded to assist an intoxicated tourist who was unable to navigate the revolving door that leads into a casino.
Some fire departments were forced into EMS.
In the 1960s and 1970s, ambulance provision was a patchwork of different delivery models. There were few, if any, EMS systems. In some communities, ambulance services were akin to the Wild West. Calls were put out and any available ambulance responded. The first to the scene would get the patient and the ability to bill for care. Transports to the hospitals were often with lights and sirens so as to have the ambulance available more quickly for the next call. Things got out of hand and attempts to fix the system failed.
Many communities, such as Dallas, Houston and others, decided that the city would take over responsibility for ambulance provision and gave that responsibility to their respective fire departments. Some fire departments and firefighters embraced the new responsibilities. Some abhorred it and it remains that way today. Working the ambulance or “box” is a rite of passage that often must be completed before moving to the fire apparatus. That said, some of the best EMS operations in the country are fire-based. They have embraced the mission (which consumes a great deal more of their time than firefighting) and provide evidence-based care with improved outcomes.
EMS in the United States chose the Public Safety model for system provision.
As EMS was being refined, the definition of EMS was unclear. Some of this was due to the various EMS operation models in the U.S. at the time (private, volunteer, fire). It was noted that EMS functioned in three domains: public safety, public health and health care. Certainly, these three domains overlapped. There has never been a strong emphasis on public health in EMS although EMS has played a role in several major public health emergencies such as the SARS epidemic in Ontario in 2003, Ebola in Dallas in 2014, and COVID nationwide in 2021. In the United States, the public safety components have predominated. Many years ago, I rode with paramedics in Sydney, Australia ,(New South Wales Ambulance Service) and Brisbane, Australia, (Queensland Ambulance Service). EMS in Australia and many of the Commonwealth countries are a part of the national health care system.
There were several things that struck me. First, there was no big rush for response times. Also, there was never any significant public safety response. You rarely saw police officers on calls (even in dangerous areas). Also, I never saw a response where the fire brigade responded (including many motor vehicle collisions). When I asked the paramedics why the fire brigade did not respond, they answered with a quizzical look and said, “There was no fire.” Also, I noticed that they were very evidence-based (limited backboards, limited use of ALS skills unless indicated). EMS in the United States clearly followed the public safety model. Uniforms are often paramilitary (as opposed to health care). Metal badges (similar to law enforcement) and various militaristic ranks are often used. Other insignia are often seen. Lights and sirens use is too common and response times are often one of the perceived major indicators of EMS quality.
Historically, public safety jobs have been lower paying than other occupations. Police, fire and similar operations are government operations that must adhere to government rules and regulations. Non-EMS health care providers tend to do much better financially than EMS providers when similar scopes of practice are compared In the United States. EMS is primarily funded through local government with some state and federal money from public payers (although many systems are subsidized by local government). The funding of EMS from public payers (Medicare, Medicaid, Tricare) and private health care insurers is woefully inadequate. Interestingly, ambulance reimbursement can be bumped up a tier or two by providing an ALS skill—whether needed or not. This has led to an increased demand for paramedics who could perform ALS skills thus allowing some level of up-charging. Soon, the indication for a prehospital IV was simply the presence of a patient. In some situations, such as major trauma and cardiac arrest, needed care may be delayed while there are undue attempts at IV access. Interestingly, as stated earlier, several studies have demonstrated that prehospital IVs are rarely used.
The public does not want to pay for EMS.
Public safety (fire, police, animal control) is generally seen by the citizenry as “free” and paid for by ad valorem taxes. They are generally not billed for these services. They see EMS in the same lens. The ambulances are staffed by people who appear to be public safety providers (and sometimes are) and simply assume that costs are covered by taxes. This free public safety mindset of the populace has been an impediment to EMS since the beginning of the profession and remains even more so today.
EMS providers have been separated from the civil service system.
While several government-operated EMS systems have allowed EMS personnel to participate in the civil service system, many EMS operations have not. Civil service assures professional employees (non-elected) have certain rights, benefits and protections. Most police officers and firefighters are a part of this system. Many EMS providers are not. This was something that Jim Page was quite critical of. Part of the perceived benefit of the various Public Utility Model (PUMs) EMS systems, developed in the 1980s, was the ability to reduce costs by keeping EMS personnel out of the civil service system. This was sometimes achieved by hiring a private service as the ambulance service contractor or by setting up a non-civil service entity (authority) that employed EMS professionals but kept them out of the civil service system. This limited the career opportunities of many EMS providers.
How do we return EMS to a functional system?
This is something that is easier said than done. It will take change in some fundamental constructs and issues related to EMS. First, we need to better understand what part of EMS practice makes a difference and what does not. An intense investigation of EMS practices has been underway and is often met with distain by providers. The current discussion of limiting lights and siren responses and eliminating the use of response times as a metric of system performance (a public safety issue) is often seen as heretical ravings by many EMS providers. We have to plant the seed of thought in all new EMS providers that EMS provision can, in most cases, be well-managed by EMTs.
Then, we can concentrate on improving patient care and determine what treatment strategies are best for the patient. Again, this would be a global shift in EMS from the public safety model to the health care model. There are features of the public safety model that are attractive to potential EMS providers. Health care provision is less sexy. That said, if we determine that the EMT level is the principal care provider for most ambulance transports, we would have less need for paramedics. Then, we could better focus paramedics on more sophisticated health care endeavors by enhancing their role and using non-transport vehicles. With that, increased pay and prestige will follow. paramedics need to be seen as fellow health care professionals and not “ambulance drivers” or “firefighters.”
So, now what?
Where do we go from here? COVID and other issues have significantly impacted EMS. EMS systems nationwide cannot hire enough providers and retention problems are worsening. Some argue that some of this may be generational where younger people find EMS uninteresting and undesirable and public safety (fire, police, ambulance) unfathomable as a career. Pay has always been poor—particularly in the private sector. It is hard to justify the time and cost of completing paramedic education from an accredited program where the income potential is not much more than that earned by fast food employees and hotel clerks with no education beyond high school. Hospital systems and private-equity owned companies have invested in EMS knowing that those who love the job will sometimes stay in it even with threat of personal financial peril.
Upward mobility in the public safety sector is less than what is possible in health care. Nobody (local governments, state governments, federal governments) wants to take responsibility for EMS. Public safety (in the United States) has almost always been a local government responsibility. Between COVID losses, a rising cost of living, and a high rate of inflation; local governments do not have the resources (without raising taxes) to properly fund an EMS system. We must get away from EMS being public safety. While public safety and public health will always be a part of EMS, the predominate domain should be health care. The federal and state governments have a history of funding health care endeavors (although one can questions costs and efficiency). While our healthcare system is considerably different from the Commonwealth countries, there are enough similarities that would suggest EMS might survive as a component of the health care system (state or federal).
I love EMS. It is among the most satisfying things I have ever done. But, with age, my personal responsibilities increased with a wife, two children, a mortgage and car payments. I saw that there was no way I could continue to work in EMS without placing my family in financial stress. Fortunately, I found a niche where I could still work with EMS (in a limited fashion) and provide my family with a reasonable quality of life. I would wish that all EMS providers will be able to say the same thing. The future can be bright. But will it?
Editor’s Note: This commentary reflects the opinion of the author and does not necessarily reflect the opinions of JEMS.
