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Critical Challenges Facing EMS

The Emergency Medical Services system is in the spotlight regularly for the role it plays attending to the health and safety of our communities. Since the beginning of the pandemic in 2020 this role has been undertaken in an ever-increasingly stressful environment. As we move away from COVID-19 as a pandemic and attempt to return to pre-pandemic levels and models of service delivery it is very clear that a lot has changed for us in EMS, and the challenges we are facing today are not likely to be fixed with time and acknowledgement alone. This period of high stress has brought to the surface, and in many cases exacerbated or at least hastened about, problems that were already developing. Here are a few of the systemic issues facing EMS agencies today, as well as some suggestions for how to address them.

EMS personnel train on cardiac arrest response

COVID-19 brought about an exodus of EMS providers from the system. Given what was asked of our EMTs and paramedics in the early months of the pandemic, who can blame them? In March 2020 they were told “we don’t know much about this virus, how infectious it is, and who’s most at risk, but it’s likely tens of thousands of people will die from it if we don’t keep everyone in their homes. Except essential workers like you….you go find these sick people and take care of them. Use N95s if you have them and wash everything. You should be fine.” There are certain workforces that have an expectation of personal risk inherent to their jobs, and I do believe that EMTs and paramedics are in that category, however the amount of concentrated perceived risk in this case was well beyond what could reasonably be expected in the normal course of performing one’s duties. A contributing factor to the sudden decrease in EMS responders during the pandemic is that a majority of our communities still rely on at least some volunteers. We asked a heavily volunteer workforce to continue to respond to medical emergencies in the face of a largely unknown threat and many of them understandably chose not to. Additionally, the average pay rate for EMTs working in paid positions is low in relation to what these responders are asked to do. For some it wasn’t a hard decision to seek other employment rather than accept the risk presented by the pandemic.

To be clear, the staffing problem in EMS began decades ago and is just reaching a crisis level now. EMS is one of two industries with a workforce split between career and volunteer staff. The other one is our close cousin the fire service, which is facing the same challenges for many of the same reasons. I believe that volunteerism is an important value to perpetuate in our communities, and what better way to volunteer than by helping a neighbor in their time of emergency. Most communities that rely on volunteers for emergency services realize a financial benefit by doing so, however this system characteristic comes with some costs that aren't always easy to recognize. First, voluntary labor can be unpredictable. When volunteers are not available as we are seeing more frequently now, communities are faced with decisions about how to fill the gaps, and are sometimes shocked by the price tag of having to provide coverage with employees or contracted services in place of volunteers. The second cost to this model is recruitment and retention into the field of EMS. An industry model where service providers with the same certifications and performance requirements sometime volunteer to do the work others are paid to do doesn’t impress feelings of job security and value upon people who may be considering EMS as a career choice. Volunteer services are often viewed as opportunities for experience and training for those wishing to make a career of EMS, but these potential future employees of EMS agencies still have to support themselves with other work while volunteering, which means they may be focused on two career paths at the same time. Additionally, asking highly trained professionals to first volunteer in their chosen profession doesn't happen in most other career fields.

The EMS workforce problem is certainly broader than just the impact of decreasing volunteerism. Generally, it’s clear that the essential service of EMS isn’t valued the same as the other essential public safety services of fire and police. This is evident in average pay rates and in municipal support differences. Some of this is a result of a lack of unity in the EMS industry around a common effort to market who we are and what we do. In my opinion however, much of it stems from an identity crisis. EMS has always existed in two distinct arenas, one of public safety and the other healthcare. While there is plenty of crossover between the two within the role of EMS, this attempt to serve sometimes competing sets of priorities creates significant challenges to how the system functions. As an example of this, both police and fire services are predominantly funded by tax dollars because they are seen as essential services that don’t typically have significant revenue streams associated with them. This means that as service demand increases within a community, the community can determine the service level they desire and fund it accordingly. EMS funding is largely tied to a reimbursement for services model, where the patient is billed for the service provided. This reimbursement collected by the EMS agency is then dependent on factors such as the patient’s ability to pay, agreements with private insurers and redu