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The State of EMS
'Three simple digits' face complex challenges

By John Erich o Associate Editor, EMS Magazine

Not enough money. Not enough people. The public doesn't understand. The government won't help.

In a lot of ways, it seems like the state of EMS in 2001 is dire indeed.
Certainly, there's no shortage of problems, and a quick survey of people's concerns can paint a picture that's pretty bleak.

Services across the country are struggling to continue to provide the high level of care to which Americans have become accustomed. Funds are shorter than ever-and for most will get shorter still under the new Medicare reimbursement schedule-at a time when the labor market is competitive, and finding employees is increasingly difficult. Yet when they dial those three simple digits, the public expects a fast response and flawless care, no matter how serious (or trivial) their problem. Sounds like a national crisis waiting to happen. Are there solutions? For everyone's sake, there had better be.

Who Are You?

Item-Number and types of EMS services in one Western state: paid fire department, 5; volunteer fire department, 20; volunteer squads, 27; private ambulance services, 7; municipal services, 14; hospital-based services, 5; funeral home services, 4; air ambulance services, 6 (part time).

A pair of related overarching problems weigh heavily on the state of EMS in America today, bearing directly on many of the more tangible issues faced at the departmental level. These, an assortment of industry veterans agree, are identity and leadership.

A lot of people feel EMS is lacking in both.

"One of the biggest issues is that we still don't have a strong, cohesive identity," says Kate Dernocoeur, editor of Merginet News and a 25-year veteran paramedic, author and speaker. "Sometimes we're fire, sometimes we're private, sometimes we're mixed up in the same city. What is EMS? Is it first responders? Is it paramedics? Is it something in between? Are we volunteer? Are we professional? Are we paid? It just goes on and on.
Smorgasbord is a good way to describe it."

That basic smorgasbord aspect makes addressing other problems difficult. To discuss the issues facing an entire profession, that profession must first be defined, given a framework to provide context to the debate. But in EMS, the endless base-level variations scatter the discussion from its onset.
With different natures and different needs, individual agencies all have their own issues to face. All require different solutions. What's tonic for your town may be poison for your neighbor's.

"EMS has kind of bounced around," says Mike Taigman, an author, speaker and self-described 'lifelong student' with 25 years in the business. "Are we healthcare? Are we public service? What are we? Who are we? We want to have all the benefits of public service, and yet we want to be respected like healthcare professionals. And since everyplace you go in America it's a different camp, the funding structures are very different. The system-design structures are very different. There are all different kinds of interests that pull you in different directions."

That diversity of definition permeates EMS from the top all the way down to the street level: the provider on the beat, what he or she is called, and what he or she is allowed to do.

"We can't even come up with what to call ourselves," notes Dexter Hunt, a paramedic since 1976 and an EMT since '72. "If you look after our names, there are ICPs, there are MICPs, there are EMT-Ps, there are NREMT-Ps. We have a bunch of different things. A paramedic in Albuquerque is not necessarily the same thing as a paramedic in Alaska-there's a lot of diversity. You don't see that in, say, nursing. You don't see that in medical school. You get an MD, you're an MD. You get an RN, you're an RN."
The reasons for this variety-fragmentation is the term that frequently comes up-are, naturally, themselves varied. Some attribute it to the lack of a single, unifying national presence that could clearly define what EMS is.
Some blame a lack of strong leadership. Maybe, some suggest, it's a natural function of a young profession that's still evolving.

"We don't have that national voice," says Hunt. "Therefore, we have no national goals; therefore, I don't really see us having any kind of real leadership on a national basis."

A Lack of Leadership

Item-Number of employees listed in the EMS Division of the National Highway Traffic Safety Administration's website: 7.

The question of leadership appears to have at least three levels. At the top is federal: There is no national executive agency solely and directly responsible for EMS. NHTSA has official oversight capacity, but not enough mission or authority to impose any kind of true standardization.

As an answer, some have proposed an executive agency, an Office of EMS, that could attack problems on a national scale and plan for the long-term.

"I believe we need government intervention to standardize what's going on with EMS, because I think it's running amok," says Lou Jordan, a National Registry representative since 1973, former EMS director for the state of Maryland, and one of the original EMT instructors first trained by the government. "I'm generally not for big government and government regulation, but I don't believe my treatment should vary if I fall on one side of the street or another."

"It doesn't help that we have no single entity in the federal government that really champions the EMS cause," says Paul Maniscalco, PhD(c), EMT-P, deputy chief of the Fire Department of New York's EMS Command and past president of the National Association of EMTs (NAEMT). "I think historically, the industry took a big blow when the Department of Health and Human Services' EMS Office went away. NHTSA does a good job for its mission, but its mission is very limited. They don't have the resources or the charter to permit them to go out and review the programs, the responses, the events, and capture it all on a national level."

Nor is the lack of strong leadership in EMS confined to the government level. At the most basic departmental levels, some say, it's lacking as well. Those who are guiding departments and crafting policy for the providers on the streets lack the background and skills necessary to do it right.

"The biggest problem, from my perspective, is that there is some absolutely abysmal management in EMS," says Hunt. "That goes for the fire services and the privates. It's hard to find anyone across the U.S. who can say, 'You know what? I've got some damn good management.'

"The fire services very rarely have paramedics at the top of the ladder. In most fire settings, you can't progress to the top of the ladder if you're a paramedic; you have to go through the [fire] rank and file to move up. And in reality, 80-90% of what most fire departments run on are EMS calls."

That changing face of fire-based EMS has naturally created a bit of a lag effect in the leadership ranks. As fire calls plummet, the fire veterans who run things now have to learn to run departments that are largely EMS. The needs are obviously different, and most are learning on the job.

"You're looking at decisions made by fire chief officers running something they don't have any knowledge of," says Alan R. Cowen, retired deputy fire chief and chief paramedic for the Los Angeles Fire Department. "It's like taking paramedics and telling them to go ventilate a roof. Paramedics don't know how to ventilate a roof-they like being paramedics."

Those who have risen through the EMS ranks to lead departments sometimes don't fare much better. As managers, they're suddenly utilizing a different set of skills-i.e., dealing with employees, including the problem ones-than they needed before.

"I think departments can take better care of their people who provide clinical medicine on the front lines," says Taigman. "But virtually everybody in EMS management is a good, well-intentioned, smart person who maybe hasn't obtained the education and knowledge necessary to make the shift from front-line practice into leadership. It's a lack of competency development and education, not a lack of good intent."

There's a third, less formal element to leadership that plays here as well:
EMS today has precious few self-appointed or de facto leaders standing up to speak for the industry-the kind of Mr. Smiths who go to the capitol and fight for the little guys.
"I wish the leaders in the industry were stronger voices, that they were a little more prominent," says Dan Gerard, chair of the NAEMT's paramedic division and a medic himself since 1983. "Nobody looks at the global issues.
A lot of people are only focused on what goes on in their communities."

"Quite frankly," adds Hunt, "what you need is some very vocal people who don't mind kicking the embers and causing some.I don't want to say turmoil, but we need to stir the fire."

Such leaders could be the gadflies who agitate legislatures, press the need for dollars and prod action out of the lethargic. While there have been some in the past, few seem eager to assume that mantle today.

"We're not lobbyers," concedes Dernocoeur. "We're not long-term thinkers.
We're not people who want to create anything except the latest wave of excitement. There are people-O.J. Doyle, for example, or Mike Taigman-who have the big-picture vision. But there's really no grass-roots EMS voice."

Instead it comes back to that basic scattershot nature: different problems, different needs, different voices asking for different things.

"There's no uniform community model" to speak for, says Gerard. "The way people do things across a broad set of communities, that's probably the biggest issue-that it's so fragmented."

From Times of Crisis.

The way things are changing, that diversity of identity is unlikely to diminish soon. In fact, it may become more pronounced, spawning hybrids that defy easy labeling. Private services may require public aid. Paid services may supplement with volunteers, and volunteer services may require some paid personnel. That, in fact, may already be happening.

"I think I can see the pendulum swinging," says Dan Manz, Chief of EMS for the Vermont Department of Health. "The movement is somewhat away from the end of the spectrum that is absolutely pure volunteer, where nobody's compensated in any way for anything. It is moving in the direction of more compensation. Exactly where it will stop, who knows?"

The queering factor is the new Medicare fee schedule being imposed this year. Its impact will vary dramatically from state to state. A few states will actually benefit from larger reimbursements. Some will mitigate funding shortfalls through legislative relief. Some, however, could see entire systems collapse. All, in some form or another, will have to reassess their operations and determine which models best maximize their resources.

"In states that are particularly hard-pressed," says Doyle, the country's only full-time state-level EMS lobbyist, "it may come down to private providers saying, 'Either we're going to have to get some sort of cash influx, or we're going to go out of business, and then you're gonna have to take over.' The pressure's going to be great."
An upside is that as the delivery of emergency care evolves, leaders may emerge out of circumstance and sheer necessity.

At the state level, EMS authorities may have to strengthen their roles in making sure their citizens are covered.

"We do have a state EMS authority in California now, but I have to tell you, the effectiveness of it is real questionable," says Cowen. "There needs to be some sort of control. It goes back to needing a clear, strong voice in EMS that runs all this stuff. Perhaps it should be through state-run organizations with a little more clout."

At the departmental level, management will have to rise to the challenge too. Public or private, fire or third service, Medicare reimbursements or no, all will have to face up, eye their operations critically and figure out how to best sustain them.

"We'll need a change in management philosophy," says Cowen. That has to be the No. 1 thing: A management philosophy that will support, once and for all, paramedics. Get rid of all the dinosaurs, and also get rid of the dinosaur eggs-the young ones that are trained by the old ones and have the same mind-set. You have to make sure all the eggs are gone too, so they don't hatch to be the same thing."

An Expensive Contingency

Item-The estimated cost to EMS in America of the Health Care Financing Administration's revised Medicare fee schedule: More than a billion dollars.
Item-Basic and Intermediate EMTs in Arkansas make no more than $17,000 a year.
Then there's the money. Make no mistake, almost everything relates back to the money. EMS continues to get the short end of many budgetary sticks. The Medicare fee schedule is but one example.

"Every day I look at 15 e-mails about EMS services that can't afford to continue in operation," laments Dernocoeur. "There's just not the money.
Everybody wants to have the best service possible, but that isn't possible without money. The funding for these townships that are trying to make sure their citizens are covered is just dreadful. I don't know what's going to come of it, I really don't. EMS is an expensive contingency."

Agencies that treat and transport Medicare patients may feel it acutely under the new fee schedule, but there are other aspects to the money crunch as well. Public agencies must deal with a bureaucratic funding process subject to political agendas and the whims of taxpayers. Private agencies must recoup their own rising costs, especially if Medicare kicks in less.
Volunteer agencies must continue to somehow scrape by.
Costs are trimmed where they can be. Maybe what a service offers (hours of operation, interfacility transfers, etc.) is cut back. Maybe a little more life is wrung out of old equipment. Certainly, already-low salaries aren't taking quantum leaps upward.

"The paramedic that's going to be called to take care of your kid is making a little bit more than the kid at McDonald's," Hunt points out. "We have EMTs here that start out making $2 an hour less than the security people who direct traffic at one of our hospitals. That's a fact of life. There are some systems that are getting paid damn well to do what they do. But we have people within our system who qualify for food stamps and reduced school lunches."

Sadly, these stories aren't rare. Most who have been in EMS for any length of time have them.

"It's scary," says Maniscalco. "I know of one individual who was an outstanding EMT and lieutenant in a large urban EMS system who just recently resigned after 18 years. He could get better salary, more control of his life, no forced overtime, the flexibility he needs to take care of his family-which isn't that big of a demand-and stock options by going to work as an assistant supervisor at Home Depot."

When Home Depot's stealing your best people, you know you've got trouble.

Baby Busting

Item-Police in North Haledon, NJ, cross-trained as EMTs to fill gaps in the volunteer coverage of the surrounding area.

It's no overstatement to say the manpower problem is nearing critical stages in a frightening number of jurisdictions.

"We have a real shortage of providers in this country," admits Gerard.
"People just aren't going into the field. We have to look at all the aspects of that. Some of the issues are labor issues, specifically what we pay people and how we take care of them."
Undoubtedly, low salaries are a major factor. But there are others as well:
overtime, injuries, job security, stress, bureaucracy and the lack of a career ladder providing anywhere else to go. Additionally, there may be an element that is simply demographic.

"The generation that immediately follows the Baby Boom generation is the Baby Bust generation," notes Taigman. "The Baby Bust generation is a demographic cohort that is 16% smaller. Right now the oldest members of the Baby Bust generation are 22 years old. What that translates to is, there are less entry-level-age people available in the work force than there ever have been in the history of EMS. That means it's very, very hard for services to attract people to replace the people who leave. They're competing with every employer out there."

Physical injuries among EMS providers, which emerging research is beginning to show is a larger problem than previously realized, is another factor, as is the way many departments treat their injured employees. A lot worry about their department standing behind them if they're hurt doing their jobs.

"This is a continuing theme," says Maniscalco. "Although our primary mission is to provide good medicine in bad places, I think somehow we got focused too much on the quality and the efficacy of delivery of patient care, and we really never embraced the whole matter of the safety and health and well-being of our members. We are crippling people with back injuries. We are killing our members with bad driving habits, and reinforcing that bad behavior by not dealing with it. Our people aren't disposable, and this behavior is crippling the industry. It's feeding into the whole revolving door of recruitment and retention problems. People have to feel that they're secure, that they're not threatened, that their world's not going to come crashing down around them."

Increasing bureaucracy is another woe. Every day, it seems, more is required in the way of forms and paperwork, documenting for legal protection (important in a litigious society, but few providers' favorite aspect of their jobs), and other basic aspects of CYA. Who wouldn't be frustrated?

"What our people don't need is having a boss saying, 'You're not getting enough signatures on your Medicare forms!' " says Hunt. "Yeah, it's important, and you have to pay bills, but again, it goes back to if you're properly funded, you're not having to shake down the patient for their checkbook.

"When I have to carry a credit-card imprinter on my hip-and I'm with a third service, but I'm only funded 30% by tax money; 70% is patient revenue-and I've got a boss saying, 'Well, we have to cut back. Patient care really isn't as big a thing as getting revenue,' you've got a problem."

The reasons differ at the volunteer level, but the problem is the same.
Volunteers still comprise the majority of providers in America, but with people juggling other jobs and devoting their spare time to EMS, it has gotten harder and harder to find those willing or able to dedicate their extra hours.

"In some communities, I hear 'Well, we can get this guy out for a couple hours a day, we can get that guy out for two hours in the morning, another guy for two hours in the afternoon, and another guy for three hours in the middle of the day,' " says Gerard.

"But unfortunately, none of them overlap. With the prosperity that came with the new economy, people are just working more. In EMS, the big joke always is, 'Well, how many jobs do you have?' Now it's not just EMS. Everybody has a couple of jobs, and they just don't have the time to volunteer. The volunteers just aren't out there."
"I think we may be seeing a transition in society where people aren't as willing to give time to their communities for emergency services as they used to be," says Manz. "I say that carefully, because the number of people certified within our system is actually continuing to rise. We're actually seeing a net increase of people. But by the same token, organizations are not telling me that it's easier to staff. In fact, they're saying the opposite."

This, Manz suspects, may be a result of increasing commitments to other jobs and responsibilities.

"Dan Manz used to say to his organization, 'I work for Joe's Printing Press down the street, and Joe knows I'm on the ambulance, and so if I need to carry a radio and punch out in the middle of a job to go take an ambulance call, Joe's willing to let me do that,' " Manz offers. "I'm not sure Joe is as willing to let Dan do that anymore. I think Dan may still be willing to volunteer, but Dan may say to his organization, 'Hey, I can do nights, I can do weekends, but I can't do daytime.' So even though the organization may have as many total people in it, or more people than it used to have, it's getting more and more difficult to get those people at the times you need them. There are more logistical problems with making it work."

At other times, some have suggested, it may just be a function of an increasingly self-centered society.

"Really, we have lost family values in this country," says Jordan. "People nowadays don't have this volunteer spirit, this feeling of community. The country did away with the draft, so kids are never put in a situation where they're part of a team or feel a responsibility to a joint problem or concern. Kids today are just not raised to be team players."


Community Interest

These are major problems, all right, but how do you fix them?

Unlike the more abstract problems of identity and leadership, the problems of money and manpower can be addressed directly. You want money, you learn to work the political apparatus like everyone else does. You want providers, you raise the public's awareness and esteem of EMS, and make it a desirable profession to get into.

Becoming more sophisticated at playing the funding game is a basic imperative.
"It's the best fund-raiser that wins," warns Jordan. "We just had a president elected because he could raise more money and have more ads than his opponent. Well, lives are being saved or lost depending on what community can or cannot raise the funds."
For this, there is a model: Minnesota's, where Doyle has been working the legislature for 16 years. It works. He's known, respected, and-get this-sometimes they can't wait to give him money.

"It's been kind of funny this year," he says. "I'll go in and say, 'Here are some of the things we're proposing.' And a number of legislators say, 'Oh, that's not enough.' Well, I agree, but I'm not sure what else to ask for! A number of them say, 'Why don't you figure out some other things. If there were no constraints on money, what would you do?' So I've had to draft 12 additional bills."

It's easier when the lobbying mechanism is in place, Doyle points out, and you've established relationships with your policy makers before going to them with your hand out. But absent that, there are other things even you, the provider on the street, can do.

o Start at the federal level. Write your U.S. Senators and congressmen. Tell them their constituents' care is threatened. Then when you move down to the state level, impress upon them that they're your last resort.

o Don't wait for a professional to speak on your behalf-do it yourself. "The impact is greater hearing from an actual provider who doesn't lobby for a living," Doyle says. "They can make the case and say, 'Here's the reality.
Here is specifically what will happen to our ambulance service.' "

o Tell it to the local media. Not the big-city papers-the small-town ones.
"Local papers are looking for stories of community interest," Doyle emphasizes. "You build a base throughout the state by dealing with your local media. Even local radio stations, that sort of thing. People who provide service locally need to get the exposure locally about what's going on."

It's not a stretch to see that increased funding could go a long way toward resolving the manpower issues as well. Paid departments could offer wages sufficient to live on without working overtime and second jobs. Other financial incentives, such as signing bonuses, could lure new recruits.
Volunteer agencies could offer more in the way of stipends and in-kind incentives, like paying for training or uniforms.

This is already happening in places.

"We actually, for the first time that I can remember in a long time, have some pretty sizable sign-on and retention bonuses being offered at the EMT level," notes Maniscalco. "I think there are certain private organizations that have contracting problems, and they're going to do what they have to do to fulfill their contracts."

Finally, EMS must raise its profile in American culture. It needs to become more visible in the community. More awareness equals more interest and more people wanting to enter the field.

"Every week," says Cowen, "there should be articles focusing on paramedics, profiling lifesaving paramedics, talking about them, building up that profession where it ought to be-on the top."

Lots of kids want to be firefighters; surely the notion of being an EMT or medic could be just as exciting and romantic. The problem lies with a lack of full integration into America's emergency fabric. People still think "fire and police," not "fire, police and EMS." They appreciate it; it's just not high on their radars.

"We're not in a high-PR, high-visibility kind of job," says Hunt. "With firefighters, everything they do is visible. It's kudos, it's pats on the back, it's 'Wow, you're so brave.' EMS, we deal in sick people, vomit, blood-people would just as soon not see that. It's kind of exciting to get that up-close-and-personal look into people's bedrooms, but it isn't real high-PR. It's not glamorous at all."

To that end, the new wave of reality-based TV shows (Paramedics, Trauma:
Life in the ER, etc.) may help raise awareness and glamorize a sometimes-icky profession.
"I think they do" pique people's interest, says Taigman. "Some of it is the people who slow down and gawk at auto accidents-I think it's probably the same phenomenon. People are maybe more interested in the suffering of the people that are being responded to on the reality-based TV shows. But at the same time, I think some of the shows do a good job of showing some of the humanistic and compassionate sides of the EMS profession, as well as the clinical stuff and the cool emergency stuff."

A Standard of Success

All is not black clouds and rain in this strange time. Certainly, EMS '01 is getting a lot of things right. Today's providers get to the majority of emergencies quickly. Knowledge and technology continue to increase, translating to innovation in patient care and better outcomes. When Joe Public calls, odds are, he'll be taken care of.
"I think EMS is typically meeting the expectations of the public," says Manz. "We might sit around and be very critical internally and say 'Jeez, we're doing terrible at saving cardiac arrests in the field.' That's the insider's view. I think from the public's perspective, we're acceptable, we're dependable, they count on us, and when they push the button, the doggone thing works pretty well in most places. I think that's actually pretty important, you know?"

"There are many, many fine EMS providers out there," Dernocoeur points out.
"The trouble is, you can have one bad situation and 1,000 good ones, but you'll never hear about the good ones. I think that's important to
recognize: That in spite of the fact that there's a lot of gloom and doom, there are still a lot of dedicated people out there doing the best they can under very trying circumstances."

Moreover, education and knowledge continue to increase. A growing body of research guides the industry's policies. Providers have more degrees, training and background than ever before. They're better equipped to make do with what they have, even if what they have is less than they'd like. People keep finding ways.

And at the core, there are still the dedicated providers who will charge into the night and break their back trying to help a stranger in need. "I have always believed," says Jordan, "that as long as God or whomever has given us the knowledge and ability to save lives, if we do not do our best to utilize that knowledge, then we have failed as human beings."

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