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Unorganized and Underprepared: The State of Emergency Medical Services in the USA
TV shows like Emergency! and ER contributed to form a public perception of what the
American emergency medical services (EMS) system is like. Viewers became used to seeing
hero paramedics take control of life and death situations, forming a perspective in their minds
that American EMS is full of thoroughly-trained paramedics who save lives every day. Its
almost taken for granted that no matter where or when, your own hero paramedic will show up
when you are in a crisis. The reality of American EMS is much more complicated, and frankly
disconcerting. American EMS is comprised of a myriad of career and volunteer organizations, all
full of different training levels. Depending on your location, you might get the hero paramedic
at your door in five minutes, but its much more likely that outside of a major metropolitan
area, you will be waiting for volunteer EMS providers who are more than likely underprepared
and disorganized. As the aging American population continues to rise, and epidemics like the
heroin overdose crisis continue to snowball, EMS systems become more in-demand every day.
Its time for EMS to join the rest of the medical community and strive for a nationally
requirements, and development as a career field to keep experienced providers working the
To begin discussing the issues plaguing EMS, its important to understand how young
the career field is. The first rescue squads were formed mostly of volunteers, often in
conjunction with funeral homes, and they staffed ambulances that were little more than
hearses with a siren attached. The level of training was low, and they carried a stretcher, along
with some cigarettes and the alcohol of choice. The first EMS systems were little more than a
Things began to change in 1966 when President Lyndon B. Johnson received a report
called Accidental Death and Disability: The Neglected Disease of Modern Society. This report
identified that in 1965, vehicle accidents killed more Americans than were killed in the Korean
War. The report claimed you had a better chance of surviving injury on the battlefield than
injury on any city street in America. It also identified a lack of organization and standard
training among the EMS systems that did exist at the time (Edgerly). This report, known as the
White Paper, made the first recommendations for a standard curriculum for EMS personnel.
The EMT was born. Still, medical professionals believed more could be done outside of the
hospital. EMTs began to receive advanced training from physicians and nurses on how to gain
IV access, administer drugs, and perform ACLS (advanced cardiac life support) in cardiac arrest
patients. Absolutely no standards had been set for these providers, and so any EMT could
receive some training from a physician and declare themselves a paramedic. In 1970, the first
governing body for EMS providers was established, known as the National Registry of EMTs.
Still, even paramedic education wasnt even somewhat standardized until 1977 when the first
NREMT Paramedic exams were introduced. Up to 40 different levels of certification have been
declared by the NREMT, most of them since phased out of service. Today, the NREMT issues
four levels of certification. The lowest is the Emergency Medical Responder, a low level of
training common among volunteer firefighters and policemen that doesnt certify the provider
to even transport a patient to the hospital. There is also the EMT-B, the most basic level of
transport provider, the AEMT, a slightly more advanced version of the EMT able to start IVs and
administer some drugs, and the Paramedic, able to run the full gamut of prehospital care. This
doesnt stop local jurisdictions from recognizing even more levels of certification such as the
EMT-Intermediate, the EMT-Cardiac Technician, the EMT-Military, and the Critical Care
Paramedic, just to name a few. This has created a disorganized and confusing environment
where the public doesnt know who is coming to their door, and levels of education are too low
EMS needs to become a nationally standardized system. Even though the NREMT has
declared four levels of certification nationwide, this hasnt stopped localities from
grandfathering in older certifications and recognizing certification levels that exist outside of
the current national system. For example, specialty certifications within EMS are handled by a
completely separate system from the NREMT. The International Board for Specialty
Certification (ISBC) handles advanced paramedic certifications such as the critical care
paramedic, flight paramedic, and tactical paramedic (Widmeier). One system needs to be able
to handle organizing all EMS certification levels instead of the current alphabet soup that makes
it difficult to track and standardize the actual levels of certification that exist within our EMS
system.
volunteer and career staff. Most volunteer EMS systems in America are failing. Americans have
less time to spend working for free, employers are no longer okay with employees leaving when
paged to answer a 911 call, and the increasing level of education necessary to be an effective
EMS provider are pushing volunteers out of a field once solely provided by volunteer workers.
American EMS needs to standardize career employees who have the time to dedicate to the
increasing amount of training and demand in the EMS service. No locality expects their
policemen or teachers to work for free, why is EMS any different? This issue is perhaps most
prevalent in New Jersey, where most of the first responding EMS units are provided by
volunteer departments, with hospital based career paramedics arriving later to transport.
Volunteer services are declining so much in New Jersey that it often takes 40 minutes for an
ambulance to arrive, and that ambulance is normally the hospital paramedic squad anyway. For
example, a call in New Jersey might go something like this: in July 2013, Francisco Reyes dialed
9-1-1 for an ambulance when his elderly mother-in-law fell down the stairs of her Hasbrouck
Heights home, fracturing her skull and injuring her spine. Police and paramedics showed up
quickly. But it took 34 minutes for an ambulance to arrive from neighboring Hackensack, since
the Hasbrouck Heights squadbased just one mile awaydidnt respond. We know that its
taking patients 20, 30, 40 minutes to get to the hospital on a regular basis in New Jersey, says
Merlin, referring to local dispatch records. Yet we dont have hard data on [statewide]
response times and health outcomes because volunteer squads dont have to report quality
measures to the state. (Rosen). Career ambulance crews need to be readily available,
especially in such a densely populated area as New Jersey. Volunteers dropping the ball in life
and death situations because there arent enough of them anymore is not an acceptable excuse
Another issue plaguing EMS is the lack of standard education requirements. EMS is a
career field based on certifications. An EMT-B license can be acquired by taking a two-week
course tailored to passing the NREMT examination. This doesnt even come close to setting a
provider up with the knowledge that will make them effective in the field. Even a full paramedic
needs substantially less education than a similarly skilled healthcare worker. Paramedics have
more autonomy and responsibility than the standard nurse, but most nurses in the current
workplace have at least a bachelors degree in the field. A fully certified paramedic in the
current system can earn their certification in a matter of months through certain programs. For
such a broad skillset, EMS workers are trained like standard laborers in any blue-collar field.
Even some hair stylists will end up with more education hours than a paramedic, as most hair
stylists must go through at least 2,000 hours of accredited training. An EMT can earn their
certification after taking a course with as little as 120 hours. The first accredited paramedic
programs were about 400 hours with 200 field internship hours.
In addition to low classroom requirements, most EMS providers are not required to go
through much disaster training. EMTs and paramedics are required to respond to anything from
tornados and hurricanes to active-shooter situations and terrorist attacks. 343 firefighters and 4
paramedics died on 9/11. This is a career where providers will be expected to enter dangerous
situations, yet they can be placed in charge of an ambulance and a patient without any kind of
This doesnt even begin to touch how requiring college degrees would encourage
critical-thinking and raise the average paramedic from a technician level of understanding to a
clinician level, being able to provide their patients with the best possible care.
The final solution to improving EMS in America is developing EMS into a true career
field. The turnover rate in EMS is sky high, with most paramedics leaving the job young and
going to school to be a nurse, doctor, physician assistant, or leaving the ambulance behind to
work on the fire truck. The root of this issue lies in a few key aspects; EMS has no route for
workers too old for the job or who become injured on the job. If a paramedic cant work in the
field anymore, there are almost no jobs left for them to take. EMS also doesnt have any room
for growth. The highest level of training a paramedic can really achieve is to be a Critical Care
Paramedic. Physicians, PAs, and nurses are almost never utilized in the field, and to become a
Critical Care Paramedic doesnt have much incentive, the average salary of a Critical Care
Wages in EMS are horribly low, largely in part due to the low education requirements
for becoming an EMT. EMTs are a dime a dozen, and paramedics are only slightly rarer. It
makes sense that the field is currently just a stepping stone to other careers. Unfortunately, this
keeps the level of experience providing care on the streets low, and contributes to the
unorganized and underprepared state of EMS. This can be solved by turning EMS providers into
true professionals through more stringent education requirements, eliminating volunteers from
Naturally, there are disagreements on how to handle bringing EMS into the future.
Many jurisdictions favor utilizing the volunteer system, even so far as to lower the
full EMS staff is expensive, especially when paid providers increase their education level and
demand to be compensated like the professionals they are. In New York, discussions are taking
place among legislators on whether the standard certification needed to provide volunteer EMS
should be lowered from the EMT to the EMR level. This would allow localities to continue
staffing their volunteer departments and meet volunteers in the middle regarding how much
time they need to spend training to be competent (Hsieh). This is without a doubt a step in the
wrong direction. Not having enough volunteers is not an excuse for allowing less competent
providers to be responsible for a patient, it is instead proof that paid professionals need to be
utilized more heavily in the American EMS system. Again, why should EMS providers be
expected to work for free when policemen and teachers are paid without a second thought?
Even firefighters are deemed as being worthy of more pay, as they make more in wages than
paramedics and EMTs in the current system. This is completely backwards, as 85% of the calls
fire departments respond to are medical calls where an ambulance is needed. A possible
solution is even a reversal of the fire and EMS services, where fire is comprised mostly of
volunteers with some career personnel to run day-by-day operations while EMS providers are
24/7 career employees who are properly trained to respond to medical crises.
The current state of the American EMS system is not conducive to effective emergency
medical care. Providers are undertrained and unorganized. The American EMS system needs to
enact true national standardization, more stringent education requirements, and career growth
in order to provide all people with effective prehospital care and transport. Volunteers should
be eliminated, or at least heavily reduced, in order to give career providers true professional
status and the pay that comes with, therefore reducing turnover rate in EMS and putting more
experienced providers on the streets. Most fire departments respond predominantly to medical
calls, and resources should be allocated accordingly, allowing more funding and priority to EMS
personnel. Certifications shouldnt be the only requirement for EMS providers to operate, and
formal education beyond a high school diploma needs to find its place in the field. EMS is a
young career in the perspective of all things, but records show that it has cemented itself as a
necessary public service with little room for error, after all, the public image of the paramedic is
the hero who inserts himself into life and death every day, and always comes out on top.
Works Cited
Caffrey, Sean. Why EMTs, Paramedics, Don't Get Paid Enough. EMS1.Com, 9 Mar. 2017,
www.ems1.com/paramedic-chief/articles/203118048-Why-EMTs-paramedics-dont-get-paid-enough/.
Edgerly, Dennis. Birth of EMS: The History of the Paramedic. Journal of Emergency Medical Services, 8
Oct. 2013, www.jems.com/articles/print/volume-38/issue-10/features/birth-ems-history-
paramedic.html.
Emergency Medical Services at the Crossroads. Washington D.C., National Academies Press, 2007.
Hsieh, Arthur. A Step in The Wrong Direction: Reducing EMS Certification Levels. EMS1.com, 2 Aug.
2017, www.ems1.com/ems-management/articles/293558048-A-step-in-the-wrong-direction-Reducing-
EMS-certification-levels/.
Patterson, P. Daniel, et al. The Longitudinal Study of Turnover and the Cost of Turnover in EMS.
Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the
National Association of State EMS Directors, U.S. National Library of Medicine, 6 Apr. 2010,
www.ncbi.nlm.nih.gov/pmc/articles/PMC2883888/.
Rosen, Peg. Terminal Case: The End of Volunteer First Aid. New Jersey Monthly, 16 Dec. 2015,
njmonthly.com/articles/jersey-living/terminal-case/.
Widmeier, Keith. Specialty Certifications in EMS. Journal of Emergency Medical Services, 9 Sept. 2015,
www.jems.com/ems-insider/articles/2015/08/specialty-certifications-in-ems.html