Asking the Big Questions

May 2024 will represent the 50th anniversary of EMS Week. As we approach this year’s EMS Week, we examine the importance of reflecting on our profession. How can we continue to honor the profession, take care of our clinicians and educate the public on the valuable role of EMS?

Here, we explore the challenges facing our community, our ever-changing roles and the collective work to be done.

 We asked the top voices in the industry to weigh in on the current forces shaping the EMS landscape and why we still have so much to celebrate.

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

Despite the challenge of recruiting, I don't think that the sole issue of recruiting is the base problem. Instead, I believe we need to change the culture of EMS. How do we go about doing this? 

First, we need to understand that the generations that are currently coming into EMS have different values than what those of us who began in the 70s did then and do now. That doesn't mean that their values are bad and ours were good, just different. The best way to do this would be to listen, really listen. 

Until we understand those that we lead, we're never going to be able to provide that kind of career that they will want.

What words of encouragement can you give to EMS professionals today?

For today's EMS professionals, I would encourage them to come into the profession with their eyes wide open. You need to understand that it's not going to be all lights and sirens and saving lives. Some of the biggest impacts that you are going to make will be simply holding a patient’s hand or placing a hand on the shoulder when you're dealing with a family member who has just lost a loved one. 

The other thing that I would suggest would be to make sure that you take care of your mental and physical health. The demands upon the EMS provider of today have never been greater! And because of that we need to be pretty active in addressing those mental and physical health challenges.

What should we be doing in the area of EMS provider wellness and mental health?

I have a vested interest in this area of mental health since I myself went through a really dark period that lasted four years. That time almost led me into the abyss and led me to the edge of suicide. Don't listen to those who tell you to simply suck it up. When you need help, whether it is physical or mental health, ask for it. The resources have never been more available.

How can we address the recruitment and retention issues facing EMS?

The issue of recruitment and retention is not limited to EMS. If you look across all areas of public safety, as well as healthcare, all of these industries are suffering a shortage. One of the things that I would suggest is to look beyond just EMS for potential solutions. Don't be afraid to look over to nursing, to fire, to law enforcement to see what the top agencies are doing to recruit, and even more important, to retain really good providers.

How would you describe the expanding role of EMS providers in 2023? What are the implications for personnel, leadership and communities?

The expanding role of EMS in the community really excites me. When I began back in the 70s, if you wanted to work in EMS, it was on an ambulance. Today you can find EMS in all areas of society. Because of this, especially within the realm of EMS education, we need to be preparing these providers to function in roles that are entirely different from JUST the prehospital arena. Our university is doing just this. We have expanded our educational content to address the paramedics that will be working in hospitals or physicians’ offices to provide care within their scope of practice.

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

Fire-based EMS is experiencing the same challenges as the rest of the profession: personnel shortages and poor reimbursement. There are no magic bullets that will help us overcome either challenge. We need to address recruitment starting in high schools, think outside the box with academy-style EMT courses for the public, finding ways to entice military veterans into EMS, and also help our leaders be more effective at retention. Municipalities and insurers need to fund the actual costs of response preparedness and care provided so that our members can be compensated competitively with other healthcare professionals.

What words of encouragement can you give to fire and EMS professionals today?

Emergency responders are a special breed. The work you do matters significantly. Despite rare shows of appreciation from the public, you are valued and needed today, tomorrow and every day.

What should we be doing in the area of fire and EMS provider wellness and mental health?

In this era of global increases in unhappiness, our members are even more challenged than the rest of society. They are the safety net for their communities. It is the responsibility of leadership and every member of every department to watch out for their brothers and sisters. Provider wellness refers to more than just how we respond to critical incidents. It means encouraging a positive workplace environment where people feel appreciated, welcome and accepted. The firehouse or EMS station is a home to our members. It should be a home they look forward to coming to.

How can we address the recruitment and retention issues facing fire and EMS?

There is no overnight solution to where we find ourselves today. A priority for every fire and EMS leader is to make our elected officials and communities aware of the struggles and challenges we are facing in recruitment and retention. Outside-the-box thinking is very necessary if we are to solve our industry problems. Newer and younger leaders may well offer some unique ideas and solutions that we might not have considered ourselves.

How would you describe the expanding role of fire and EMS providers in 2023? What are the implications for personnel, leadership and communities?

COVID showed our communities and our healthcare colleagues the full capabilities of EMS. It allowed us to use our special skills and talents to vaccinate, test, treat and educate our communities. The implications of this are broad and will be long-lasting. Community paramedicine and continued involvement in solving healthcare problems will likely demand significant participation by fire and EMS well into the future. It is imperative that we stay seated at the healthcare tables in our community, actively involved in public health, hospitals and the full spectrum of service delivery.

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

EMS is critically underfunded at the local, state and federal levels. This underfunding, combined with overwhelming stress during the pandemic, has led to an extreme workforce crisis. This crisis has compounded stress for practitioners and agency leaders. It has also resulted in tremendous increases in mental health issues. 

Advocating for higher reimbursement levels, and changing reimbursement so that practitioners are paid for the services provided rather than only for transport, are among our highest priorities at NAEMT. Another key priority is advocating for grant funding to support programs that help our practitioners cope with stress and build their mental health resilience. 

What words of encouragement can you give to EMS professionals today?

Polls and surveys tell us that EMS is highly respected and valued by the community. Patients and their families routinely express their sincere gratitude for the care they received from EMS practitioners. Although we are under a great deal of pressure, we still show up every day for our patients, our co-workers and our communities.

NAEMT is aware of the workforce crisis and is advocating for positive changes by working with other national EMS and fire organizations as never before to address the challenges that EMS faces. Through this united effort, we magnify our message and make real changes happen.

What should we be doing in the area of EMS provider wellness and mental health?

All EMS agencies should recognize mental health resilience as a core component of agency success, and all agencies should have a wellness and resilience program. 

Their program should include a trained member of their staff serving as the agency’s mental health resilience officer, who can raise awareness about mental health, create a culture of resilience and emotional wellness within the agency, and navigate colleagues to the right services in the community. All agencies should be able to refer their personnel who need professional care to a trained, licensed and qualified mental health professional with experience providing care to EMS practitioners.

How can we address the recruitment and retention issues facing EMS?

There are three main approaches. First, we need to work as a united front with other national and state EMS and fire organizations to secure more funding for EMS, so that we can increase pay and benefits, improve working conditions, and make EMS a more attractive career option for more people.  

Second, EMS agencies and educational institutions must work together to recruit a greater diversity of students into the EMS education system, support them during their education, and welcome them into the EMS profession once they graduate.

Third, all agencies should have a meaningful EMS workforce engagement program that helps EMS personnel feel valued, appreciated and respected. 

How would you describe the expanding role of EMS providers in 2023? What are the implications for personnel, leadership and communities?

EMS practitioners are now providing medical care in a variety of settings. Our role has become much broader than ambulance transport.

EMS practitioners provide a full array of emergent, urgent and preventive patient care to those in need in prehospital and out of hospital settings. EMS is an integral part of our nation’s healthcare system and has been proven to be effective in major public health emergencies. There are many opportunities for paramedics and EMTs in EMS and the broader healthcare community as well.

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

I think the number one issue facing EMS today is the workforce challenge – retention and distribution. Notice that I didn’t say shortage. Overall, the number of EMS clinicians the National Registry tests and certifies continues to increase year over year, and the number recertifying remains relatively constant. But, we aren’t retaining EMS clinicians, and those that do stay are finding opportunities in other areas of healthcare – they aren’t necessarily in the back of an ambulance where we do need people.    

The second issue is reimbursement. Though it is something that is outside of what we do at the National Registry, it is having a direct effect on EMS agencies and is a contributing factor as to why EMS clinicians are not getting the proper level of pay. That, of course, puts us right back at problem number one – retention and distribution. 

The third challenge is the recognition of our profession. Despite more than 50 years of existence, EMS has not been recognized in the same ways as other public health and public safety professions. We have the ingredients – education, certification, licensure and associations. But we haven’t achieved the level of legitimacy in some regions or states that others in public safety, public health, and/or medicine have achieved.  

In terms of addressing the issues – from the National Registry’s perspective it starts with valued partnerships that we have forged with others in the industry. We are working closely with the National Association of EMTs (NAEMT), the National Association of State EMS Officials (NASEMSO), the American Ambulance Association (AAA) and many others to understand these challenges, to conduct research and to understand the data so we can make informed decisions and choices to have a positive impact in addressing the workforce challenges, the lack of reimbursement, retention and recruitment.  

The National Registry’s Research Team has played a valuable role in all of this. They conduct the studies, asking difficult questions and gathering important data that will eventually help us get to the root causes of these challenges. But we all must work in concert to bring change to our profession and I think we are seeing that happen.   

What words of encouragement can you give to EMS professionals today?

In speaking to the industry as a whole, I would say, we are not in this challenge alone. Other professions, including the nursing profession and other healthcare professions, are similarly challenged - workforce, pay, hours and so on. Collectively, we can have more of an impact. We can do a lot more to bring change if we work together than if we go at it alone. The National Registry is committed to working with our partners at the associations and throughout EMS to address these challenges as one voice in EMS rather than multiple, smaller voices. We are more powerful together.

To the individual EMR, EMT, AEMT or Paramedic, I would say, “Work with your organizations and believe in their efforts.” There are a lot of organizations and associations in EMS with many different specialties that can help shape your career in EMS.

What should we be doing in the area of EMS provider wellness and mental health?

We at the National Registry recognize the importance of wellness, mental health and overall well-being. We value this for the EMS clinicians and our industry as a whole. We recently did a pilot study focusing on the resilience, wellness and mental health of EMS clinicians – to measure and better understand what this means and our current status to help define the appropriate resources to help. An important piece to come from this is for the National Registry to give continued competency credit to EMS clinicians who are mindful and in tune with the importance of their own well-being, mental health and overall health. We are working with CAPCE and others to determine what that looks like moving forward. 

We also have data that shows the top two reasons for leaving EMS over the past few years are COVID and burnout. So, it is clear that we have to take better care of ourselves, and we have got to make sure we have that resilience and focus on our own well-being.  

How can we address the recruitment and retention issues facing EMS?

The National Registry has been and will remain committed through our research team and other venues, to better understand what is happening with recruitment and retention. We want to determine and understand the reasons why people are leaving the profession.   We are focusing on EMS education because that is the gateway or the portal into the EMS profession. From a retention perspective, we are working with employers and other associations across the industry to better understand the reasons why people leave and then we are searching for solutions and resolutions to the issues. 

How would you describe the expanding role of EMS providers in 2023? What are the implications for personnel, leadership and communities?

I think one of the positive aspects of the expansion of roles in EMS is diversity. You know the rest of the world recognizes the value that EMS provides to our communities, both at the local level as well as the state and national level. The challenge is that as we put our workforce into all these new and different avenues, we spread ourselves too thin. And that, of course, is a contributing factor to the earlier question about workforce challenges.  

I think that expansion is great as long as we can increase the number of people entering the EMS profession itself. Expansion also gives us greater opportunity for a higher level of management within EMS.  

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

Some of the top challenges facing EMS today are staffing, education and the increasingly complex nature of patient care in the rural setting. The National Volunteer Fire Council (NVFC) is mindful of the challenge of maintaining adequate volunteer staffing levels for many rural EMS services, which is forcing many areas to reduce services or close their doors altogether. The lack of volunteers comes from the increase in the initial educational requirements which makes recruitment difficult. Many rural areas of our country are covered by volunteers who provide a valuable service. The ability to keep staffing levels adequate needs to be a main focus by tailoring education to meet the needs of the community. Utilizing technology and hybrid courses can help draw upon a vast wealth of knowledge and have it delivered to small class sizes in the areas that have the most need. 

What words of encouragement can you give to fire and EMS professionals today?

The words of encouragement that I can give to our front-line responders today is that you’re making a difference, you’re saving lives and you’re the lifeline in your communities. Without the brave men and women who give up their time and talents on behalf of the communities they serve, many people would be underserved and left waiting for help. Continue the great work as we work on elevating the profession to be recognized as the vital resource it is. 

What should we be doing in the area of EMS provider wellness and mental health?

We definitely have started in the right direction with regards to provider wellness and mental health, but we have a long way to go. We need to devote more resources into our personnel to ensure their own mental wellbeing and wellness. It is not easy to see the things we see and do the things we do, and it needs to be ok to say, “I am not ok.” We also need to not wait until responders say they need help; we need to proactively provide the tools, benefits and resources to get ahead of the issues so that providers don’t get to the edge of the cliff with their wellness. 

How can we address the recruitment and retention issues facing fire and EMS?

Recruitment and retention are huge issues in the volunteer fire and EMS service. We need to focus on programs that build up our staffing by reaching out to young people and share the passion through youth and cadet programs. Then as we onboard new people, we need to provide strong positive leadership, growth opportunities and mentorships. We need to refrain from “eating our young.” Retaining our people is just as important, and valuing their time and efforts is a great starting point. It is easy to overwork and understaff, but this leads to burnout and loss of personnel. Even the greatest human assets can only do so much, and by working to prioritize them will help them give more for longer.  

How would you describe the expanding role of EMS providers in 2023? What are the implications for personnel, leadership, and communities?

EMS providers are being asked to do more every year. Ambulances have turned into mini emergency rooms and the scope of practices are increasing. Providers are being asked to do community medicine and outreach along with advanced skills that were once thought only to be performed in the hospital setting. These issues require more education, more equipment and increased budgets. Often communities are already facing budgetary constraints amidst the expectation to do more. EMS and community leadership need to come together, along with the public in town hall meetings to discuss what is required, what is expected and what are the realistic capabilities of the personnel and agency. Community investment in the services being provided will be vital in the future growth of capabilities and funding.

What are the top two or three challenges facing EMS today, and how does your organization think we should address them?

The biggest challenge coming out of the pandemic is really to find a way to sustainably continue to serve our communities unscheduled health care needs. We’ve seen prices for everything from band-aids to ambulances sky rocket and that’s when we’re fortunate enough to find some to buy. Salaries have become a bidding war in a way most of us would have liked to see years ago but, unfortunately, revenue hasn’t kept pace with what agencies of all types need to keep up with the bidding war. Volume has been going up and up with more and more of those calls being for low to very low acuity calls. We’ve seen more and more un- and under-insured patients which, combined with insurance companies paying less and less, means much less revenue to keep up with price increases.

This is happening not just to private companies but municipal ones as well. It’s truly a national issue that is leading us to crisis. As my agency’s director, Ken Simpson, has been saying… EMS is the duct tape that holds the emergency healthcare system together and our tape is about to break.

EMS has historically been considered a transportation benefit with payment provided only for transport. Not only are we not paid for the care we provide, but we’re paid only for the calls we run, not the calls we must be ready to respond to 24/7 with short response times. The system is failing and it is failing at an increasingly faster rate.

My organization is adapting in several ways. We’re re-focusing on our 911 call triage to focus our most resource-intensive responses to only those EMD determinants with the highest acuity, those that a rapid response actually has clinical benefit for. We are also moving our system from an exclusively ALS one to a tiered system with a majority of BLS units paired with fewer paramedics in non-transport units, as well as looking at ways to better meet the needs of those very low-acuity patients who can be cared for without transporting them to the hospital at all, thus freeing up transport units for those the highest-acuity patients.

What words of encouragement can you give to EMS professionals today?

While this is a challenging time, it is also a very exciting time. EMS was ‘born’ around the same time I was. I’ve always read the history of EMS and felt it must have been so exciting to be there as an entire new profession was born and the EMS system we know today was developed. I think we are at a point now where our systems are going to be undergoing dramatic change. While change can be scary, we also have the opportunity to build a system that better serves our patients AND our clinicians.

What should we be doing in the area of EMS provider wellness and mental health?

Our clinicians are our most important assets and we need to treat them like it. We pour tons of money and resources into hiring and training clinicians but not nearly as much on making their jobs safe, rewarding and intellectually stimulating. We also need to recognize the toll this job takes on our clinicians, particularly in this time coming out of the pandemic. We need to clearly acknowledge the dangers of substance abuse and suicide lurking within our midst and provide support for dealing with them but also be methodic about identifying the underlying causes for this stress and actively mitigate it.

How can we address the recruitment and retention issues facing EMS?

Recruitment is hard and there are no easy answers to it. We have to understand what brings people into our profession, make sure that we are transparent about what the actual job is and isn’t. We should be clear that we are recruiting servants to a profession that isn’t just about saving lives, but making lives better in small ways. We also need to design our systems around making our clinician’s jobs and lives on the job more manageable. This may mean alternative schedules that better match their personal schedules, providing more frequent feedback, more education, and, of course, salaries that keep up with the expenses they’re facing.

How would you describe the expanding role of EMS providers in 2023? What are the implications for personnel, leadership and communities?

Most systems around the country are facing higher call volumes at lower acuity. We have designed our modern EMS system to meet the needs of high acuity patients well and we must continue to maintain that ability. We must recognize, however, that the same design of maximum resources with maximally trained clinicians may not be the best, most sustainable system for the demands we are seeing. Most systems will need to find ways of responding to those low acuity patients and serving them where they are, often not transporting them to the hospital. This almost certainly means a different scope of practice for some of our providers, likely focused more on lower acuity conditions. Our leaders, particularly our political leaders, need to deeply understand the changing dynamics of our health care system and decide to financially support medical readiness and not just transportation.