Ethan Hamilton

August 26, 2017

ENG 112 College Composition II
Tues/Thurs 11:00-12:15
Argument #1

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

standardized system of equally trained career employees, more stringent education

requirements, and development as a career field to keep experienced providers working the

streets instead of moving to greener pastures.

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

service to the dying.

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

to create fully prepared providers.

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.

In addition to a disorganized certification system, American EMS is provided by a mix of

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

for subpar care.

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

training in how to work in a true disaster.

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

Paramedic is $36,000 (Glassdoor).

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

the system, and allowing room for growth in the field.

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

requirements to become a provider in a volunteer system to keep membership up. Fielding a

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