EMS in the United States
BY ARTHUR HSIEH
© 2012 FrontLine Security (Vol 7, No 3)

Emergency Medical Services (EMS) defines a relatively young public safety profession in the United States, when compared to law enforcement and fire services. In a scant 50 years, the delivery of pre-hospital care and transportation of the sick and injured has evolved rapidly. This rapid development has challenges as well, frequently stemming from oft-ignored and underlying major structural concerns that have not been fully addressed.

A Brief History
Civilian ambulance services in the United States have existed since the mid 1800s, beginning in the major metropolitan cities of New York, Boston and San Francisco. Two major developments in the mid- 20th century improved the delivery of pre-hospital care. One was the successful demonstration of rescue breathing and closed chest compressions by non-physician medical personnel. Pilot projects conducted in Belfast, Ireland and Columbus, Ohio demonstrated that acute cardiac care and resuscitation could be rendered at the site of the emergency, before evacuating the patient to a hospital.

The second was the publication of a seminal report titled “Accidental Death and Disability: The neglected disease of modern society” which was released by the National Academy of Sciences in 1966. More commonly known as the “White Paper”, this report centered around the sobering fact that more Americans were dying from trauma in the United States annually, than from the Vietnam and Korean Wars combined. Importantly, the report recommended the development and implementation of “modern” emergency medical systems that could deploy quickly to arrive on the crash scene, render effective medical care and also transport victims safely to hospitals designed to care for trauma victims.

As early as 1972, national panels recommended the implementation of emergency medical systems on a nation-wide level, coordinated by the federal government. The 1973 EMS Systems Act was designed to implement those recommendations, however, funding was cut off in 1979 – resulting in an incomplete system. Today, EMS systems are organized along state lines, with each state coordinating and managing its own systems and personnel. Large states, such as California, further subdivided its EMS systems at the county level, delegating local regulatory agencies with much of the oversight for emergency medical services. The end result is a national system with very different service delivery models from one region of the country to another.

WHO DELIVERS EMS?
A common saying in EMS is “Once you’ve seen one EMS system, you’ve seen… one EMS system.” This is because significant variables contribute to the uniqueness of each system. One of the major variables relates to who provides the actual service. The following is a brief list of major service providers:

  • Fire Services: Fire departments have provided some level of EMS care  for many decades, often at a “first responder” or basic care level. Some departments such as Metro Dade (Miami, Florida) and Seattle (Washington) have cross- trained firefighter-paramedics on ambulances since the early 1970s.
  • Commercial Services: The private industry has a long tradition of providing ambulance transportation services, stemming from an era when hearses and ambulances were built on similar automobile chassis. In general, local governments contract with commercial providers for all of the EMS response within their jurisdictions. While many commercial services are for-profit, nonprofit organizations are also in existence.
  • Hospital-based Services: Similar to commercial services, systems owned and administered by health care organizations can also be found throughout the United States.

Government-based service providers (also called “third service”): governments may also provide their own EMS.

In a specific region, it is not unusual for EMS to be provided by a combination of two or more types of service providers.  Overall there are an estimated 20,000 agencies in the United states providing EMS services.

EMS PERSONNEL
While the specific scope of practice for the EMS provider is governed at the state level, there are four general levels of EMS practitioners in the United States.

  • Responder: The Emergency Medical Responder (EMR) has typically 60-90 hours of training designed to assist personnel render basic first aid at the scene. This may include techniques such as ­airway management, bleeding control, oxygen therapy, spinal immobilization, and childbirth.
  • Technician: The Emergency Medical Technician (EMT) has a range of 100 to 170 hours of training that expands upon the skills of an EMR, and adds a very limited range of medications to administer. Much of the additional classroom hours involve an understanding of human anatomy and physiology at a basic level.
  • Advanced Technician: The Advanced Emergency Medical Technician (AEMT) expands the scope of the EMT, primarily in advanced airway management and a greater number of medications. This level is a recent evolution from an older term known as EMT-Intermediates. In general, it takes several hundred hours to train an AEMT.
  • Paramedic: The Paramedic requires the greatest number of hours for a certification license (approximately 1200 or more). The student spends significant time in both clinical and field settings. The paramedic is the only level of EMS provider that is accredited by the Committee on Accreditation of Allied Health Education Programs (CAAHEP). Not all programs are accredited, but the trend is moving in that direction. The paramedic performs all of the skills of the EMT and AEMT, and has greater understanding of human anatomy, physiology and pathophysiology. They can administer a significant number of medications. Paramedics can insert endotracheal tubes to assist a patient with breathing, can initiate intravenous (IV) access, and perform a variety of electrical therapies for patients with cardiac rhythm disturbances, including cardiac arrest.

Overall there are about 826,000 licensed or certified EMS providers in the United States. Though working primarily within the emergency response system, EMS providers can also be found in emergency departments, urgent care centers, and other facilities.

Not all EMS providers are compensated for their services. There is a significant number of volunteers that either entirely support their community’s EMS response, or supplement the “career” or paid staff. This is especially true in rural regions of the country, although volunteer EMS organizations can be found in such densely populated cities as New York.

EMS providers that are compensated for their services are overwhelmingly underpaid. Various studies continue to show that compensation for EMTs and paramedics are generally much less than the country’s median income level of $52,000 USD. EMS providers who have been cross-trained as firefighters qualify for higher income levels.

How EMS is funded
Funding for EMS comes from a variety of sources. Much of it is reimbursed through healthcare funding sources such as federal Medicare and Medicaid programs and private health care insurers. Tax assessments also offset some of the operating costs. Overall, however, funding for EMS systems across the United States does not cover operational costs. The federal General Accounting Office (GAO) estimates that urban EMS transport is underfunded by 6%, while “super rural” transport is underfunded by 17%. Some EMS systems attempt to make up the shortfall through special district assessments and subscription models.

Challenges facing EMS
Over the past fifty years, the objective of covering the country with “wall to wall” EMS systems has largely been accomplished through the hard work of countless individuals and organizations. However, the development of the nation’s emergency medical response system has not been consistent nor fully effective. A host of challenges not only confront future U.S. EMS development, they actually threaten the existence of present systems.

Funding
As indicated earlier, funding for EMS systems is inadequate. Scarcely a week  goes by without a report of an EMS agency threatening to close its doors or reduce its level of service because of budget shortfalls. While underfunding results, to some extent, from the present global economic slowdown, it will continue to plague EMS systems nationwide.

Lack of Identity
There is a lack of clear understanding by the general public about what EMS is beyond emergency transport, and who provides the service in their community. Within the industry, the variety of associations, representing various perspectives of its mission, create a challenge to achieving consensus on political issues. Nationally, there are competing efforts to locate a federal home for EMS: the Department of Homeland Security, favored by the fire service, or the Department of Health and Human Services, endorsed by other more-healthcare oriented organizations.

At the local level, there is tension and occasional animosity between career and volunteer EMS providers. While volunteers view themselves as providing a service that would otherwise go unmet, career personnel argue that volunteerism depresses compensation throughout the industry and relieves government of the burden of providing such service.

Resistance to change
Essentially, the elemental mission of EMS response has not changed .Meanwhile, the nature of the average EMS call has changed dramatically, The majority are not urgent and do not require transport to an emergency department. This conflicts with the current funding philosophy where the majority of financial reimbursement is based upon transportation of the patient. Additionally, the training that EMS providers receive often does not address the issues of today’s EMS patients, remaining focused instead on providing rapid care to highly critical situations.

While several EMS systems are trying innovative ways to evolve the level and direction of care in their communities, most struggle to continue providing a “traditional” response.  Given the lack of funding, rapidly changing health care reform, and the spiraling cost of overall health care, systems must seek alternative ways to grow and thrive.

Summary
EMS in the United States has seen an incredible phase of growth and development during the past half century. Today, it stands at a crossroads where it must decide which way it should continue to develop, if at all. For all of its heterogeneity, EMS providers, and the public at large, believe that medical response and transport is a basic service, accessible to all people, regardless of their ability to pay. How we do it, who does it, and how we pay for it are the devils in the detail.

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Arthur Hsieh has been in the EMS profession since 1982. He has worked as a volunteer, line medic, educator and chief officer in private, third service and fire-based EMS. He is a published textbook author, editorial columnist and has presented at conferences nationwide.
© Frontline Security 2012

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