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EMS Workforce Issues


     Nels Sanddal is president of the Critical Illness and Trauma Foundation (CIT), a private nonprofit organization whose focus is on improving outcomes for people who become suddenly ill or are injured in rural areas. He recently completed a three-year assignment as director of the Rural Emergency Medical Services and Trauma Technical Assistance Center (REMSTTAC), a CIT program. He has been involved in EMS for more than 30 years and has held multiple state, regional and national positions in organizations furthering EMS causes. He recently served on the editorial board for the Rural/Frontier EMS Agenda for the Future and the Institute of Medicine's (IOM) Future of Emergency Care in the U.S. Healthcare System reports.

What were the major issues identified in the Institute of Medicine's report regarding the EMS work environment?
     Aside from the workforce issues of increasing turnover, challenges with recruitment and concern with worker wellness and safety, the main focus was on volunteers and whether the volunteer model (which is still an extremely strong presence in EMS) is sustainable. Over the next decade there will be migration away from the volunteer workforce and mixed models will become more common. A major challenge in this paradigm shift will be defining what additional roles this new workforce can play in the healthcare and public health arenas.

What, if any, recommendations did the IOM's Prehospital Emergency Medical Services Subcommittee make given these issues?
     There were two recommendations:

  1. That Congress appropriate $88 million a year for five years for demonstration projects in various regions of the country. Some portion of this appropriation must include large rural areas so that we can test various alternative staffing models and find best or promising practices.
  2. Establishment of an advisory committee to work with CMS to change policy regarding EMS reimbursement so that organizations can attempt to recoup for "readiness" costs. Also, that there be reimbursement opportunities that are not tied directly to transport (i.e., treat and release, or even assess and referral to an appropriate clinic). This opens up the option for alternative models for EMS personnel.

While it seems as though other emergency medicine specialties have experienced significant professional growth and development in the past 30 years, for the most part, EMS has not. Do you believe that this stagnation is a result of the EMS workplace environment?
     I think EMS as an industry has at times been its own worst enemy. As individual prehospital care providers, we have attempted to shift blame for our shortcomings onto oversight agencies or governmental bureaucracies, but the reality is that we have not always acted in our own best interests. We are too mired in tradition and haven't embraced change in regard to prehospital medicine. We also tend to have this notion that "more" or "new" is always better without having statistically valid, solid research to document that the change will meet our true operational needs. For example, it doesn't make any sense for a barely surviving rural BLS service to become an ALS service just because ALS is "more." I also feel that a great deal of the workforce dilemma is currently related to the maldistribution of personnel. This can be demonstrated by some fire services' perceived need to have a paramedic (or two) on every piece of fire suppression apparatus-a move that, despite research that challenges the wisdom of this response model, has been replicated in a number of communities around the country. We are also in a conundrum in regard to our identity. We have one foot in healthcare, one in public safety and yet a third in public health. The IOM firmly feels that EMS is part of the emergency healthcare continuum and that is where our first obligation needs to be.

What impact do you think a project such as the IOM report, as well as other initiatives like the Longitudinal Emergency Medical Technician Attitude and Demographic Study (LEADS) being undertaken by NREMT, can have on EMS as an industry in evaluating and addressing its workforce concerns?
     While consensus-driven processes can lead to important watershed documents, their impact on day-to-day EMS operation has traditionally been minimal. An organizational-level administrator doesn't understand there is a lot of ammunition contained in these various documents that he can leverage to his benefit, whether at the local, county or even state level, without recreating the wheel. A perfect example of this is currently occurring in Montana, where our legislature is in the midst of evaluating a bill that would do a two-year study of EMS needs. The IOM report was released less than a year ago, and chances are the Montana study will come up with nothing new. Unfortunately, the mind-set we deal with in EMS is that if we (whoever we is) didn't do the study or assessment, it will somehow be less applicable. We need to get over that type of intellectual parochialism if we're to see any meaningful progress in advancing EMS concerns.

Raphael M. Barishansky, MPH, EMT-B, is executive director of the Hudson Valley Regional EMS Council in Newburgh, NY, and a member of EMS Magazine's editorial advisory board. He can be reached at

Ray Barishansky is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit

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