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A Troubled State, Part 3: What Can We Learn from Iowa’s Experience?

This is the third in a four-part series written in response to several articles published in the Des Moines Register in April that outlined significant design and response challenges facing Iowa’s EMS system. Find the original articles at

Last month we looked at the lack of state-level mandates for EMS in local communities and at the roles of, and the issues surrounding, state EMS offices. This month we look at the roles played by volunteers in America’s EMS systems—the good, the bad and the ugly.

EMS as we know it began in the late-1960s and early-1970s. At that time, many of today’s EMS organizations and systems began with volunteers. Prior to that time, a few large urban cities had paid ambulance services, and some smaller communities were served by ambulance services operated by funeral homes or towing and wrecker services. But volunteers provided basic life support-level care to a huge portion of the United States. Most of my generation of paramedics came out of the volunteer services, with a smaller contingent having roots in the enlisted medical services of the armed forces (Army medics, Navy hospital corpsmen and Air Force pararescuemen). My own start included both—I served as a Navy hospital corpsman, where I got a great medical and EMS education, and I served as a volunteer in ambulance corps and rescue squads from 1973 until 1988.

During that same timeframe, call volumes were much lower than we see today. There weren’t many “frequent fliers,” interfacility transfers were extremely rare, and ambulances were called for only when very bad things happened. This made for an interesting environment at the local squad building. We trained a lot because things were very new, and we learned about and cared for our new equipment. We also developed a terrific social environment, with music, television, pool tables, ping-pong and other diversions. Heck, our next-door volunteer fire house had an open-tap keg policy with cold beer always available. We raised funds with bingo, bake sales, fish fries, chicken barbecues and field days, just like our brethren in the volunteer fire companies.

Over those years, our volunteer rescue squads became very important to our communities, and for many, they became the center of the social life of their members. They organized into “district councils” and state associations and, in some states, they gained great political influence. The New Jersey State First Aid Council was able to get a law passed exempting its members from regulation, and even as recently as this year they were able to pressure the governor into twice vetoing a bill that would have imposed minimum standards on every EMS organization in the state.

These groups began to oppose anything that would make it more difficult to “stay volunteer,” even if those things would improve EMS care and be better for the citizens of the community. Examples of such changes that were opposed include increased educational standards; mandatory performance standards; age requirements (to make sure emergency care was at least provided by adults); reporting of clinical and operational performance data; and background checks to make sure thieves, violent criminals, sex offenders and drug abusers didn’t show up in response to a call for help. It became more important that the service “be volunteer” than that it provide high-quality care delivered by competent and trustworthy individuals. In short, the train had come off the tracks, and in many communities and states it remains so today. The mission—providing quality emergency medical care to the community—had been superseded by the desire to maintain control of EMS in the hands of the volunteer group. Career EMS folks, on the other hand, unfortunately seem unwilling to organize and balance the volunteer force, so in many states the volunteers hold all the political “cards.”

The availability of volunteers willing to serve their communities has, for the EMS community, been a mixed blessing. There are areas in the United States where it would be costly and inefficient to deliver EMS with career personnel. Not that it would be impossible—those areas are able to fund to their level of desire and satisfaction schools, financial services, retail services, healthcare services, plumbers, electricians and contractors, as well as law enforcement services, all of which rely on career personnel. But these areas have enjoyed nearly-free services for so long it would be a major shock to their financial environment to have to pay the cost of career EMS personnel.

On the other hand, career EMS personnel often bemoan low salaries relative to their expertise. A law enforcement officer with six months of training may be paid twice what a paramedic with one to two years of training is paid. One of the major factors in the salary-setting process (conducted by human resources professionals) is finding out what “the market” pays in the county, region or state under discussion. The results get plugged into a formula and where a significant portion of the salaries are $0.00 per hour, those numbers tend to lower the regional compensation base. While the market drives salaries in the private sector, compensation decisions in the public sector are made (or at least approved) by elected officials. It is hard for a city counselor or county supervisor to understand why paramedics in his county should be paid a higher-than-minimum wage while two towns or one county over EMS personnel are not paid at all.

The issue of training and educational standards and the influence of volunteers on those decisions remains a great concern. Personally, it frustrates me that the educational requirements for entry-level and advanced EMS practitioners in the United States are the lowest of any “first world” country. Canada’s entry-level “primary care paramedic” program is twice as long as the U.S. EMT standard. In Australia, entry-level paramedics receive a three-year baccalaureate degree prior to entering the workforce. The result is their paramedics are better-compensated, more respected as professionals, and enjoy a much greater degree of autonomy and self-regulation than their American counterparts. In both Canada and Australia, paramedics are considered among the most respected professions when communities are surveyed. In the United States, nobody in EMS is even on the list! To this observer, it appears the negative influence of the American reliance on volunteers EMS providers is at best a draw, at worst a detriment.

So where do we go with from here? Can we harmonize the involvement of volunteers with the delivery of quality, progressive emergency care and its offshoots, like community paramedicine? I think we can, but it will take some significant changes in the way we do business.

There was a time in my life when, because I worked for the state EMS office, I was not allowed to affiliate with any EMS agency, career or volunteer. I learned that in my new state, volunteers were also utilized in law enforcement—as fully sworn officers, armed with powers of arrest. So, needing some of the “street action” I’d experienced for 20 years, I got involved. Yep, I was a volunteer cop, a sworn reserve deputy sheriff. There was a difference, however. The volunteers worked with, and for, the career staff. The sheriff, himself a career law enforcement officer, was fully in charge. Training standards were set by the state, and they were the same as those for career officers. It was the same with field training and evaluation, etc. Volunteers were free to—and did—serve their communities, helping to improve the quality of life, and keeping the taxes low. But they were not a political force and, in fact, the reserves provided a great impetus for new and additional training and activities. The career guys trained during the week, in 40-hour blocks, and the reserves trained evenings and weekends. It took a little longer, but it worked.

The career staff played another balancing role in this environment. Through the Deputy Sheriffs’ Association, the “regular” guys made sure the reserve force remained a supplement to the career staff and didn’t get “outside the lines” of the mission and goals of the sheriff’s office.

Lest I be cast as an enemy of volunteers in EMS, I am not. But I do believe the pendulum has swung too far toward the “status of volunteer” side of the arc, and away from the “best possible patient care and service delivery” side. I think it is possible to get this back in harmony, but it will take some effort. The volunteer community needs to step up and re-focus itself on being the most modern, progressive, best EMS practitioners they can be, not the force that keeps the rest of EMS from moving forward. And the career EMS cadre needs to step up, participate in politics and governance, and serve as a balancing force to the volunteer organizations.

Asking too much? I sure hope not!

Skip Kirkwood, MS, JD, EMT-P, EFO, CEMSO, is drector of Durham County (NC) EMS, past president of the National EMS Management Association and an editorial advisory board member for EMS World. He previously served as Chief, Emergency Medical Services Division, Wake County, NC.

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