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State Department: California

If you’re an EMS worker who is thinking of relocating or just wants to learn more about life across the U.S., EMS World’s State Department is worth a look. We start with “snapshots” of featured states, then bring you exclusive guidance from local EMS leaders. Our goal is to highlight everyday aspects of potential destinations from a prehospital provider’s point of view.

California Snapshot

  • Approximate number of EMS providers: 62,000 EMTs, 120 AEMTs, 23,000 paramedics
  • Average straight-time wages: EMT $14.30/hour, paramedic $25.07/hour1
  • Cost of living index: 145.3 (U.S. average = 100)10
  • Recertification cycle: 2 years
  • National Registry certification: Required for initial license and reciprocity but not renewal
  • Opportunities for volunteers: Some in rural areas; about 98% of providers are paid
  • Large EMS employers: AMR, Los Angeles County Fire, Los Angeles Fire, Falck
  • Paramedics with degrees: Not a major issue but a consideration for advancement
  • State EMS website
  • Approximate state population: 39,537,000
    • Change since 2010: +6%
    • Average population per provider: 465
  • State area: 163,695 square miles
    • Average population per square mile: 242
    • Rank (↓): 11
  • Most populous cities (approximate): Los Angeles 3,976,000; San Diego 1,407,000; San Jose 1,025,000
  • Violent crime one-year change: Los Angeles +2%, San Diego -5%, San Jose 0%2
    • State violent crime rank (↑): 363
    • State property crime rank (↑): 243
  • Health rank (↓): 174
  • Top state income tax: 13.3%6
  • Average sales tax: 8.5%6
  • Average property tax: 0.76%6,7
  • Median home value: $544,9008
    • One-year change: +6.5%8
  • Median monthly rent: $2,7508
  • Average cost of electricity: $0.21/kwh9
  • Average temperatures: Summer 73ºF, Winter 46ºF5

Plenty of Attractions

What’s California like? Big and diverse—the most populous and third-largest state—with major cities, sprawling suburbs, and unspoiled wilderness north and south. Its climate, culture, and attractions offer something for everyone. Consider these features:

  • California is roughly 250 miles wide, with 50-degree temperature differences between coastal and inland areas due to the state’s distinctive topography. We’re talking mountains and valleys, but not just any mountains and valleys: the highest peak in the contiguous U.S., Mt. Whitney (14,505 feet), and the lowest point in North America, Death Valley (282 feet below sea level).
  • California has 840 miles of shoreline that stretches from the Northwest to the Mexican border. Only Florida and Alaska have more oceanfront territory. Average summer temperatures vary by 20 degrees from Eureka in the north to Los Angeles in the south.
  • With so much access to the Pacific coast, it’s not surprising that water sports are a prime source of recreation—but so is skiing.
  • All five major professional sports—football, baseball, basketball, hockey, and soccer—are represented by at least three teams each and 20 in all.
  • California has two of the five most populous urban areas in the country, Los Angeles and San Francisco, but 45% of the state is forest, and 25% is desert.
  • Per the Modern Language Association of America, 43% of Californians speak languages other than English at home.
  • California’s tourist attractions are as dissimilar as they are famous, from grandiose amusement parks like Disneyland to natural preserves like Yosemite National Park.

Disasters and Other Challenges

More important than climate or recreation to some incoming EMS personnel would be environmental challenges posed by California’s geography. Wildfires were the most publicized risks to health and property in 2018, but you can add floods, droughts, tsunamis, strong winds, landslides, earthquakes, and volcanos (eight in the state are primed for eruption, according to the U.S. Geological Survey) to the list of conceivable West Coast disasters. Those could be deal-breakers or career-defining events, depending on your point of view.

Howard Backer, MD, MPH, FACEP, FAEMS, director of California’s Emergency Medical Services Authority (EMSA), oversees a multilevel disaster management system that includes ambulance strike teams and widespread access to patient details through SEMS—the Standardized Emergency Management System, a precursor to the national NIMS database. “The counties have primary responsibility for operations,” he says, “but we have mutual-aid support at the regional level and then, of course, the resources of the state.”

Most recently EMSA’s disaster teams were activated in November for the first of the catastrophic wildfires in Butte County, 90 miles north of Sacramento. The town of Paradise was hardest hit—13,000 homes destroyed, 26,000 residents displaced, and 200 patients transported. Four helicopters, four fixed-wing aircraft, and 34 ambulances responded from outside that 1,700-square-mile region to support local assets.

Day-to-day prehospital care is more conventional, including ongoing efforts to help patients overcome socioeconomic issues. “Lots of the people we see are battling poverty, substance abuse, and mental illness,” says Dan Smiley, chief deputy director of EMSA. “Getting them to the right place the first time is the goal. Community paramedicine helps with that.”

Overseeing 85,000 Personnel

Before getting into the structure of EMS in California, it’s important to understand the local terminology: An EMS “provider” isn’t a person; it’s what many of us call an agency—an ambulance company, fire department, or first-response service. So what do Californians mean when they say “agency”? Any of 33 local regions or councils, typically county-based, that are responsible for planning, coordination, discipline, data analysis, and offline medical direction. Online medical control is handled by physicians or mobile intensive-care nurses at base hospitals.

California’s EMS titles coincide with three national levels of practice: EMT, AEMT, and paramedic. EMTs are certified at the agency level, while paramedics are licensed by the state. Renewals require the following:

  • EMTs: 24 hours of CME or a refresher plus verification of skills competency;
  • AEMTs: 36 hours of CME or a refresher plus verification of skills competency;
  • Paramedics: 48 hours of CME or a refresher.

Backer credits California’s health information exchange as a valuable tool to track caregivers and their calls. “Medics in the field can send their PCRs to hospitals and access patient data on their tablets or laptops,” he says. “We’re hoping to get outcomes as well. We’ve been piloting that.”

An Upbeat Outlook

According to Smiley, there’s plenty of room for incoming EMS personnel. “We have quite a bit of capacity here. We handle more than four million emergency calls annually—the majority with ALS capability. You can come here and work for public or private providers in urban, suburban, or rural areas. People think of California as mostly big cities, but there’s lots of wilderness too.”

Backer mentions cultural diversity as another selling point for the state: “Anyone can find their niche and be comfortable here, no matter how fringe they are.”

As large as California’s EMS system is, Backer favors a hands-on approach to oversight. “In some ways we might be disadvantaged because we’re decentralized and can’t mandate statewide protocols,” he says. “On the other hand, we spend a lot of time collaboratively trying to move forward. We have a very strong group of administrators and medical directors. I think we’re considered fairly progressive.”


1. EMS World. EMS World Salary Survey 2018,

2. FBI. Uniform Crime Reporting System, 2017 National Incident Based Reporting System,

3. Ibid., 2016.

4. America’s Health Rankings, United Health Foundation. 2017 Annual Report,

5. Current Results. Average Annual Temperature for Each U.S. State,

6. Tax Foundation Facts and figures,

7. Ibid., Property Taxes Paid as a Percentage of Owner-Occupied Housing Value.

8. Zillow. United States Home Prices & Values,

9. Choose Energy. Electricity Rates by State in 2018,

10. Missouri Economic Research and Information Center. Cost of Living Data Series, 2018 Annual Average,

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at

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