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State Department: Hawaii

If you’re a paramedic or EMT who’s thinking of relocating, or you’d just like to learn more about life across the U.S., EMS World’s State Department is worth a look. We start with data-driven “snapshots” of each state, then add a few paragraphs about regional practices and lifestyle. Our goal is to highlight everyday aspects of potential destinations from a prehospital provider’s point of view.

Hawaii Snapshot

  • Link to state EMS website
  • Average straight-time wages: EMT $17.90/hour, paramedic $31.18/hour1
  • State area: 10,931 square miles
  • Approximate state population: 1,420,000
    • Rank (↓): 40
    • Change since 2010: +4%
  • Most populous cities (approximate): Honolulu 351,000 (others < 50,000)
  • Violent crime one-year change: Honolulu 0%2
  • State violent crime rank (↑): 133
  • State property crime rank (↑): 373
  • Health rank (↓): 14
  • Average temperatures: Summer 72ºF, Winter 67ºF5
  • Top state income tax: 11%6
  • Average sales tax: 4.4%6
  • Average property tax: 0.30%6,7
    • Rank (↓): 507
  • Median home value: $616,0008
    • One-year change: +2%8
  • Median monthly rent: $2,3508
  • Average cost of electricity: $0.34/kwh9
  • Cost of living index: 190.1 (U.S. average = 100)10
  • Best states rank (↓): 2411

Bungle in the Jungle

My first visit to Hawaii almost included a ride with Maui EMS. As a patient.

I was driving with family and friends in the late 1970s along Maui’s northwest coast when we decided to stop at a heavily forested area. The gnarled trees and hanging vines looked like scenery from Tarzan movies I’d watched as a kid, so I figured I’d impress my fellow travelers with my best Johnny Weissmuller impersonation.

From an incline overlooking the trail for normal people, I clutched a hanging vine, backed up a few steps, and sprinted over the edge into the mist. It was exhilarating. I became one with nature. Then nature said, “See ya,” the vine broke, and I landed hard on some of my favorite ribs. So much for playing Lord of the Jungle.

I was sore, but with lots of landmarks still to see on Hawaii’s second-biggest island, I didn’t want to spoil our trip with something as tedious as x-rays. By the time we headed back to the mainland a few days later, my chief regret, besides difficulty breathing, was not exploring more of the state’s rich and sometimes quirky culture.

Sand, Surf, and Spam

What’s not to like about a laid-back tropical climate, 750 miles of ocean coastline, warm water, beautiful beaches, fresh seafood, and exotic scenery? If I could take day trips to Hawaii from Tennessee, I’d be a lot less conflicted about retiring.

Hawaii’s only been a state since 1959. Before that it was a U.S. territory, but if we go back to 1893, it was still a monarchy. Imagine growing up under the king of, say, Massachusetts. Besides Whitey Bulger, I mean.

Hawaii has hundreds of islands, but only six are considered inhabited:

  • Oahu—The most populous (950,000) and the site of the state’s capital, Honolulu.
  • Kauai—Geologically the oldest island. Known for its scenic canyons and waterfalls.
  • Molokai—“The Friendly Isle” features ranching, pineapple production, and rustic charm.
  • Lanai—Only 5,000 people live on its rugged terrain.
  • Hawaii—The largest island, known for its beaches, coffee farms, and active volcanoes.
  • Maui—World-famous beaches and one relatively safe but spectacular volcano.

Speaking of volcanoes, the last one to erupt on Hawaii was Kilauea in 2018. I’m told lava spewing from Hawaiian volcanoes tends to flow more slowly than average, which sounds just as comforting as tornadoes that travel less far.

If you’re a film buff, you’ve already seen lots of the Hawaiian landscape. I found seven movies featuring our 50th state, five of which are so spectacular, they’re simply called Hawaii. And that doesn’t count six TV series set in the Hawaiian Islands, including two generations each of Magnum, P.I. and Hawaii Five-O. Book ’em, Danno, and pass the poi.

Hawaiian cuisine combines proteins and plants from Polynesia, the Far East, Europe, and the West Indies, but Hormel Foods of Minnesota may have had the biggest impact on everyday dining. I’m talking about Spam—not the stuff that crowds your inbox, but low-budget lunchmeat many baby boomers remember as a staple of 1950s fallout shelters.

Spam with a capital S is a distinctive brand of canned cooked pork with a shelf life measured in eons. It’s also a Hawaiian delicacy, grilled and wrapped sushi-style with rice in dried seaweed. I haven’t tried it, but I would if I could stop associating those rectangular yellow-and-blue tins with nuclear winter.

Spam-a-lot isn’t the only Hawaiian custom unfamiliar to many mainlanders. When visiting friends, be sure to remove your shoes before entering their homes. Then greet your hosts with a traditional kiss on the cheek. If you’ve been invited to celebrate a child’s first birthday, that’s a big deal—one that’s often celebrated with a luau, a local feast that used to be a rare opportunity for women to dine with men. Be sure to bring a monetary gift. Later, as you drive home with your “take plate” of leftovers, don’t honk your horn unless you’re just saying hi.

Unfortunately, life in our country’s very own Polynesian paradise costs more than many of us in EMS can afford. Hawaii has the priciest homes, the steepest state taxes, the most expensive electricity, and the highest overall cost of living of any state. It’s also the healthiest place to live in the U.S., presumably because of the breezy, balmy, blissful setting. Or maybe it’s the Spam.

Me Tarzan, You Medic

I was still many years from becoming a paramedic when I visited Hawaii, but here are a few details about the state’s EMS system I’ve learned since:

Hawaii has two levels of providers: EMTs and paramedics. The latter are known as mobile intensive care technicians in Honolulu, the state’s biggest city.

National registry is required for initial licensing. After that EMS personnel need either NREMT cards or the following prerequisites for biannual recertification:

  • EMTs: CPR, 24 hours of refresher training, and 48 hours of additional CME;
  • Paramedics: CPR, ACLS or the equivalent, 48 hours of refresher training, 24 hours of additional CME, and documentation of skills maintenance.

The paramedic curriculum includes pericardiocentesis, while EMTs get to do 12-leads. Nice, but I didn’t see any protocols for airborne apemen with cracked ribs.


1. EMS World. EMS World Salary Survey 2018,

2. FBI. Uniform Crime Reporting System, 2018 National Incident Based Reporting System,

3. Public Safety Rankings,

4. America’s Health Rankings, United Health Foundation. 2018 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,

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

11. Best States 2019: Ranking Performance Throughout All 50 States. U.S. News & World Report, 2019.

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

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