The Current State of EMS as I See It.

We’re getting closer and closer to EMS Week. What does that mean? For many of us, it leads to a slice of cold, cheap pizza and some random piece of EMS Week swag. For others, it’s a chance for them to prove their bona fides as either an “EMS leader,” “emerging leader,” or “opinion leader.” Most of these people will either share some sort of clickbait, shopworn idea, or conventional wisdom in order to remain relevant or to get clicks.

Since I preach from the pulpit of the “EMS Church of the Painful Truth,” I’ve never been relevant in the usual gang of EMS people trying to solve the problems they helped create nor am I cool enough to be worthy of clicks. As such, here we go with my take on where EMS is these days, at least in my part of Texas.

The hot topic in Texas EMS as of late is the impending dissolution of the MedStar system in Fort Worth and Tarrant County to be replaced by an EMS division of the Fort Worth Fire Department. There are a lot of unknowns (both known and unknown unknowns) about how this will look. Will the medics be covered by state civil service laws? Will the new FWFD EMS cover the other communities under MedStar? But one thing is clear to anyone who’s not a MedStar executive or an EMS consultant. The public utility model of EMS is broken. Contracting EMS out to a private contractor to operate “high performance EMS” (AKA posting at street corners) no longer works. With the current EMS shortage that’s been exacerbated during and after COVID, there’s no longer a steady stream of EMTs and paramedics willing to work 12 hour shifts driving around a metro area. In fact, both MedStar and EMSA in Oklahoma have been unable to find contractors who meet the performance goals, meaning that MedStar and EMSA have both been operating the system directly. And like Fort Worth, EMSA’s collapse is at the point that the Oklahoma City Fire Department has moved past running paramedic engine companies to putting their own ambulances in service as “supplemental transport units.” Whether MedStar and/or EMSA have failed to effectively persuade the public and/or elected officials of their value or the fire service is better at politics (and they are), the fact is that the fire service gets public relations and political power in ways that EMS has yet to accomplish, regardless of whether you show up once a year on Capitol Hill in a uniform that confuses EMS with a hotel doorman or a third world field marshal.

That brings me to my new controversial position. And it’s one I would’ve had myself admitted to a mental health facility for less than six months ago. Namely, if you do not have a well-funded third service public sector EMS agency (whether funded by the city, county, or a special tax district), the best option may well be a separate EMS division of the local fire department. Such a system needs to have a career track for single role paramedics that extends past the two of options of working on the ambulance until retirement or “promoting” to the suppression division. Several departments in Texas (Georgetown and The Colony) have single role medic positions with an EMS promotion track. While many urban fire departments still have a struggle with accepting the EMS role, there are many examples of smaller departments, especially suburban departments, where EMS excellence and the fire service are not mutually exclusive. And with the right leadership and commitment, even an EMS cesspool of an urban fire department can make the decision to improve. The fact that the District of Columbia’s Fire Department is now administering whole blood prehospital says that the impossible is sometimes merely the improbable.

Which brings me to leadership. I’ve been a bit of an EMS nomad over the years, usually because patience is still a skill that I’m working on. In many of these organizations, I see similar challenges. More than one formerly volunteer organization in a rural area transitions to a combination or potentially even a fully paid department as the rural area transitions to a suburban area. Along the way, the growth means that those hired early in the organization’s development promote into officer and chief positions. This growth becomes even more of a challenge based on the preexisting talent pool within many of these departments where people who weren’t competitive for positions with larger departments have now been at said small department long enough to have the seniority to promote into roles they may not be capable of performing. The “Peter Principle” is a real thing and we have more than a few EMS “leaders” who’ve been promoted to a level of incompetence. Worse yet? Once these people ruin an EMS system, they pollute the rest of EMS by hitting the EMS conference circuit and/or becoming EMS consultants. In the rural EMS setting, you’ll see something similar, yet different, where a crowd of locals controls the department to the detriment of anyone from outside the clique and/or with new ideas. “This is the way we’ve always done it” and “We’re just a poorly funded EMS system” are their catchphrases.

And that brings up my final controversial idea. Civil service protections are absolutely needed in EMS. Just like unions serve a needed role as a check on management, so too does civil service provide a check on management and/or political games in the EMS workplace. Yet civil service oftern has one other challenge. Namely, internal promotions. This means that new ideas rarely get brought into an organization because civil service limits promotions to those already employed by the organization. In some organizations, the chief can appoint their executive staff, but not always. My policy prescription? Allow for external hires of officer ranks with them serving in a probationary status like any other civil service position until vested in the system. Not only will it attract qualified people to a department, such new voices destroy the echo chamber that exists within so many civil service organizations. On a similar, related note — paramedic should not be a promotion position nor should it require the completion of a department’s “special” paramedic course (looking at y’all Boston EMS, Seattle Medic One, and King County Medic One). The only time someone in EMS should be promoted to paramedic is when an EMT employed by that organization obtains their paramedic and is moved into a paramedic slot. Likewise, the only initial paramedic course that an EMS agency should offer is an internal paramedic class for those EMT employees wishing to advance professionally.

There. Several hot, potentially controversial takes on EMS that you wouldn’t likely hear from one of the usual conference speakers or consultants. Remember, y’all, I can bring these opinions and others (as well as high quality EMS medical-legal education without BS or dogma) to your organization in the form of a lecture, presentation, or an appropriately titled and compensated full-time postion. As Captain Clay Higgins has said, “I’m easy to find….”