Winter storm Grayson had done his worst, the polar vortex was finally in retreat, bringing the temperature up to a balmy 35 degrees, and I was nestled in the front seat of my ambulance glancing through my Facebook feed, preparing for another day filled with drama punctuated by memes.
As the screen scrolled up, I ran across a column titled Are EMS providers first responders? by blogger and author Michael Morse. In it, he describes hearing an announcer at a football game take a moment to recognize the emergency medical teams and the first responders who responded to the Hurricane Harvey disaster. Morse writes he took the announcer’s separate citation of both emergency medical teams and first responders to mean that EMS providers are not considered first responders.
Wait a minute…did I read that right? EMS providers are not considered first responders?
Is that what the public thinks of EMS? Or is it what Morse thinks? Did Morse not understand that the Hurricane Harvey disaster required additional medical personnel, including those from private companies, to backfill medical facilities inundated and closed by the effects of the storm?
I guess not. Many of us have not had the opportunity to respond to a National Disaster-level event unless the disaster occurs where we live. Most of those additional EMS providers come from privately-operated as for-profit businesses. Nurses, aides, respiratory therapists, and physicians are just a few of the professionals who respond as part of disaster Emergency Medical Teams. The National Disaster Medical Service is not called the National Disaster Emergency Medical Service because it is not so narrowly limited to the disciplines of EMTs and Paramedics.
This would be the part where I insert my pedigree and experience, but I won’t bore you. If you’re that interested, just Google search “Dave Konig EMS.” That’s me.
My time on the ambulance was every bit as dangerous as when I worked in a stadium, a steel mill, an arena, or a construction site. My partner and I, when I had one, would many times be the first on scene for the shootings, stabbings, fall incidents, motor vehicle collisions, sick adults, ill children, intoxicated people and those who had passed on without immediate recognition. Other times while on the ambulance, we would be the only ones on scene for the chronically ill adult going home up five flights of stairs in a building without an elevator, ventilator-dependent children who needed a round trip to a doctor’s appointment, bed-confined patients in kidney failure who needed treatment to continue living, and terminally ill patients who needed to be either in a facility or at home for their comfort during the last moments they would spend on this earth. Despite the diversity in environment, my function remained the same, as a First Responder EMS Provider.
The focus of law enforcement is scene security and protection. The focus of the fire service is protection of property and the ability to sustain life. Our job, the focus of all EMS providers, is to ease suffering and preserve life. Although the holistic approaches vary, the essential goal remains the same.
We help people when they are unable to do for themselves.
PRIVATE EMS VS FIRE-APPROPRIATED EMS ENTITIES
Just as a sports-based media agent—such as, say, a football announcer—is not qualified to provide us with an accurate understanding of the public’s perception of EMS, neither is a limited Fire Service-based officer (active or retired) qualified to dictate what constitutes EMS. The Fire Service appropriated EMS to bolster their budgets after their unparalleled success in curbing structural fires resulted in a lower demand for their services. I’d argue the uncoupling of EMS from Fire is the separation that needs to occur.
We simply cannot be considered a third arm of public safety if we are already being operated by an already existing arm. Perhaps we can be considered a thumb, or an index finger, or even a whole hand, but never an individual arm.
The argument often made—and made by Morse in his article—is that private EMS providers operate “for-profit,” a notion at odds with the interest of the public. The truth is that all of healthcare is a “for-profit” business including those entities that are actually “not-for-profit” but easily mistaken for being “non-profit.” For an entity to truly be “non-profit” there would be no billing of insurance or the patient whatsoever and there are very few agencies that would pass that test, including the venerated Fire Department of New York.
FDNY does, in fact, bill for ambulance transports with a $704.00 BLS base rate, a $1,190.00 ALS base rate, and $12.00 per mile. In 2017, Medical Emergencies comprised 83% of FDNY call volume, yet only 25% of FDNY’s workforce consists of Uniformed EMS. An FDNY Firefighter’s starting salary is $43,904 while an FDNY EMT’s starting salary is $35,254. Paramedics do fare a little better to start, but after five years, a paramedic is earning $65,226, while that same entry-level firefighter is earning $85,292 after five years at top pay.
City-provided statistics for 2017 show FDNY with 1,758,241 ambulance runs. Taking into account the BLS base rate without mileage from above, as well as the considerable salary difference between a firefighter and an EMT, it seems fairly “for-profit” to me that FDNY sees a minimum billable amount of $1,237,801,664 using 25% of their workforce at a 20% pay disparity.
The pay gap between tax-payer subsidized services and private entities is even larger. Morse is absolutely right that most private operators pay their employees barely above minimum wage. Despite putting in full-time hours, many, if not most, private agency EMTS are forced to work two or more jobs to earn a living wage. Part of this is because of the perverted value we place on the EMS providers who perform inter-facility and discharge services.
We place a higher value on the “emergent” side of our service in both pay and reimbursement. On the emergent side, we have additional resources at our disposal from both the fire service and law enforcement, quicker response, turn-around times, and no requirement to obtain medical necessity for reimbursement. The “non-emergent” side suffers by having only crew resources on scene with patient carries generally being up against gravity. The result is a greater injury rate, longer travel times, delayed turn-around times for a variety of reasons with few options to expedite, and medical necessity documentation that can be retroactively denied for reimbursement, with little to no recourse.
The fact is, without inter-facility services to move these patients, hospitals would be unable to receive the newly acute and ill patients brought in by the “emergent” side of the service. In many communities across the nation, the crew that has just completed an “emergent” transport is then used for an inter-facility transfer or discharge. Resources are not necessarily specific to a single role and this is not limited to rural areas.
If the “emergent” side of the industry were held to the same reimbursement standards of medical necessity and lower rates as the “non-emergent” side, I suspect we would see salaries level out with more municipalities looking to contract private providers rather than fund their own services. Surely fire departments would no longer see EMS as the funding source it has become for them and would separate themselves from it.
THE FIRST STEP IS CHANGING HOW WE PERCEIVE OURSELVES
The first step to changing both the public and the sports-based media’s perception of EMS is to first change the perception we have of ourselves.
We are an industry wrought with burnout, depression, and dissatisfaction with EMS because from the very beginning, we perpetuate the lie that EMS “saves lives.” We focus the vast majority of our recruiting and training efforts on cardiac arrest, one of our statistically rare calls and the one with the least scientifically proven and successful treatment.
We should be setting realistic expectations of the job as a whole. We should focus on empathy as much as we do assessment. We should practice compassion as much as we do splinting. We should train to provide a Service, which is what the “S” in EMS stands for.
We need to have the courage to change the things we can, such as training, focus, and how we refer to ourselves. We need to be able to accept the things we cannot change, such as the inevitability of death and those pesky taxes. Once we are able to change how we perceive ourselves, we can go forward and change the misconceptions and poor perceptions of the community.
Most importantly, we should care for one another as much as we care for the patient, regardless of whether it is a municipal, private, or not-for-profit agency patch on our uniform. Regardless of our shift schedule, the types of calls we run, or the types of ambulances we ride in, we have all been trained to be capable EMS providers. More importantly, we are all still human and this job takes a toll, no matter what sector or agency type you are working for.
So yes, Michael, ALL EMS providers are indeed First Responders.
We are also so much more than that all-encompassing title in many communities and those other roles are equally important. We are vital to the infrastructure of this country, but before we can prove it to others, we need to believe it ourselves. To do that is going to require change — often the toughest part of any industry’s organization.
Personally, I’d be happy if we could all just agree to the title of “medics.” If we could agree on that amongst ourselves, the rest is more easily attained.