By Brian J Maguire, Dr.PH, MSA, EMT-P, Scot Phelps, JD, MPH, Paul Maniscalco, PhD(c), MPA, MS, EMT/P, LP, Daniel R. Gerard, MS, RN, Andy Gienapp, NRP, Kathleen A. Handal, MD and Barbara J. O'Neill, PhD, RN | 5.14.20
An effective paramedicine system operates at the intersection of public health, disaster management, health care and public safety. (See Figure 1) Within that structure, an effective paramedicine system provides mobile health care, including emergency medical services (EMS), and a range of community health services. (See Figure 2)
Figure 1: Paramedicine at the intersection
Although many professions are on the front line of this pandemic, paramedicine is at the tip of the spear on the "far forward" front lines, going into patient's homes, crawling into overturned cars and treating patients in many uncontrollable environments. In other countries, the paramedicine system has evolved to meet the needs of citizens in the 21st century. In the United States, the system that was once among the most advanced in the world, has been largely abandoned by government leaders and funders, and has been left to languish for more than four decades. The outcome of this dangerous neglect has become obvious as the COVID-19 pandemic unfolds. As a result of this lack of vision, lack of investment and lack of a rational finance model, the system is only marginally integrated into disaster mitigation, planning, response and recovery. Nor is it effectively integrated into public health initiatives such as injury prevention and community health. The current system poorly integrates with health care as evidenced by the pre-COVID-19 policy of being reimbursed for transportation and not for expert clinical care that occurs in the absence of transporting a patient. This creates an untenable scenario where community care, clinical care and clinical decision making that may be in the best interest of the patient, the community and the health care system, is largely non-reimbursable unless it includes a ride to the hospital.
As paramedicine clinicians (emergency medical technicians and paramedics) were putting their lives on the line working at Ground Zero on 9/11, many thought that U.S. society would finally recognize the dangers they faced and their important role in both disaster response and day to day community health. However, after decades of providing emergency medical care in disaster situations, and after experiencing hundreds of September 11th-related deaths as a result of their service, paramedicine clinicians remain very poorly paid and the U.S. paramedicine system remains isolated and underfunded. Many of the system deficiencies can be traced to three main factors. First, there is no single U.S. federal agency solely charged with supporting paramedicine operations. Second, no legislative mandate exists to engage in paramedicine operational research. Third, there is no paramedicine-specific financial support to advance core initiatives at the federal, state, tribal and local levels.
This condition is in stark contrast to those federal programs legislated to support law enforcement, firefighting and public health. Further evidence of this disconnect in regards to disaster events is illustrated by the lack of any substantive representation within the National Response Framework (NRF), which is part of the National Strategy for Homeland Security, regarding support for, or coordination of, paramedicine resources, personnel, or the provision of this crucial discipline's functional and operational responsibilities.1,2 As a result of these shortcomings, the paramedicine system in the U.S. is isolated, inefficient, and largely ineffective at reducing the burden of illness and in helping to create a healthier society. The lack of a coherent and sustained investment in the system results in poorer patient outcomes, disjointed disaster responses and higher health system costs than would be seen if the paramedicine system was adequately recognized and funded.
The mobile healthcare component of the paramedicine system is poorly understood, downplayed or ignored and remains isolated within the healthcare system. Mobile health care includes: pre-hospital care that provides emergency medical care before transportation to a healthcare facility; inter-hospital care that provides care when patients are transferred between hospitals; post-hospital care that provides care when patients are transported from hospitals to home or to a sub-acute care setting; and, ex-hospital care that provides care when transporting patients between two non-hospital settings such as transporting patients from home to a physician's office and back. This mobile healthcare component controls a significant portion of the input, throughput, and output of both hospitals and skilled nursing facilities. This component of the system alone responds to over 30 million calls for assistance a year.3
The paramedicine system in the U.S. has been largely isolated from public health initiatives such as injury and illness prevention. Although a 1994 study showed that a paramedicine system in the U.S. was able to reduce the pediatric drowning rate by 50%,4 a lack of funding and integration with the public health system has meant that such initiatives, although incalculably valuable, remain rare. In addition, activities of state-level Offices of Emergency Medical Services (OEMS) often lack any significant integration with injury prevention, acute and chronic disease epidemiology, or ability to address contemporary public health issues such as opiate use, drowning or falls among the elderly.
Paramedicine has been almost universally underfunded and understaffed despite continual call volume increases over the past four decades. One reason for these shortfalls is that public insurance programs like Medicare and Medicaid consistently fail to pay adequate rates to cover the true system costs.5 As a result, the safety net that should be provided by the paramedicine system is perpetually on the verge of unraveling. The system underfunding has resulted in dangerous working conditions for clinicians. Although the systems are required under 29CFR1910.120(q)(6)(ii)6 to train and equip their responders, anecdotal information suggests that many agencies ignore the requirement. This has resulted in paramedicine clinicians working without adequate personal protection equipment (PPE) during the current pandemic.7,8
Subsequently, by April 1, 2020, dozens of paramedicine clinicians had tested positive for COVID-19.9 One site lists over a dozen paramedicine clinicians in the U.S. who had died as of April 1710 and over two dozen who had died by May 4.11 In New York City, a quarter of the EMS personnel in the Fire Department (FDNY) were sickened.12 There is no information of the number of ill paramedicine clinicians nationwide, nor the number who are available, or working. The fact that this vital information is not being collected, analyzed and published by a national agency, further underscores the gross national EMS system deficiencies. There is perhaps no more powerful an example of a system teetering on the edge of collapse than a recent event in Alameda County, California. On March 30, 2020, an executive in the private ambulance company issued a note to employees letting them know they might be soon furloughed. Call volume had dropped due to decreasing hospital admissions and decreases in car crashes and other emergencies due to the growing pandemic. So, although they knew the tsunami of patients was going to arrive in just weeks, they had insufficient resources to pay their personnel.13,14
The example is even more poignant when the story goes on to say that, although the agency had just allowed sick leave for COVID-related illnesses, prior to that, the agency provided its employees no sick time; if an employee became sick or was injured on the job the employee had to take vacation time. This is grossly insufficient support for professionals working in one of the most dangerous of all occupations.15 With no system to monitor providers nation-wide, there is no way to know how many fail to provide such basic benefits for their clinicians.
Operating with insufficient funding means that paramedicine agencies cannot afford to pay clinicians a professional wage. According to the U.S. Bureau of Labor Statistics, the 2018 median pay for nurses is $71,730,16 for police 63,380,17 and firefighters 49,620.18 The median pay for emergency medical technicians (EMTs) and paramedics is $34,320.19 The median U.S. salary is $48,672.20 To become an EMT takes about six months and requires 120-150 hours of training. To become a paramedic requires an additional 1,200-1,8000 hours of training. Two-year paramedic degree training programs are offered at some community colleges.21 The training is demanding and requires courses in anatomy, physiology, as well as training in advanced life support, advanced pediatric life support, and basic trauma life support. Paramedic education averages 48 credits in the U.S., while registered nursing education at the same colleges averages 42 credits.22
Other countries recognize the value of their paramedicine clinicians. For example, in London, a consultant paramedic (a senior clinician) earns US $91,734,23,24 compared to a nurse consultant who earns $64,345;25 the average salary in London is $52,000.26 In Australia, the current paramedic average salary is US $86,167,27 compared to $77,801 for nurses,28 $65,788 for firefighters29 and $62,524 for police.30 The median income in Australia is $48,360.31 The paramedicine clinicians in those countries also have increased their minimum education standards to a Bachelor's degree. The salary and benefits deficiencies have left the U.S. system with a largely transient, undereducated workforce.
In the 2008 NHTSA (National Highway Traffic Safety Administration) EMS Workforce Report, the research team identified and reported that: "Pay and benefits were among the most frequently cited factors in both the recruitment and retention of EMTs and paramedics. Most informants said that pay in the field is generally too low given the level and types of responsibilities held by EMTs and paramedics.32 Moreover, the AAA/Avesta 2018 Ambulance Industry Employee Turnover Study reported turnover levels at 20-30% for both EMTs and Paramedics. "With percentages that high, an organization is looking at replacing most of its workforce within a four-year period. In other words, over a four-year period there will be 100% turnover. Also, at a national level, turnover has been trending upward since 2008. Therefore, turnover and retention should remain a concern."33 The estimated mean price when an agency loses one full-time EMT is $6,411; the loss of one full-time paramedic costs $7,728.34
Currently there are three paramedicine system designs common in the U.S.35 The most common is a system provided by a government run agency that focuses on paramedicine and is staffed by paramedicine clinicians; this is also referred to as a "third service" and runs in parallel with police and fire services. The next two systems are about equally popular; one is a system run by a private ambulance provider and the other is a system run by a fire department. Compounding the complexity is that in some of the first two system types, the fire department provides a first response on some types of calls such as cardiac arrests. The costs and benefits of these system types have not been sufficiently evaluated.
Call volumes continue to increase in part because the population is aging. People are living longer, and their medical needs are complex. The current system does not allow for paramedicine to play a role in helping persons age in place. Instead, paramedicine clinicians are using their skills to stabilize and transport the older persons to the hospital when those skills might be better utilized by providing on-site care and allowing patients to remain in the home.
Furthermore, paramedicine staffing models have not kept pace with changes in the physical requirements of the profession. Although two-person ambulance crews have been common since the 1800s36, the weight of the crew's equipment even through most of the 20th century, was less than the weight carried by paramedicine crews in the 21st century. This failure to reevaluate current staffing needs can lead to poorer patient outcomes and longer times needed to care for patients; the weight may also contribute to paramedics being at high risk for occupational injury.37 38
The flaws in the current system design are most evident in the wake of COVID-19. As a result of poor planning, the paramedicine system has little resources to expand capacity to meet increased demands for service. Solutions now proposed or enacted have included degrading the standard of care by permitting under-licensed or even unlicensed personnel to work in the paramedicine system, failing to terminally disinfect vehicles after presumably contagious patients, refusing transport or, transporting to other types of healthcare facilities. Recent procedures even suggest that paramedicine clinicians both work without the basic protections against a highly communicable disease that are required by federal law and that they work even when exposed or sick, potentially transmitting the disease to others including our most vulnerable populations.8,39 With incongruously staffed systems, no coordination and no paramedicine built-in surge capacity, response times may increase from minutes to hours during an actual surge. At the same time, as hospitals are at or over capacity there is an increased demand for ambulances to provide interfacility transfers. Outside of metropolitan areas, these interfacility transfers may mean many hours of transport time; hours that leave local communities shorter still of life-saving paramedicine resources.
The paramedicine system in the U.S. needs a sustainable national strategy and consequential support at both the federal and state levels. During April 2020, a very high priority for many paramedicine system leaders was personal protective equipment (PPE).8 However, if PPE is where the hockey puck is, funding and manpower is where the hockey puck will be. Beyond a certain amount of necessary drum beating, any additional time and energy will likely have a negligible effect on the outcome. The urgency of the changes we propose is underscored when we consider that when the first wave of the pandemic subsides, paramedicine agencies will have to begin preparing for the second wave. If salaries and system deficiencies have not been addressed, a significant proportion of the already insufficiently sized workforce, may choose to leave for better paying, safer jobs.
The first priority that must be addressed is system funding. The current funding provided by the federal government through the Centers for Medicare and Medicaid Services (CMS) does not pay for the well documented expenses of a professional paramedicine system.5 At the federal level, the starting point should be a law mandating CMS funding at 110% of regional per-capita true system costs, subsequently indexed to the Healthcare Consumer Price Index (CPI). States must also contribute to paramedicine funding through changes in Medicaid payments and grants for system improvements. These federal and state grants must be specifically earmarked for paramedicine. In the short term, paramedicine agencies need direct grants to support them ramping up to the capabilities needed to provide a fully professional 21st century level of service. A professional level service includes these components:
The value to the community for such a professional level of service includes having clinicians who are more closely integrated with public health and the health system, and who are doing a range of activities such as injury prevention, community care and expanded scope of practice. This would include doing home wellness checks, treatment on the scene and referral to the patient's personal physician for follow up, in addition to providing expert emergency medical care. Professional level services are also involved in the full range of disaster mitigation, planning, response and recovery. A professional service has the capacity to have a planning team that can learn from other jurisdictions. For example, Germany credits their ambulance system for keeping the hospital case load low during the COVID-19 first wave. The paramedicine clinicians accomplished this by being out in the community doing regular, at-home examinations of COVID-19 victims. They were able to catch patients before they decompensated and only brought victims to the hospital when the patient required hospital care.40 Every community in the U.S. needs access to a paramedicine system capable of providing these services.
The COVID-19 pandemic has shown how critical it is to have a nationally coordinated public health response that is synchronized with all levels of government. This pandemic has also shown how critical it would be to have a nationally coordinated paramedicine system that is synchronized with all levels of government. A single lead agency is needed at the federal level to ensure national coordination of both the needs of the nation's paramedicine system and its efficient and effective deployment. This is not a new issue but one that has been recommended but neglected for decades. Immediate changes are imperative.41
After the impact of the pandemic and without immediate and sufficient support, it is easily conceivable that the U.S. paramedicine system may revert to a pre-1960s model staffed by minimally trained personnel tasked primarily with removing people from the street so that traffic is not blocked. Americans would receive better care in other countries where paramedicine clinicians with master's degrees are involved with injury prevention, are performing comprehensive patient assessments and treating many people at home, offering the most humane and the most cost-effective outcomes to both patients and to the healthcare system.
A lack of support has meant that the paramedicine system in the U.S. was not optimally prepared for the first wave of the 2020 pandemic. In the short term, immediate action must be taken so that paramedicine agencies will be sufficiently supported for the second wave and beyond. Short and long-term support is also needed to begin creating the paramedicine system the U.S. needs for the 21st century. Our communities need a paramedicine system that will meet their needs. Our health care system needs a partner that can work with it to provide the best possible care in and out of the hospital. Our public health and disaster response systems need a partner that can not only respond to disasters but that can also be an integral component of the mitigation, planning, and recovery phases of disaster.
For the past four decades, many people responsible for leading, planning and funding the paramedicine system in the U.S. have followed the easy paths, the paths of least resistance. But that is not the journey that history has carved out for us now. Like it or not, we live in times of great danger. The future does not belong to those who are comfortable with today, willing to accept the status quo, afraid of bold proposals and new ideas. The future belongs to those of us who can balance the ideas, reason and courage in a commitment to the principles and values of paramedicine. We are proposing a new paramedicine system in the U.S., a new direction, a new framework for tomorrow. To that end, federal and state representatives must immediately invest in the EMS system in order for the system to care for the immediate victims, to prepare for the next wave of this pandemic and to create the paramedicine system U.S. citizens need in the 21st century.