By Benjamin Podsiadlo
The COVID-19 pandemic has posed persistent, wide-ranging existential threats to effective 911 emergency response.
The EMS (Emergency Medical Services) system, which sits at the intersection of emergency medicine and public safety, is the out-of-hospital component of the acute care health care system. The EMS mission is targeted at identifying, responding, assessing, treating, and entering suddenly ill and injured patients in the community into the health care system.
The EMS system’s viability is entirely dependent upon the capacity of its workforce of EMTs, paramedics, and 911 EMS telecommunicators to respond 24/7/365.
The devastating impacts of the COVID-19 pandemic on EMS include: severe damage to workforce sustainability; grossly insufficient logistical resourcing; and further erosion of cohesive system identity.
The outlook for the EMS workforce’s sustainability is grim. Frontline EMS providers’ wellbeing and livelihood is jeopardized by the pandemic’s persistent economic, mental health, physical health, and social impacts.
Countless EMTs and paramedics have been infected and sickened by COVID-19. Many have died from coronavirus; the group has the highest COVID-19 mortality rate of all first responders, and one of the highest of health care providers. Mental wellness of EMS providers, a longstanding but inadequately addressed concern, reflects extraordinarily high rates of PTSD and suicide during “normal” times. At a baseline, paramedics commit suicide at greater than twice the rate of the general population.
EMTs are consistently recognized as amongst the lowest-paid essential high-reliability workers in the American workforce by the Bureau of Labor Statistics. The burden upon the nation’s ambulance and EMS response capabilities is now so destabilized by the pandemic that in many cases it has permanently collapsed local EMS provider operations to the point of service disintegration.
While many EMS services expected to be overwhelmed by the pandemic’s imminent wave, some services saw catastrophic reductions in volume as fear of elective health care reduced ambulance use. This caused severe revenue shortfalls and resultant workforce reductions, with employees laid off and the EMS system inadequately staffed for the return of volume post-surge.
Conversely, specific dense urban areas that were hit hardest, such as New York City, were so inundated with life-threatening ambulance calls for critically ill or dying COVID-19 patients that a massive task force of federal mutual aid had to be summoned to NYC, comprised of ambulance services from around the country, to fill the void.
Expected to respond with inadequate or even absent PPE, provide transport in confined and poorly ventilated spaces for prolonged periods of time, care for legions of infectious dead and dying patients and families, and adjust to constant fluctuations in the standard of care, the EMS workforce was virtually pounded into dust.
Further, EMS has been forced to meet ever-broadening expectations to provide just-in-time and lower-cost primary and preventative public health services, through activities such as mobile care for worksite monitoring, COVID-19 testing, vaccination clinics, and even home-delivered monoclonal antibody infusions.
While these expansions of EMS have demonstrated incredible flexibility and opportunity, it has continued to overextend the EMS workforce and marginalize its core mission of 911 response.
Many EMS professionals have expressed a strong desire to exit the EMS field as soon as possible. Citing the chronic stress factors, low pay, poor benefits, stagnant career options, and impacts of the pandemic, some EMS providers hope that once the pandemic is under control and the economy improves, they will find better employment outside of emergency services altogether.
Paul Maniscalco, the first President of the International Association of EMS Chiefs and former Deputy Chief of NYC EMS has advanced the mantra: Respect the people – with parity for EMS with police and fire colleagues; Resource the system – with public funding on par with public safety peers; and Value the EMS mission, with policy recognition of EMS as a distinct public safety discipline and access to it as a public right.
In the face of the accelerated EMS workforce decay from the prolonged pandemic, it seems only a bold and robust national initiative using this three-pronged approach will suffice to bolster the EMS system.
Like all things in America, the subordination of EMS before and during the pandemic is financial. As the invisible or lesser emergency service, its fragility is its hyper-reliance upon end user health insurance billing rather than public funding.
Unlike tax-based police and fire services, a funding model predicated on their acceptance as a public right and good, EMS is largely dependent upon narrow margins of cost and profit, as well as stark disparities in utilization and revenue collection in economically or demographically challenged and vulnerable communities. EMS generally operates beyond the limits of operational and human efficiency while simultaneously functioning as the majority 911 service provider of both last or most desperate resort response.
Under-resourced and grossly underpaid, EMS also suffers from chronic power differentials, resting at an inferior position in both the health care and public safety landscapes. The EMS workforce will develop sustainability only if it is recognized as a critical component in the nation’s response to the pandemic and that it is worthy of moving to a visible, distinct, and coequal place alongside its public safety counterparts and colleagues and away from its past subservient and silent role in America’s first response posture.
A Path Forward
The federal government must identify and define EMS as a distinct response discipline and function, fund it robustly, accountably, and sustainably for efficient and effective emergency response and disaster preparedness. We must ensure that the EMS workforce is carefully selected, highly educated, continuously experienced, and properly allocated in a manner that reflects the expectations of the nation and the support needed for those doing this lifesaving work.
To do so, EMS must be funded and delivered through regionalized EMS entities whose workforces are selected, educated, allocated, and robustly supported through public funding, not insurance billing revenue. EMS services must be a public right to address the alienation and disintegration of a career workforce. This is pandemic preparedness and everyday EMS readiness.
Benjamin Podsiadlo is the Clinical Director of Armstrong Ambulance Service, Arlington, MA.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.