Improving EMS part 2: Pay

How do we improve EMS in one word?

Now before you all begin chanting praise, hear me out, this isn’t a simple catch all.

I am in no way saying pay should be increased for all in EMS. I think one of the things may people make the mistake of doing is they lump up all EMS as one, and it just isn’t the case. Different areas even within the same state can often be completely different from each other and require much different systems. Some EMT’s and Paramedics out there are medics who are very competent, very proficient at their service and deserve so much more pay than they are currently getting. We all know the horrible retention rates that plague EMS, better pay for these medics would go a long way in securing their positions. There are EMT’s and Paramedics who can surprise even the most jaded doctors and nurses, I have seen EMT’s school people on patient care regardless of certification level. There are paramedics who not only have the courage but also the knowledge to outperform respiratory techs with ventilation and advanced airway placement. These medics should not have to work 60 or more hours of OVERTIME a pay period to make a living!

There are other medics, however, who do the very minimum with their patients. We have all seen them and heard of their stories. Sometimes it is that they are older and set in their ways, sometimes it is just that they are lazy and complacent. IV, oxygen and ECG monitor if their patient is lucky. If there are no obvious fractures they won’t even think of using analgesics. These are the types of medics that get upset at training, would never dream of going to a symposium of any kind, resent change and even nominal improvements in their service. They have never picked up an EMS magazine and laugh if anyone says they just read a medical journal. Pushing refusals is common place for them. Doing a 12 lead is rare and only for severe chest pain. Reading a 12 lead is left up to the ECG machine entirely, they don’t have the time to learn it, and their number one excuse? They don’t get paid enough for that.

You know them, they are around you, I hate to say this, but many of you reading this post could be these types of medics. I am saying, in no uncertain terms, whatever these medics are getting paid is well above what they deserve and if the world was just, they would be put out of a job.

I am not saying critical care, I am not saying that every medic should be flight medic certified, I am saying you should be competent in the equipment you are using. You should be treating your patients not to the basic necessities but to your greatest level. You should be very up to date in the latest practices and procedures. You should not hide behind your protocol. These medics are borderline incompetent and should be removed, but we can’t can we? We don’t have enough medics to man all the emergency vehicles as well as the transfer services.

Which brings me to the second part of my post: pay for the EMS companies.

Without the EMS companies getting paid, reimbursements or through city contracts, the medics can’t get better pay and benefits. With the way reimbursements are coming from insurance companies and the government it is now more imperative than ever to push for change.

There are three components to just about any service. These are called the Project Management Triangle (also known as the Triple Constraint or the Iron Triangle) basically it goes like this: there are three components that always affect each other. How expensive a service is, how good the service is and how fast that service is delivered. You can excel at two of them if you are lucky, but the third will suffer for it. Any serious deviation in one area will impact the other. If you are operating an ambulance service and are very fast and very cheap, chances are you will be suffering in quality. Why? Simply because good quality costs money, good equipment is not free, training has to be maintained or there will be degradations in knowledge as well as current trends in medicine. Ok, so the service is exceptional with all the latest and greatest technology and is very fast, response times well below the national averages. Without looking into the crystal ball I can tell you that that service will not be cheap.


For this reason pay should be increased, not only to the individual medic but also to the company for providing the service. If half of the emergencies are not being paid for obviously there will be a degradation in the triangle at some point. If reimbursements are not being received for their service, while the ambulance service might not want to, they will begin to go into the cheap area and their effectiveness and quality will suffer.

Ok, so I’m preaching to the choir right? The big question, how do we start to improve pay for those that are deserving and to the companies that are employing them? While the answer is not simple, I believe one of the ways is by educating the public and pressing the issue of emergency services. The vast majority of the public views EMS as a business, the cheapest provider is picked in many areas and no one bats an eye. I have sat in city commissioner meetings as three ambulance services come up and argue against each other, each saying they can outdo the other for less and less money. A simple diagram showing how most MICU ambulances cost approximately 250,000 dollars a year to operate will show how ridiculous it is to demand 4 or 5 in a city for emergencies and want to pay nothing for them. Can you imagine if the police department was put up for bids and the company with the lowest bid won the contract for a few years? Do you really think the citizens would back up that plan? What if the fire department of a major city, such as New York or Los Angeles was to go out for bids? But when it comes to ambulance services that is all taken in stride.

Take this example for instance, there is a city near where I work that runs a dual system, firefighting and EMS. The EMS portion is ALS but is very basic in its functionality. There are many things that the EMS personnel for the city cannot do, both due to a lack of training as well as a lack of equipment. If a vent patient, a patient that requires advanced medication administration, a patient that requires IV pumps or CPAP is encountered they call us and we go into their city and transport the patient out. While this is great for my company, since we gain the transfer and the pay for that patient, sometimes the patient suffers because they have to wait for us to send a unit from far away for them. In critical cases we have even had to respond code 3 to the hospitals in their city because the patient is in need of critical care and immediate transport out of that facility. This is a fire/ems department that has a multimillion dollar a year budget, a massive training facility and multiple university affiliates. They are the highest paid service in our area, but cannot handle these types of calls. It is not that they do not have the personnel, they are currently upping the requirements for everyone that is hired to become paramedics, at their expense. Can you for a second imagine if that same service said they couldn’t handle a specific type of fire? What uproar would be heard throughout their city? Imagine if they had to ask for another fire department to come into their city to handle something like difficult car extrication? Is it that they don’t have the staff? No. Is it that their staff is not competent? No. It is that the general public can accept something like that, because they don’t know any better.

“Oh the fire department can’t take my mom out of a car?! Where are the petitions to change this I’m signing them all!”

“Oh the same EMS service can’t handle taking my mom out of the hospital to a better hospital? No problem, just go over a few cities to the lowest bidder who has taken the time to learn how to and use them. No worries.”

EMS has to be a bigger part of public safety and should be viewed as a necessity at least on par with Police and Fire. Understanding that a service can only operate within the constraints of the Iron Triangle and explaining that to the citizens is imperative now.

Any thoughts would be greatly appreciated. Thanks for your time.

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