AMA Journal of Ethics^®

Abstract

Emergency medical services (EMS) clinicians, including emergency medical technicians and paramedics, are skilled professionals whose expertise is leveraged routinely to meet a wide range of patient needs. Collaborative interdisciplinary care requires mutual understanding, trust, and respect. Yet, among EMS clinicians and in- and out-of-hospital clinicians, these values are too often not expressed in working relationships. This article offers guidance on how to nourish successful partnerships with EMS clinicians and motivate good care.

Undervaluing EMS Clinicians

Prehospital professionals—specifically, emergency medical responders (EMR), emergency medical technicians (EMT), and paramedics, presented here in an ascending order of training, experience, and scope of practice—make up the core of emergency medical services (EMS) in the United States. Despite the wide range of vital and highly skilled services that EMS clinicians provide, their contributions are often unknown to, or misunderstood and not acknowledged by, other health care professionals. Even patients often do not understand EMS and its full range of capabilities. This lack of appreciation and awareness adversely affects EMS clinicians, the patients they care for, and the health care system more broadly in terms of missed opportunities to fully leverage EMS clinicians’ expertise and increasing rates of burnout within EMS.¹ The resulting departure of EMS clinicians from the workforce and pervasive shortages within EMS can negatively affect community safety and health.^2,3 We argue that there are 3 primary drivers of EMS underappreciation and its negative consequences: inadequate understanding of, trust in, and respect for EMS clinicians by other health care professionals and the community at large. Inadequate understanding of and appreciation for the vital role that EMS clinicians play within society is both manifest in, and worsened by, the reliance on volunteer EMS services in many areas of the United States,⁴ which suggests that emergency medical care is not a profession but a volunteer activity—and which seems to justify the low wages that professional EMS clinicians are paid.⁵ These barriers need to be recognized, called out, and addressed if we are to strive for higher quality, more efficient, and more accessible patient-centered care.

Burnout, Divorce, Suicide

Multiple factors contribute to EMS clinicians leaving the field for other—safer, easier, more valued, and higher paid—professions. Burnout rates in EMS exceed 60%.¹ Divorce and suicide rates among EMS clinicians are significantly higher than in the general population.^6,7 The average career span of EMS clinicians is just 5 years.⁸ The high rates of stress and burnout among EMS clinicians are in turn due to a number of factors, including (1) low wages, often resulting in the need to hold multiple jobs; (2) heavy workloads and physical demands of the job; (3) the stress of responding to a wide range of emergencies in unknown, uncontrolled, and potentially unsafe environments; (4) exposure to potentially emotionally traumatic events; (5) lack of rest and chronic fatigue, likely the result of the first 4 factors; (6) documentation burden; (7) aggressive or violent patients; (8) poor career recognition, in part because of low wages and in part because of inadequate understanding of the full scope of EMS practice and expertise; and (9) emotional burden, likely a summation of all the above factors.^{1,9,10,11,12,13} Moreover, these factors are all interrelated and stem from the societal and individual devaluation of and disregard for the vital role that EMS professionals play in the care of individual patients, the health care system, and society. Importantly, they are all amenable to change.

There are multiple manifestations of society’s failure to acknowledge, appreciate, and value the contributions that EMS clinicians make to patient care. The “you call, we haul” attitude within EMS is emblematic of the erroneous perception that EMS clinicians lack clinical acumen, agency, and decision-making capacity.¹⁴ Low wages in EMS are both a manifestation of the devaluation of their skills and contributions to society and a driver of burnout and departure from the profession. The median annual pay for EMTs and paramedics in 2021 was $36 930 compared to $48 070 for licensed practical nurses (who have, in many respects, comparable educational backgrounds to paramedics) and $77 600 for registered nurses.¹⁵ Fellow health care professionals’ ignorance of EMS clinicians’ knowledge and expertise, coupled with the clear pay differential, conveys to EMS clinicians their designation as a “lower status” professional. This designation, and the accompanying negative attitudes and disregard of fellow health care workers, can stall forward momentum of EMS advocacy to improve EMS wages and working conditions and contributes to other health care professionals’ role-based microaggressions that ultimately lead to EMS burnout and distress.

Dysfunction

Microaggression is defined as “commonplace daily verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.”¹⁶ While seemingly harmless and often delivered by well-intentioned individuals, the consequence of microaggressions is to “invalidate the group identity or experiential reality of target persons, demean them on a personal or group level, communicate they are lesser human beings, suggest they do not belong with the majority group, threaten and intimidate, or relegate them to inferior status and treatment.”¹⁷ While the vast majority of microaggression research is focused on race, ethnicity, gender, sexual orientation, or disability stereotyping, microaggressions exist within any social hierarchy and are thus apparent within the health care workplace as well. In health care, these class-based microaggressions focus on individuals’ occupational identity, education, language, prestige, and social location.¹⁸

Microaggression toward EMS clinicians can be overt or subtle. As a community paramedic, the first author (A.J.T.) has frequently encountered dismissive attitudes from physicians, nurses, and other health care professionals when caring for patients in the home or transporting them from sending facilities, such as nursing homes or hospitals. For example, a common task EMS accommodates is routine transport of patients between health care facilities, referred to as interfacility transports. Patient acuity and risk for acute deterioration vary widely, yet discharging physicians and nurses rarely perform a warm handoff to EMS clinicians caring for the patient en route to the next facility, while a warm handoff to physician and nursing peers is both expected and the norm. This lack of communication creates potential safety concerns for the patient, as EMS clinicians might not have sufficient information about the patient to inform the management of acute clinical deterioration. Ultimately, being left out of the care process signals to EMS clinicians that they are not important contributors to the patient’s care.

Other clinicians also routinely make assumptions about EMS clinicians’ presumed lack of knowledge, training, and experience, which occasionally manifest in offhand and dismissive comments regarding their care. One microinsult that reinforces these misconceptions is the use of the term ambulance drivers to refer to EMS clinicians. This microinsult suggests that EMS clinicians do little else but chauffer the patient from one location to the next.^19,20 There are also fewer depictions of EMS clinicians as story protagonists in the media and public culture in contrast to physicians, nurses, firefighters, and law enforcement, who feature in multiple shows. In the media, EMS clinicians are too often simply the backdrop, stretcher jockeys, or a mechanism to carry the patient away. This stereotype, too, reinforces the perception that EMS clinicians’ most—and perhaps only—valuable trait is their ability to transport. And while being “drivers” and having ambulances with stretchers is an important aspect of EMS, the true value of EMS clinicians is their ability to treat critically or acutely ill patients at the site of injury, which is only possible because of their rigorous medical training and practical experience, and to ensure that these patients make it to their destination alive.

Low wages in EMS are both a manifestation of the devaluation of their skills and contributions to society and a driver of burnout and departure from the profession.

While microaggressions, such as using the term ambulance driver, might be unintentional or subconscious, all health care professionals can help stop microaggressions by purposefully changing how they act and how their behaviors and attitudes are perceived. These changes include (1) learning about and understanding EMS clinicians’ roles and scope of practice, (2) trusting EMS clinicians to perform their duties competently and professionally, and (3) recognizing the contributions of EMS clinicians to the health care system and to patient health. Below, we offer our suggestions for implementing these changes.

Improving Working Relationships

Understanding. The first step in countering EMS underappreciation and reducing burnout is fostering a better understanding of EMS clinicians’ training, expertise, scope of practice, and roles within the health care system. Indeed, while low wages^21,22 and difficult working conditions²³ are important drivers of burnout in EMS, the failure to recognize EMS’ contributions to patient health and care delivery is at the core of both low wages and challenging working conditions and is an independent driver of burnout and distress. Although the name emergency medical services suggests that EMRs, EMTs, and paramedics are called upon only at the time of emergency to transport patients to the emergency department where they will receive definitive care, EMTs and (to a much greater extent) paramedics also evaluate and treat a wide range of health conditions across a variety of settings. The training for paramedics is extensive, with some programs taking upwards of 2 years to complete to ensure competency across multiple domains.²⁴ Patient complaints vary widely, ranging from the highly acute (eg, chest pain, respiratory failure, stroke, multisystem trauma, childbirth) to the chronic (eg, pain, malaise, weakness, fatigue), and include behavioral, mental health, and substance-use related concerns. For each condition, EMS clinicians evaluate patients, stabilize them on site, and initiate treatment at the scene and en route to a higher level of care.²⁵ The breadth of patient populations and clinical scenarios that EMS clinicians encounter requires familiarity with all medical specialties, along with more focused education in critical interventions within certain specialties, such as cardiology, pulmonology, and trauma. EMS clinicians make decisions about patient care and perform interventions with limited information and often without the need for—and potentially without access to—real-time consultation with a physician.

Leveraging the profession’s unique training and skills, the relatively new role of community paramedic has further expanded the reach of EMS to encompass the evaluation and management of lower acuity health conditions, chronic illness, and social determinants of health.²⁶ Community paramedics care for patients in a home environment—whether a private home, a long-term care facility, a shelter, or the street—with the explicit goal of providing definitive care and preventing emergency department or hospital use. As a result, community paramedics have the potential to narrow the gaps in access to medical care for underserved rural and urban communities, improve chronic disease outcomes and self-management skills, help address social determinants of health, and reduce health care utilization. The expanded scope of practice of community paramedics is a testament to the level of training EMS clinicians receive during their education, yet their attainments can be met with skepticism and disbelief, ultimately precluding the growth and expansion of community paramedic programs and the overall advancement of the EMS profession.

Trust. The second step is ensuring that we trust EMS clinicians to do their jobs competently and effectively. EMS is vital to reducing mortality and injury^27,28 and is often the initial entry point into the health care system, particularly for patients who struggle with physical, financial, or psychological barriers to care. Microaggressions that call into question or second-guess EMS clinicians’ knowledge, competency, and ability to perform services that they are trained, certified, licensed, and credentialled in²⁵ reflect a lack of trust in EMS clinicians and negatively impact both their professional well-being and their ability to fully care for their patients. Moreover, once a patient arrives at their destination, the EMS handoff, both oral and written, can provide valuable information to the receiving clinicians, yet such information often is not sought or accepted by the destination physicians and nurses. This information might include trained observations of the scene, such as the conditions surrounding a motor vehicle collision or the patient’s home environment, which can affect clinical decisions made by hospital staff.²⁹ EMS is a vital link in the patient’s chain of survival and has the incredible responsibility of stabilizing a patient in the field with limited resources. Trust is an essential aspect of mutual respect, and we urge our colleagues across the health care profession to learn more about core EMS skill sets and responsibilities, trust them to do their jobs, and seek their insight and expertise as appropriate. Such professional collaboration is vital to maximizing the value of EMS to the health care system and to patient health.

Acknowledgement. Finally, EMS clinicians are core members of the health care team, yet most physicians and other health care clinicians have few interactions with them. We therefore urge our colleagues to learn more about EMS, take time to meet the responders who work in their area and care for their patients, and engage them as partners in the journey to patient health. Taking these steps includes interacting with EMS in a clinical capacity whenever possible, engaging EMS clinicians in discussions and decision making related to patient care, being present for EMS handoffs, and reciprocating a warm handoff when releasing a patient for transport or accepting a patient in the emergency department. At the leadership level, we urge individuals to consider other engagement opportunities to recognize and elevate EMS’ scope of practice, including supporting community paramedicine services and EMS staff utilization in emergency departments and urgent care settings. A wide range of care delivery models can benefit from engagement of EMS clinicians; leveraging their unique skill sets and clinical expertise in out-of-hospital care would benefit patients, support physicians and other health care staff, and reduce the operational costs of the health care system—all while increasing the visibility and value of EMS clinicians to other health care clinicians and society at large. Ultimately, confronting and disarming class-based microaggressions against EMS clinicians will require efforts similar to those used in addressing microaggressions against any other marginalized population.

Integral Team Membership

As the population ages and patients become increasingly complex, and as health care resources are stretched thin, interdisciplinary team care has become essential for safe, effective, and efficient patient care. Our collective experiences—as a community paramedic and as a primary care physician—underscore the incredible value that a partnership between EMS clinicians and other health care clinicians can bring. EMS clinicians can be physicians’ eyes and ears in a patient’s home and a patient’s voice in clinics or hospitals. Whether treating patients in acute care settings (EMRs, EMTs, paramedics) or chronic care settings (community paramedics), EMS clinicians have unique insights into their patients’ health and psychosocial experience that can inform and enrich physicians’ decision making. Most of all, while the roles EMS clinicians play in health care differ from other clinicians’, health care is—by necessity and value—a team endeavor. Each member of this team has a unique and important function that contributes to the overall health and well-being of the patients served.