Wanted: Warm and Willing Bodies to Fill Vacant Seats

There's nothing too unusual about North Branford, CT. It's your typical small New England town, storied and picturesque, with a history reaching back more than a century before the American Revolution.

With a population of 14,000, North Branford lies somewhere between urban and rural. Big cities don't encroach--the state capital, Hartford, is 30 miles to the north; Boston and New York City are drives of several hours--but New Haven, with almost 125,000, is some 8--10 miles to the west, and the scenic Thimble Islands, a popular tourist destination, lie off the beaches of the Long Island Sound, five miles to the south.

With a median household income of $64,438, North Branford is fairly well-heeled compared to many small towns across America, but like so many others, the town has historically relied on volunteers for its essential public-safety services. Since the 1940s, fire and EMS responses have come via the North Branford Fire Department (NBFD), which fields four companies' worth of protection that has been, traditionally, all-volunteer.

Until recently, that worked fine. But at some point, it began to appear that the volunteer arrangement was no longer sufficient for getting the job done. The ranks of those willing to ride calls thinned. It became harder and harder to field timely responses.

"A lot of our members left to go to commercial services," says NBFD District Chief Anthony Esposito, Jr. "It seemed the ambulance company became a stepping stone for people to gather experience and then proceed on to services where they could be paid for doing the same things they were doing as volunteers. It deteriorated over time to the point where a significant percentage of initial calls for service were being missed."

For any service in any town, that's going to be a problem.

Getting People in the Ranks

North Branford's dilemma will seem familiar to EMS providers elsewhere. The issues faced in that small Connecticut town are far from uncommon. Nationally, almost everyone involved in the emergency medical services will tell you they need more people. The need is especially acute in small towns and among volunteer agencies, but even in the big cities, it seems, there often aren't enough warm and willing bodies to fill all the vacant ambulance seats. It's a problem that transcends the traditional EMS boundaries of paid vs. volunteer, public vs. private, fire-based vs. third service, ALS vs. BLS.

"The most pressing EMS work force issue," concluded attendees at the EMS Issues Summit, convened last May by the American College of Emergency Physicians (ACEP) to identify the issues and problems facing EMS and discuss ways to address them, "is ensuring that enough qualified and experienced EMTs and paramedics are available to meet current and future EMS work force needs."

In their final report, Summit participants--including such major national organizations as the National Association of EMTs, the American Ambulance Association, the National Association of State EMS Directors (NASEMSD), the U.S. Fire Administration, NHTSA and more--cited work force recruitment and retention as one of the top seven EMS problem areas. They acknowledged that many states are seeing declines in the numbers of students completing paramedic training programs; that some organizations routinely require their personnel to work overtime to compensate for shortages; that some have to search beyond their areas to find the people they need; and that many report increasing call volumes and training requirements (think WMD and disaster preparedness) impacting their work force needs. "Some of the direst

staffing shortages," they determined, "are reported to be in rural, frontier and tribal areas, where volunteerism seems to be declining."

From state to state, and within states, situations can of course vary greatly. But an overarching trend seems clear.

"In Connecticut, we've seen significant decreases in the number of people recertifying and the number of people taking initial provider courses, so we are seeing the aggregate number of field providers drop," says EMS consultant Bob Holdsworth, principal of the East Berlin, CT-based training/consulting firm Holdsworth Pelton. "I think everybody's having issues with getting people in the ranks."

"It's hitting the rural and volunteer areas the most, but I'd say it's becoming across the board," says Gregory Scott, acting division chief of the Illinois Department of Public Health's Division of Emergency Medical Systems and Highway Safety. "From what I'm hearing from my colleagues across the nation, it's a national problem."

Grim Accounts

Whatever the scope of the problem, it's not confined to EMS--all the emergency services are suffering. According to the National Fire Protection Association (NFPA), at least two-thirds of the nation's fire departments are understaffed. This has resulted in stations closing, slower responses and the understaffing of trucks. By the NFPA's count, the U.S. currently needs 75,000--85,000 additional paid firefighters in its cities.

On the law enforcement end, big-city departments in places like New York, Denver, Minneapolis and Cleveland are losing officers--3,000 over the past three years in NYC. The Oregon State Police recently laid off almost 22% of their troopers. And the Bush administration is phasing out a Clinton-era program designed to put more cops on the streets.

But in EMS, it may be the worst of all. A cursory Yahoo search for the term paramedic shortage turns up grim accounts from coast to coast. Consider:

• Within the next five years, according to one estimate, Florida is expected to be 8,000 paramedics short of what it needs.
• Honolulu providers, during one stretch of 2001, collectively averaged 200 hours of overtime a day to run 16 public ambulances.
• According to Biloxi's WLOX-TV, only 34 paramedics graduated from Mississippi training programs over 2002--03, while 200 a year are needed to meet the staffing requirements of the state's ambulance providers.
• According to the National Registry of EMTs (NREMT), 19 states saw a decrease of at least 15% between 1999 and 2003 in the number of students taking its paramedic exams. (Note that not all states use the National Registry.) In Arizona, the decline was 46%. Just five states saw increases of at least 15% during the same period.

Other stories abound. At least 37 states, according to one report, have fewer medics than they need. What's worse, those who get them can't keep them. The NREMT estimates that 22% of the EMT work force and 17% of the paramedic work force turn over annually.

The Struggle to Juggle

The effects of these trends aren't pretty. Beyond the forced overtime, there are slower responses and longer waits for service, and the unspoken threat of lifesaving interventions being performed by providers who are dangerously tired and stretched too thin.

Worse even than that is the possibility--and in some cases, reality--of services shutting down altogether.

"Obviously, the worst effect we may see is services closing," says Scott. "They can't provide staffing, so they end up closing their doors. That's the worst-case scenario. We've had some in Illinois close over the last few years."

Short of closure, many agencies are scrambling to make do. This can involve a certain cutting of corners that may not always prove beneficial to those in need of emergency services. Consider, from the fire side, the high-profile February 2003 blaze at the West Warwick, RI, nightclub The Station.

The fast-moving fire, ignited by pyrotechnics used during a rock concert, killed 99 and injured 200. Several factors contributed to the disaster: the size of the crowd, which exceeded the club's allowed capacity; flammable stage dressings that ignited and burned with frantic speed; exits that weren't used; and a lack of sprinklers in the old wooden building. What you may not have heard was that the first fire engine to arrive at the scene carried two firefighters--half the minimum staffing recommended by the NFPA.

When it rolled up, according to the Providence Journal, each firefighter grabbed a hose and ran for the club's entrance. This left no one at the truck to turn on the pump. A video of the scene showed a delay of 35 seconds before any water flowed.

The other four trucks to arrive at the scene, according to USA Today, all carried two-man crews.

In the months after the event, no one blamed West Warwick's firefighters for the carnage. Many, however, asked a seemingly reasonable question: Could more firefighters on those trucks have saved more lives?

Some people thought so.

"With more firefighters there early, more people would have been rescued quicker," Frank Montonaro, president of the Rhode Island State Association of Firefighters, told the Journal. "If you could have gotten them earlier, you could have saved more lives, because many of them suffocated."

"Obviously, if you pull up with a fire truck with four people on it, you can do more, and you can do more safely, than you can with a fire truck with two," said Warwick Fire Chief Jack Chartier. "That's only common sense."

Now meet the Hamilton Ambulance Service, which serves the small town of Hamilton (population 3,000) in western Illinois. Last year, the service fielded five volunteers. This year, there are four.

"We're struggling," EMT Roy Washburn told his city council in January.

Hamilton's providers struggle to juggle families, paying careers and other commitments. Some work multiple jobs to make ends meet. Revenue is tight: There's no one to do the service's billing, and the wait for new Medicare and Medicaid numbers, required after the city took over ownership of the service, is now six months and counting.

More difficult still is the Illinois law that requires at least two EMTs--one to provide care and one to drive--to respond to emergency calls. Used to be, the driver didn't need the certification.

Nor is help on the way. According to a January profile in the local Daily Gate City, only two Hamilton residents expressed any interest in attending basic EMS training planned for February, and, according to Washburn, "that won't be enough." Moreover, the paper reported, county commissioners turned a collective deaf ear to pleas for help. "We told them, 'We can't do this--it's a dying thing. We need paid services throughout the county,'" Washburn told the paper. "They said 'No.' They wouldn't even discuss it."

Hamilton's neighbors are no better off. According to the same report, "Warsaw ambulance is not in service all the time, Carthage is often busy and the Lee County [Iowa] service no longer will cross the river unless there is a big emergency." At one point last year, reporter Cindy Iutzi noted, the town of La Harpe, 30-plus driving miles distant, had the only in-service ambulance in Hancock County.

While noting that hard-pressed services can apply to the state for staffing waivers, Scott believes reducing the medical expertise delivered to 9-1-1 callers isn't the best way to alleviate personnel deficits.

"We shouldn't just focus on what the standard of care is and try to lower that," he says. "Our citizens expect a basic standard and level of care in their communities. I think we need to look at all the other factors that have led into this national problem--financial changes and social changes and things like that."

A solution proposed by Hamiltonians is to train firefighters and others as first responders, and have them provide basic first aid and non-transport rescues, thus relieving some burden on the ambulance service. If that doesn't work, Washburn said, "You throw your hands in the air and say, 'The community doesn't want it.' If no one steps up, people have to wait, catch a ride with a neighbor or look out for themselves. It could be 15 minutes to a half hour before the ambulance comes, rather than five minutes."

Reasons, Known and New

The reasons for the EMS provider shortage are many and complex. What they're not is new--you'll know most of these by now:

• Salaries, in many places, are too low.
• Volunteerism is in decline.
• EMS working conditions--with long shifts, overtime, heavy lifting, bodily fluids and other assorted unpleasantness--aren't alluring.
• Education and training requirements are significant and often costly.
• There's frequently no real defined career path for those wishing to move beyond EMT-P.
• And too many of EMS's best and brightest, for many of the reasons enunciated above, simply burn out.

"There are a lot of reasons," says Scott. "First of all is financial. There's really a need at all levels--local, state and federal--for better financial support of EMS. No. 2, I think our society as a whole has changed. In the rural areas that are impacted the most by these staffing issues, the jobs and businesses just aren't there anymore. Now your volunteers have to travel outside their communities to where their places of employment are. They aren't in the community 24 hours a day, like they used to be. I think the spirit of volunteerism is still there, but other dynamics have diminished the time allowed for volunteerism."

It's all about competition.

"With the agencies we're working with, we've found increased commitments--things like Little League and church and other charitable organizations competing for people's time," says Holdsworth, whose firm works predominantly with volunteer organizations. "People realize, 'I'm working two jobs to make ends meet. My kids are growing up, and I need to be involved in softball, Little League, after-school stuff. I have to do more training and more recertification than ever before. There are fewer people in the organization, so now they're expecting everybody to pick up an extra shift. And I might take something home that could kill me... Well, softball's not so bad. I think I'll coach.'"

That's the conventional wisdom, and there's a lot of truth to it. Undeniably, there are true personnel paucities hamstringing operations in some places. In others, however, shortages may not be all they appear. In fact, they may not be shortages at all.

Take Mississippi. The statistic reported by WLOX notwithstanding, the state's Department of Health examined paramedic coverage by county in early 2004 and found something surprising: From 1996--2003, ambulance calls in the state increased by 23%, while the number of paramedics certified rose by 43%.

That was also the case in Maryland, which doubled its number of ALS providers in the past 10 years.

"We don't think demand's gone up that much, so I'm not really sure where the issue is," says Robert Bass, MD, FACEP, executive director of the Maryland Institute for Emergency Medical Services Systems, which oversees EMS in that state. "We suspect there's an issue, perhaps, of how ALS providers are being used."

It is certainly possible that providers in some places are not being deployed in optimal ways. Some jurisdictions, for instance, send two paramedics per call as opposed to one paramedic and one EMT. Some places have medics performing administrative duties instead of treating patients in the field. Some dispatch paramedics on every response, meaning they might be tied up on a BLS call when an ALS patient needs help.

To what extent these practices are happening is not precisely known, but it makes a good case for studying the issue.

"Our findings suggested that misalignment was more of an issue than a provider shortage. There were ample paramedics; they just weren't necessarily in the right place," says Jim Craig, director of Mississippi's Office of Health Protection, which oversees that state's EMS bureau. "It's one thing to bring the people in, but another to figure out an equitable distribution of those resources."

Efforts are underway to collect data that can shape some firmer conclusions about what's happening where. At the national level, NHTSA, for one, has created a task force that will examine staffing issues. Some states are on the case too; Maryland is one. It features a work force questionnaire on the front page of its state EMS website, https://miemss.umaryland.edu.

"There's myriad issues to look at," says Bass, who is also president of the NASEMSD. "It's going to be important, at a national level, to look at all the data we can. We looked at our state, particularly at ALS, where we were getting such complaints, and found that, in terms of availability, it may not be worse than it's been. It could be that we have more need. I've talked to fire chiefs who tell me they're recruiting because they want to have, for instance, an ALS provider on every response unit. The question I asked them was, 'Do you need a paramedic on every response unit?' These are the kind of data we need to look at to try to get a handle on exactly what's going on."

Developing these data would not only allow EMS systems to tackle their manpower issues more scientifically, it would also let them make a considerably stronger case for any federal relief or involvement that might be needed. Instead of anecdotes, EMS advocates can come to the capitol armed with facts.

"We may find there are different issues and different reasons for shortages," says Bass. "You hear, for instance, that volunteers are having a difficult time with recruitment and retention, but that may be a different set of issues than we're seeing with career folks. It's important to define the issue before we just leap out and make assumptions."

"You make informed decisions based on good information," says Craig. "That's something we really have to have."

In the Meantime...

As we wait for those data to be developed and analyzed, efforts are nonetheless proceeding to ameliorate staffing shortages. At the federal level, one newer possibility is the Fire Corps. This program, which kicked off in December, is aimed at supporting fire departments across the country by training community volunteers to handle nonemergency activities, thus freeing emergency providers to handle actual emergency operations. A partnership of the National Volunteer Fire Council, the U.S. Fire Administration, the Department of Homeland Security's Office of State and Local Government Preparedness and Coordination, the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs' Volunteer Combination Officers Section, the Fire Corps will work through Citizen Corps Councils to train those willing to help.

Also, last fall, Congress approved the first funds for the SAFER [Staffing for Adequate Fire and Emergency Response] program, which provides grants for fire departments to hire additional personnel. The $65 million it appropriated "is a far cry from what is needed," according to the IAFF--in fact, Congress had authorized $7.6 billion over seven years for the program, but President George W. Bush didn't seek any funds for it in his 2005 budget, and Congress ultimately approved less than 1% of the authorized amount--but will get the program established and provide a foundation on which future efforts can be built.

States are also taking steps. Mississippi, for one, trimmed 500 hours from its required paramedic training, taking it from 1,700 hours to 1,200, which is more in line with the National Registry. It also offers a scholarship for would-be EMSers. "It provides all the funding for books and everything else for them to attend a paramedic training course at one of our participating colleges," says Craig. Other states are exploring actions like tax breaks, job training and more.

Incentives like this are a common inducement, especially for volunteers. But they rely on having the people to incentivize. If that pool isn't there, all the goodies you can dangle won't bring the numbers in. And incentives can create new problems even as they solve old ones.

"If you don't have that group in the first place, you can incentivize all you want, but they're only going to take so many more calls," says Holdsworth. "You incentivize so much, you get to a point where you might as well just go to paid. People will routinely try to incentivize the problem areas: 'We'll give you an incentive if you do day-shift calls.' Then everybody's on day-shift calls and nobody comes out at night, because the nature of the beast is, 'Sooner or later, they'll incentivize us for the night shift too.'"

Incentives didn't do the trick for North Branford, which first tried pensions, then stipends to keep people involved. Ultimately, the NBFD found a novel solution that, while it's not available to everyone, might represent a wave of the future: For the 2003--04 fiscal year, it outsourced its primary ambulance staffing to Vintech Management Services, a Connecticut company that provides contract EMS staffing within the state.

Vintech, which fields staff in 13 towns supporting 122,000 citizens, now covers around 75% of the NBFD's shifts.

"From the patient's perspective, it's a vast improvement," says Esposito. "Previously, when a tone would go off, there would be calls for 'I need a driver,' 'I need a tech,' that sort of thing. Now there's an immediate response out the door with a staffed ambulance and no delay."

The benefits of this solution are many. Not least among them is the fact that Vintech hired many of North Branford's existing providers to deliver its care in the town. This takes full advantage of these employees' familiarity with the town, the service and their fellow citizens. Even better, these employees can come back from paid shifts and volunteer some more, if they so choose, without running afoul of the Fair Labor Standards Act.

Other changes accompanied the retention of Vintech. For one, holdovers who answer the 25% of calls that Vintech does not are now compensated on a pay-per-call basis. These personnel are now required to be in-station during their shifts, which has meant faster responses. Since the moves, response times are averaging less than a minute and a half.

"There's been a service improvement that has allowed us to get our BLS house in order," says Esposito--one so successful that the department is now planning an upgrade to ALS service.

Elsewhere in Connecticut, this arrangement is getting positive reviews. Another Vintech client, the town of Brookfield, is "getting a lot of cardiac saves that we may not have had five years ago" in the days of slower responses by non-contract providers, a town EMS captain told the local Danbury NewsTimes newspaper. In other small towns surrounding Danbury, conversely, personnel numbers are down and response times are on the rise.

"Vintech is doing very well, still growing," says Holdsworth. "A lot of people don't want to deal with the hassle of payroll and all the rest of it, so it's easier to go into the rental system, if you will. I've seen a couple of other outsource agencies that have popped up on the scene as well. It's a good idea."

Conclusion

As with so many aspects of this business, it's difficult to generalize about the apparent shortage of willing EMS providers. Undoubtedly, there are some services in some places having genuine crises of recruitment and retention. In other places, what appear to be shortages may relate to how providers are being deployed. And there can be as many causes, effects and exacerbating factors surrounding personnel issues as there are jurisdictions experiencing them.

Given that disparity, it's difficult to conceive of a solution that would benefit everyone. New York, NY, and Hamilton, IL, don't need the same things. But if there's a broad bottom line to take from their respective difficulties, it's this: Both serve constituencies that could probably stand a greater appreciation of EMS.

Odds are, you do too. Across the U.S., too few citizens have any real idea what you do, how it's done and what you need to continue doing it.

Giving them that, then, is a strategy that can be useful across the board. Whatever your specific circumstances, communicating with those you serve is the first step to improving them. They can't help you if they don't know what you're up against.

"We can always do better," says Craig, "at promoting the good work that our paramedics and EMS professionals do every day. There are a lot of competing forces for students now, and we need to continue to promote the profession and support our providers in recruiting and retaining their people."

"People just aren't aware, as a whole, of what kinds of shortages are out there within EMS communities," says Scott. "They really don't think about those issues until they or a family member is actually in need Even when people move to new communities, most of the time, they'll look into schools and services, but in my experience, I don't ever see citizens asking about fire protection or EMS protection. They just assume it's going to be there.

"Those agencies, volunteer or paid, that do a better job of educating their citizens and their communities may get better support and better response to their needs. It comes down to educating the public."