EMS Associations: More Than Just Alphabet Soup?

When you think of lawyers, you think of the American Bar Association. When you think of seniors, you might think of the AARP. When you think of EMTs and paramedics…well, who do you think of?

Unlike many other fields, EMS isn’t dominated by a single powerhouse entity that serves as its putative voice, always speaking for it and providing its default face to the general public. The NAEMT—the National Association of Emergency Medical Technicians—is as close as we come to that kind of standard-bearer. And while it has the largest and broadest membership of the various EMS organizations, it is still—like the profession behind it—relatively young, and it hasn’t yet achieved, to the public or to policymakers, identity as the de facto face of EMS.

That’s not a knock. The NAEMT does terrific work that yields great benefit throughout the spectrum of prehospital emergency medical care. Rather, it underscores the disparate, fragmented, still-evolving nature of emergency medical services in America today. Instead of a single champion representing and advocating for it, EMS features a plethora of groups each standing for a particular constituency—pieces of a puzzle, but not, in and of themselves, the full portrait.

Is this the best way to serve EMS? How did it get this way? Before we tackle these questions, let’s get to know the players.

NAEMT

The association most representative of EMS as a whole is the National Association of Emergency Medical Technicians (NAEMT). Formed in 1975, NAEMT’s mission is “to promote the professional status of the EMT, paramedic, EMS educator and EMS administrator.” It works for national standards and accreditation for educational programs, develops continuing education programs, supports legislation and other beneficial initiatives, and promotes EMS to those in it and the public at large.

It doesn’t seem a leap to think that a big, strong, vibrant NAEMT could be a great boon to all of EMS. Yet it counts as members just a small fraction of America’s EMS providers. There are an estimated 800,000 EMS personnel in America; the NAEMT has a membership of about 10,000.

“Over the years it has improved. Certainly we would like to increase our membership, but so would every other organization,” says NAEMT President John Roquemore. “Being a young group, it’s one of those things we’re working hard on.”

NAEMT works across a number of fronts to improve the lot of EMS providers and the patients they serve. Of the groups discussed here, its charge is the broadest. Imagine the NAEMT as the awning: Everyone standing underneath may have their own umbrellas to keep them dry, but the awning must protect them all. It is the first and biggest line of defense. That gives it a unique responsibility to speak for everyone.

“We’ve got fire-based, hospital-based, volunteer, paid, police departments, military, health agencies, physicians, nurses and administrators,” says Roquemore. “It’s not one small group, and we try to listen to everyone.”

There are many issues of interest to the NAEMT, but three top the list these days: pay, recruitment/retention and worker safety. In support of these and other causes, NAEMT members have testified before Congress, lobbied for improvements and worked to address issues from within EMS. For instance, in 2003, the organization created a Health and Safety Task Force, which established as its top priorities increasing the use of seat belts and reducing the incidence of back injuries among EMS personnel. It will develop educational programs on these points, and create an information database to encourage the development of good habits in these areas.

The NAEMT has also rallied behind the cause of Project USEMSA, a national effort to promote the establishment of a federal EMS Administration under the Department of Homeland Security. As called for in the final report of the Congressional Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction (aka the Gilmore Commission, of which the NAEMT’s Paul Maniscalco was a member), such an administration would lead and coordinate EMS at the federal level, including ensuring a dedicated stream of funding for all-hazards preparedness and response.

On matters like better pay and safer working environments, virtually any group can enjoy a consensus support—who doesn’t want a higher salary and lower risk of harm on the job? But with such a wide range of constituents—public and private, paid and volunteer, fire-based and third-service—the NAEMT, like many EMS organizations, necessarily faces the occasional disagreement. What’s best for one member may not always be best for another. Then what?

“There are a lot of different views out there,” acknowledges Roquemore. “We try to maintain an open-door policy. If someone is concerned about an issue that we can take more of a hard line on, we will, or we’ll seek input from the individuals with the expertise. Say it’s something specific to physicians. We have several physicians, especially in our PHTLS division, so we’ll seek out the individuals with the expertise. We go back to the members of the organization to try to reach a decision on any issue we may be approached with.

“At times we will have different opinions, but that’s just like any other profession,” says Roquemore. “Everybody has their own views, but in the end, we’re all striving for the same thing. The end result for all of us is always the best possible patient care.”

AAA

Now in its 25th year, the American Ambulance Association (AAA) represents services that combine to serve more than 75% of the U.S. population. Its charge then is its charge now: To help providers of ambulance services to get what they need to do the job right—before the fact and after.

“Historically, the AAA was born out of reimbursement—ensuring that we got equitable reimbursement for the services we provided,” says the group’s president, Jerry Overton. “One of the biggest challenges was educating the payors that the true constant of providing prehospital care is the cost of readiness.”

That educational effort continues. Currently, the AAA’s main focus is the recently revised Medicare reimbursement fee schedule, which compensates many ambulance operations at rates below their actual costs of providing service.

The AAA is active here on two fronts: For its members, it provides news updates, mechanisms for lobbying elected representatives and even a tool for analyzing the fee schedule’s financial impact on their services. Also required, though, is a full immersion in the political process. To this end, the AAA has a Federal Reimbursement Committee to work specifically on the Medicare issue, and a Government Affairs Committee to represent it in other national healthcare policy matters.

This Capitol Hill reach is an important one. It not only provides a voice for specific EMS concerns about reimbursement and other pressing issues, but on a larger scale, it establishes the ambulance industry as a player in the political process. The AAA’s presence in DC lends EMS credibility and legitimacy in the eyes of policymakers, and reinforces its role as a vital emergency service.

“It’s incumbent on us to get that word out there,” says Overton. “EMS needs to be recognized as a profession. Even today, 2½ years after September 11, paramedics and EMTs don’t get the recognition they deserve. And at the end of the day, we’re actually interacting more with the public [than the fire service]. We need to be recognized for the critical role we play in our communities.”

Other issues of concern to the AAA include recruitment and retention—it has recently formed a task force to investigate those problems—terrorism preparedness and ambulance worker safety.

Like the NAEMT and other organizations discussed here, AAA has a range of members that sometimes have individual interests. Its emphasis is on reaching out and making sure those interests are heard, and then working toward a consensus.

“One of the things I’ve done since becoming president is visit more than 20 state ambulance associations in their home states,” says Overton. “We listen to their needs. At times in the past, frankly, I think we may not have heard their needs, but understanding those needs and beginning the communication process is incredibly important and has been integral to us in forging our future.

“There are always situations that are challenging, but we try to engage our board and our membership. All of our interests are in providing quality patient care—that has been and always will be No. 1. As long as we keep that in focus, I think our differences become somewhat minor.”

NAEMSP

Who puts the medical in emergency medical services? EMTs and paramedics have good training and do important work, but another indispensable component of EMS is the physician. System medical directors, emergency docs in the ED, and MD researchers and scientists all have big roles to play.

Carrying their banner is the National Association of EMS Physicians (NAEMSP). Now in its 20th year, the NAEMSP came about in the vacuum of the mid 1980s, after the federal government had dramatically scaled back its EMS involvement, when a group of physicians involved in EMS realized they had some common issues to discuss.

“We put out a notice that we were going to have a meeting of docs who do EMS,” recalls the group’s president, Robert Bass, MD. “It had never been done before. We called that meeting and 150 people showed up. We realized we had all these issues and things to talk about, so we incorporated NAEMSP.”

The docs were concerned with, among other things, clinical issues and the evidence behind common EMS practices.

“We’re very interested in EMS research,” says Bass. “One of the things we really promote is evidence-based medicine—that the things we’re doing in the field ought to be evaluated carefully to make sure they’re effective and safe, and that new interventions ought to be evaluated for the same reason.”

The NAEMSP produces regular position papers on clinical issues, but also deals with system issues like quality assurance, system configurations and dispatch. It has taken on seminal projects like the EMS Agenda for the Future and the EMS Research Agenda for the Future, and is a founding partner of Advocates for EMS, perhaps the most notable recent effort to amplify the voice of EMS in the nation’s capital.

Formed with the National Association of State EMS Directors (NASEMSD), Advocates for EMS (www.advocatesforems.org) is dedicated to educating lawmakers about EMS and getting them to fund prehospital care. It retained a veteran lobbying voice, Cornerstone Government Affairs, signed on other partners, and in less than two years has established a political presence in the District.

“When we go to the Hill now, people know what EMS is,” says Bass. “The educational piece, which was one of our big goals, is starting to work. And we’ve had some success in trying to make sure EMS is mentioned and our issues are addressed with respect to Homeland Security funding.”

NAEMSE

The backbone of EMS is education. EMTs and paramedics require initial training, and continuing education on top of that. The National Association of EMS Educators (NAEMSE) represents the causes of those who further the profession by teaching and training.

“Occupation-wise, it’s a diverse group,” says the NAEMSE’s executive director, Joann Freel. “The EMS educator who belongs to NAEMSE can be a CPR instructor, a program coordinator, a field training officer, a program administrator, an MD, an RN, a paramedic instructor, a flight paramedic instructor. It really reflects a wide range of certifications and career professionals.

“Because of our diversity, we have a range of different professionals on both our federal projects and our in-house projects. We value their opinions. We’ll talk about the issues and form alliances in support. And overall, with the issues that affect us on a national level, we’re usually in agreement.”

An outgrowth of the NAEMSP, the NAEMSE was formed by a small group of educators led by Walt Stoy, PhD, EMT-P, who in the 1990s directed the National Highway Traffic Safety Administration’s revision of the EMS National Standard Curricula. Stoy served as the NAEMSE’s first president, and its advocacy for educators began in earnest in 1996.

Since then, the NAEMSE has been responsible for many educational advances in prehospital care. It has developed model curricula, and created lesson plans and workshops for NHTSA to help teach the National Standard Curricula. It joins the Committee on Accreditation of Educational Programs for the EMS Professions for annual symposia and regular pre- and post-accreditation site visits. It conducted the State of EMS Education Research Project (SEERP) and produces a steady stream of position papers and educational rollouts.

As important as work like that has been, one current project of the group will likely have an impact on EMS that’s even farther-reaching: In the coming year, the NAEMSE will work on producing the next National Standard Curricula for NHTSA, thereby defining the essential skills and competencies EMS providers will be required to have in the future. It also wants to develop an instructor certification process.

“These kinds of things,” says Freel, “raise the bar of our professionalism.”

NASEMSD

Pity the state EMS director. He oversees an often-awkward amalgam of city, county and regional operations. Most contend simultaneously with combined departments and strictly-EMS providers; paid professionals and unpaid volunteers; local-government services and private operations. They bear the responsibilities of ensuring quality in their own states and bridging the local level to the federal. Is it any wonder they came together to share strategies?

“It’s a difficult job,” says Mark King, president of the National Association of State EMS Directors (NASEMSD). “It has a lot of political pressure; there’s a lot of monies that come and go, and a lot of systems building. When we say EMS was jump-started by the original federal legislation in the mid ’70s, they just literally threw thousands of dollars at states and said, ‘Here, train EMTs and buy ambulances.’ And state offices had to try to formulate some kind of system out of that. It was out of necessity that state directors came together to learn what each other was doing and to share. And we still come together for the same purpose.”

NASEMSD includes the top EMS figure from every state and U.S. territory. And while these 56 individuals may face an unwieldy assortment of issues at home, they have enough in common to make access to a group of peers valuable indeed.

Biggest among these in the 21st century is terrorism preparedness. Ask these 56 directors if their EMS systems are fully prepared for all threats they might face, and you’ll likely get 56 nos.

“The biggest thing for us right now is preparedness for weapons of mass destruction and emerging diseases,” says King. “EMS has been left out of the loop. We have to beg, borrow and steal to get a position at the table. It is a critical error on the part of our leaders in this country—you will not be able to deal with an incident involving casualties without your EMS system being there. And how can they be there if they’re not prepared and equipped to deal with the situation?”

It falls to the directors, then, to make sure the services they represent are as prepared as they can make them. Logically, this requires a lobbying presence in Washington, educating lawmakers about EMS and pressing for a fair share of the funds they dole out. That’s why the NASEMSD partnered with the NAEMSP to create Advocates for EMS.

“Our hope and belief is that Advocates will become a broad, unified EMS community voice that will become powerful enough to get the attention of Congress and the administration,” says King. “We’re already being heard; we’ve been able to get EMS included in certain things, like the HRSA hospital preparedness grant program. That was our first big win.”

The State Directors have been and remain involved in a number of other important projects, such as the EMS Agenda for the Future, the equivalent Research and Education Agendas, EMS for Children programs, communications projects like ComCARE, and the EMS National Scope of Practice project. But it is the Advocates effort that perhaps best illustrates the challenges central to this story, and the way to resolve them.

“We can’t lose sight of the fact that we have to represent everybody,” says King. “It can be difficult. But we have common ground: Reimbursement is a common issue. The fact that it’s not covering you well enough to stay in operations—that’s a common issue we all need to deal with. Same thing with EMS not being at the table in a meaningful way on issues of weapons of mass destruction and terrorism. We can find common ground regardless of our particular positions on issues.”

IAFF

The asssociations discussed thus far are membership and advocacy groups. The International Association of Fire Fighters (IAFF) is a labor union. But with thousands of EMS members among its ranks and an impressive clout in Washington, it merits discussion here.

More than three-quarters of the IAFF’s approximately 263,000 members are trained to at least the EMT-B level. A quarter or more are paramedics. Most of these serve in combined departments, but the IAFF also represents employees of EMS third-services in such major metro areas as Seattle and Kansas City.

“Just about every one of our affiliates has moved into EMS provision in one form or another,” says Jonathan Moore, the IAFF’s director of Fire and EMS Operations. “We’ve got our fingers in EMS from top to bottom.”

They’re busy fingers. Moore’s division provides consulting services and other technical assistance to members. A Labor Issues and Collective Bargaining Department deals with wages, working conditions and benefits. A Governmental Affairs Division lobbies in DC and helps shape legislation that benefits IAFF members and emergency services in general. IAFF representatives also participate in national forums and programs such as EMSC and the Federal Interagency Committee on EMS (FICEMS).

This brings it into regular contact with many of the stalwarts of EMS, including most of the other groups discussed here.

“All of those EMS stakeholder groups, we touch on a regular basis,” says Moore. “We’re all on the same page, clinically speaking. A paramedic’s a paramedic, and they need to do certain things. By and large, we’re all together. We sit on the same panels, work together and communicate well.”

Of late, bolstered by a series of reports documenting the scope of the problem (and its effects during the raging wildfires in California last fall), the IAFF’s top issue has been staffing: getting the funding to hire, equip and retain more personnel.

“We’re continuing to see jurisdictions downsizing their departments, doing more work with fewer people and trying to balance the budget on the backs of the people we represent,” says Moore. “Fire and EMS are essential public services, and we need more people so that companies can be staffed safely and appropriately.”

In EMS, of course, not everyone views fire-service interests as overlapping with theirs. Some proponents of third-service EMS, frankly, view firefighters as rivals for limited emergency-service dollars. In some instances that may be true; on the other hand, the IAFF does represent some non-fire EMS services, and must keep their welfare in mind too. It would not be well-served to promote one constituent at the expense of another.

“We have to be careful we don’t pit one against the other,” says Moore. “Their issues are usually consistent. But in those places like King County (WA), where we represent EMS and fire, we just have to make sure—through plain old open communication—that everyone’s working together.”

100 Arborists

These associations are only the tip of the proverbial iceberg. There are many others throughout EMS that do important work, and their efforts should not be overlooked. Each contributes in some way to the growth and improvement of the field and better care for those it serves.

Some questions remain, however: Are all these groups necessary? Are key messages being diluted because there are so many speaking? Does the greater good become subjugated to individual interests? Could one overriding entity communicate everyone’s concerns more succinctly and powerfully? In short, will 100 arborists, each tending one tree, ensure the long-term health of the forest? Most of those represented here say yes—because they’re different kinds of trees.

“We have to keep in mind that EMS is a system, and we’re really representing and advocating for different components of an EMS system,” says Overton. “At times there will be competing interests; that’s natural. But as long as we keep our common goal in the forefront—as long as we keep the patient as our focus—then I think we’re OK.”

EMS has been fragmented from its outset. Back in the 1970s, systems were developed in the most expedient way—what worked best varied by jurisdictional circumstances. This led to different needs, different issues, different perspectives. Different problems arose in different places. Different groups developed around different problems. Everyone started from the same place, but took wildly divergent paths for the next 30 years. How, then, can one size fit all three decades later?

“Sometimes people need their own environments to fully address their issues,” says Bass. “What you find sometimes is that unless you have an organization dedicated to your special interest, when issues come up, you can find yourself overridden or shortchanged. Most of us in NAEMSP are emergency docs, but we felt like we needed a forum separate from [the rest of] emergency medicine to address what EMS physicians do. ACEP [the American College of Emergency Physicians] is an outstanding organization, but their agenda is full with malpractice issues, with ED overcrowding, with a myriad of issues. National organizations have only so many resources, and our issues are not always priority issues for them. So yeah, I think there’s a place for niche organizations like ours.”

The answer seems to be twofold: Sometimes, each must take care of his own—organizations must work individually on issues specific to their members. But on the big questions that face EMS as a whole, they must simultaneously band effectively together—through mechanisms like Advocates and joint efforts on projects like the various Agenda documents—for the common good.

“We can discuss, through our individual forums, our specific interests, but there are a certain number of national issues we have to come together on,” says Bass. “It’s critically important that we come together on those. If we don’t work together for the future, in 20 years, we’re going to be right where we are now.”

Inside the NAEMT

“To assure a professional representative organization to receive and represent the views and opinions of prehospital care personnel and to thus influence the future advancement of EMS as an allied health profession.”

Inside the AAA

“To promote healthcare policies that ensure excellence in the ambulance services industry and provide research, education and communications programs to enable its members to effectively address the needs of the communities they serve.”

Inside the NAEMSP

“An organization of physicians and other professionals partnering to provide leadership and foster excellence in out-of-hospital emergency medical services.”

Inside the NAEMSE

“To promote EMS education, develop and deliver educational resources, and advocate research and lifelong learning.”

Inside the NASEMSD

The NASEMSD “supports its members in providing vision and leadership in the development and improvement of EMS systems and national EMS policy.”