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Charting the year in review

Looking back into the data on EMS activations and trends, and looking forward in hope


TIP and TILT have allowed us to treat the patient in the right place, first time during the pandemic.


Data has long been my professional four-letter word. And in conducting a review of 2021 and a look forward into 2022, I looked to data from the National EMS Information System (NEMSIS) to help tell the EMS story.

As of this writing, NEMSIS data guru, Dr. Clay Mann, informed me that the system had collected 43,327,506 activation records from 12,782 agencies in 52 states and territories in 2021. Dr. Mann reported that in 2020, 43 million records were received and this year he expects to receive north of 46 million – a new record. If the year felt busy with less people – it was! Using the informative NEMSIS TAC weekly “EMS by the Numbers” charts, we can review the year through our own activity levels and draw lessons and conclusions.

A time to respond

EMS volumes have remained high against previous years. The constant that remained is the requirement to respond within a given time – and the frequent use of lights and sirens to get there. The arbitrary requirement to hit a target response time throws up a perverse incentive: arriving under the required time is a success even if the patient dies, and arriving late is a failure even if the patient lives – a case of hitting the target and missing the point. Academic research has clearly demonstrated that not every patient needs a very rapid response, and the associated emergency driving should be preserved for truly life-threatening conditions only. In any case, why get to the patient in under 10 minutes only to then spend an hour to hand them over at the ED?

Looking forward. This discussion will continue into 2022, with several of our national associations already coming together with federal agencies to continue this safety dialogue.


Response volume has run hot in 2021, outpacing previous years … but are there enough people to respond?


Drugs of addiction

Despite the presence of the pandemic, the real underlying theme to 2021 has been the continued acceleration of the opioid crisis. In November, the CDC announced that there were an estimated 100,306 drug overdose deaths in the United States during a 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before. As we know, this isn’t a criminal issue and it isn’t going to be solved through arrest and detention. Intervention and rehabilitation are the only way out of this epidemic.

Looking forward. On the streets, EMS remain front and center in the epidemic in terms of understanding where and when ODs are occurring via our data systems and are on scene to manage the patient and transport to hospital. We have the continued opportunity to take a lead in this area.


Naloxone may well be the most used EMS treatment in 2021.


Politicians on drugs

Response to behavioral health patients also remained a constant. We all became interested in the ruling of Colorado lawmakers that placed restrictions on the use of ketamine by paramedics outside of hospitals. All those in favor of the bill, House Bill 21-1251, signed into law by Governor Polis, hoped it will keep law enforcement officers from influencing paramedics’ decisions on whether to use the drug on people who are experiencing agitated delirium. The view (and stated response) of the house of EMS and medicine has been that we would rather not see lawmakers legislate patient care. Within the tense political landscape, we must be prepared for more of the same.

Looking forward. Issues such as this are always accelerated by the fact that we practice our craft in the full view of the public, whereas everyone else’s medicine mainly occurs behind fully closed and guarded doors. While we are doing the right thing and operating within direction and protocol, everyone is watching – which may make us open to public misinterpretation. Public education before the fact is the answer to many of these issues.


Response to behavioral health patients remains at an all-time high.


Hijacked ambulances

An exceptionally frustrating point of tension in 2021 has been the amount of time spent waiting to hand over the patient at the hospital. The knock-on effect of waiting on the wall for hours at a time means that the ability to respond to the next call has been severely diminished. This has led to EMS systems to the situation where they may have to put more staff on (if they even exist) to react to delays, which is an inflated cost. On the other end, they suffer criticism and contractual penalties for not meeting response time requirements which can run into six figures and add more pain to the operational bottom line – for a problem not of their making.

Looking forward. The recent trilogy series by Page, Wolfberg & Wirth is a must read as well as downloading their fact sheet that highlights the legal requirements around EMTALA. This issue will no doubt roll on and if Omicron picks up and takes off as other countries are seeing, we will be back on the wall and sitting in the lengthy line again very soon.

Read more about hospital bed delays:


Average offload time across the nation.


Tipping and tilting

The pandemic has allowed us to treat the patient in the right place, first time. The push to keep the patient from hospital if they don’t absolutely need to be there has been encouraged by programs such as treatment in place (TIP) and treatment in lieu of transport (TILT). Spending a little longer on scene but saving the transport is getting a little reimbursement now which bucks the EMS model of funds only for transport, and this is the way to go. We still await the full commencement of ET3 as many of the services selected for the demonstration program have yet to get underway, but it is one to watch next year.

Looking forward. To continue the motion of getting paid for doing the right thing versus taking the patient to where they don’t want to be and were they (because of their lower acuity) are not wanted will take further political briefing, influencing and lobbying. It is good to see that this will be continued by a coalition of some of our largest national associations with funded lobbyists and political action funds – give them all the support you can, whether it is in membership or joining in with letter writing and legislative initiatives.


COVID precautions and treatment in the home increased the overall on scene time over the last 2 years.


The great resignation

Finally, and no chart needed, without a doubt, people have been the biggest story of 2021 – keeping them, keeping them healthy and keeping them mentally intact. Many providers have moved on from the front lines, through exhaustion, burnout and frustration. Recruitment continues at a pace and large sums of money are offered to entice folk from one service to another, however losing one and adding one in a particular locality is a zero-sum gain and doesn’t get us all where we need to be. Retention and looking after the people we have must be a main effort, leading to the question: how does the size of the retention budget compare to the retention line?

Looking after the mental wellbeing of our providers has received considerable focus in 2021 and all are working at doing better. It is encouraging to see that there are considerable meetings and discussions underway to identify further ways to ensure we provide support and pastoral care to the most important thing in our world – our people.

Additionally, the retention issue of pay is a delicate one. Your local supermarket, store or fast-food outlet can simply increase their prices to account for outgoing pay and incoming supply; EMS cannot. Our rates are set and contractually locked in, insurance pays what they think we are worth, which is far from the usual and customary rate, and Medicare has not kept up (some states have not had an uplift in years possibly decades). Our lack of money in the bucket prohibits money out.

Looking forward

The answer to most of the above is politics at the local, state and federal level. If we don’t influence the influencers, then we can’t increase income and funds outgoing. Joining in with state and national associations, putting uniforms in front of locally elected officials is an essential activity. Learning to tell your story using data and facts versus the time-honored anecdote and gut must be a new year’s resolution for all.

In closing, here’s to us surviving 2022. It’s going to be a challenge, but for those who stick with it, thank you so much for your service, your sacrifice and your dedication to the patient and your fellow provider. I fear however, as Churchill said – this isn’t the beginning of the end, but merely the end of the beginning.

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.