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Dear Congress, now is the time to fix EMS

COVID-19 is overwhelming the already over-stressed and underfunded emergency medical services system. This is what EMS needs to survive the pandemic


Communities across the U.S. are desperately depending on EMS. It is time to give EMS agencies the funding and support they require.

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By Brian J. Maguire, Dr.PH, MSA, EMT-P
Daniel R. Gerard, MS, RN, NRP
Scot Phelps, JD, MPH, Paramedic
Barbara J. O’Neill, PhD, RN
Kathleen A. Handal, MD
Paul Maniscalco, PhD(c), MPA, MS, EMT/P, LP
Richard A. Bissell, PhD

Today, as the number of COVID-19 cases in the U.S. surpasses 155,000, New York City is experiencing unprecedented daily increases in calls for emergency medical services (EMS). This should serve as a warning of what is to come. Already overloaded, the first wave of cases is expected to peak in April, but if history is repeated, EMS must also urgently prepare for a second, even deadlier wave in the fall.

The purpose of this paper is to describe for Congress and for local, state and federal officials, the specific, urgent and unique needs of EMS and to demonstrate that preparing for the second wave is critical even as the nation’s EMS professionals respond to this first wave of the pandemic.

EMS is in dire need of PPE

EMS personnel cannot stay six feet from their patients, and they cannot completely control a patient’s coughing or sneezing. Personal protective equipment (PPE) is needed to stop the patient from spreading the disease and to protect the EMS personnel. EMS personnel need PPE to help prevent further spread of the disease to subsequent patients, colleagues and community and family members.

EMS needs a method for rapid equipment and ambulance decontamination

EMS requires an effective, efficient and expedited means of total decontamination emergency response vehicles – patient care areas, equipment and crew cabins – to prevent the cross-contamination of clinicians and patients.

EMS needs support for ongoing patient care and operations

EMS is in urgent need of funding to continue to respond to ongoing cardiac and trauma calls in addition to unprecedented demand from overwhelming numbers of COVID-19 patients. More and more over the coming days and weeks, EMS personnel will be expected to provide long-distance transport to the closest ventilator and to attend to those needing care at home when no hospital beds are available.

EMS needs funding to improve pay and benefits

EMS preparation for the second wave means that in order to recruit and retain EMS professionals, they must be paid professional salaries, and they must have benefits and protections comparable and commensurate with other emergency services. Today in the U.S., EMS personnel who are paid salaries much lower than other emergency services and health professionals are putting on uniforms, working on ambulances and putting not only their own lives, but the lives of their families at risk.

For years in the U.S., many EMS agencies have struggled with attracting and retaining personnel because of inequitably low salaries and poor benefits that fail to recognize the unique difficulties of this professional discipline. Many EMS agencies have few veteran clinicians because dedicated EMS professionals have left to join another profession in order to pay a child’s tuition or even to pay the rent.

EMS needs death and disability benefit equality

Many EMS clinicians have minimal or no health insurance, despite their well-documented risks. The health of our EMS personnel must be protected. When EMT Tracy Lee was exposed to another communicable disease – HIV – in 1994, she documented the exposure and kept on working. After she became ill, and up until the time she died of the disease at age 34, her requests to get her diagnosis listed as a line-of-duty illness were denied.

Across the U.S., while other emergency services and healthcare professionals have disability benefits that will cover their care, many EMS professionals have no such assurances.

EMS needs funding to scale operations

EMS agencies urgently need funding to hire and prepare logistics and materials management support teams. They need funding for training and to support community health initiatives, such as treating people at home and transporting to non-hospital health facilities. EMS agencies need funding dedicated to preparing for the next wave of this pandemic as well as for future mass emergencies, including support for drills, local and regional disaster supply caches, research and ongoing planning teams.

EMS needs a new funding source

One of the reasons for the low pay and poor benefits for EMS is that Medicare and Medicaid reimbursement covers only a small fraction of the actual costs of professional EMS services. Using a fee for service or even a capitated system is not sustainable for the provision of EMS.

There are funding solutions that should be implemented. The EMS system in the U.S. must be funded beyond reimbursement for transports to hospitals and instead be funded for response, community care and preparedness including surge capacity. EMS agencies must be sufficiently funded not only for 911 calls, but also for transportation and care in the inter-hospital, post-hospital and ex-hospital settings. If hospitals are unable to transfer people to definitive care or to discharge people, the system collapses.

EMS needs a single, lead federal agency

A single lead agency is needed to help coordinate the needs of the nation’s EMS system and to support operations. For example, today, there is only anecdotal information noting that many EMS professionals have already become ill. We do know that there is at least one EMS professional in an ICU and intubated, fighting for her life against COVID-19. While some U.S. hospitals have reported that the number of their staffs with COVID-19 has quadrupled in less than a week, the number of afflicted EMS personnel remains unknown. Why? There is no system in place for monitoring the availability or health of the nation’s EMS workforce. That must change. EMS has specific needs different from police, fire and health agencies and needs one central coordinating agency to support EMS.

This is the time to give EMS the support it deserves

The EMS system in the U.S. was already vulnerable. EMS systems in other countries including the UK, Canada and Australia, have long had logistic teams to clean and materials management teams to stock the ambulances. They have EMS personnel who are paid salaries and receive benefits commensurate with other emergency services and health professionals, who, because they are paid well and protected, have long careers in EMS. In those countries, EMS agencies are funded not only for patients they take to the hospital, but also for community healthcare, non-hospital transports and disaster preparedness. All those things are true in other countries, they must become true in the U.S.

The COVID-19 pandemic has demonstrated that every community in the U.S. needs access to an EMS agency that has the resources to pay professional salaries, employ sufficient people for day-to-day emergencies, and to prepare for future disasters. Communities across the U.S. are desperately depending on EMS. It is time to give EMS agencies the funding and support they require.

Now is the time for action

This is a desperate plea from a front line rapidly being overwhelmed by an unseen enemy. We request, no we demand, that local, state and federal officials immediately dedicate funds to EMS that can be used to:

  • Purchase sufficient quantities of PPE
  • Hire logistics and materials management support personnel
  • Build a national communications portal to facilitate the sharing of urgent updates, best practices and requests for assistance
  • Establish a single coordinating federal agency to directly support EMS operations and development
  • Develop national training programs to train new support personnel and to provide ongoing training for EMS personnel

We are proposing a new EMS, a new direction, a new framework for tomorrow. To that end, EMS needs this help now in order to care for the immediate victims and to prepare for the next wave of the pandemic.

About the Authors

Brian J. Maguire, Dr.PH, MSA, EMT-P

Dr. Brian Maguire began his career as a New York City paramedic. He went on to achieve a doctoral degree in public health and was one of the first paramedics in the world to be appointed as a university professor. As a Senior Fulbright Scholar and an adjunct professor at both Central Queensland University in Australia; and Mitchell College in Connecticut, he has been one of the most published paramedics in the world in the area of paramedic safety. Dr. Maguire now works as an epidemiologist for Leidos in Connecticut, where his work is focused on improving occupational health and safety for the U.S. military.

Daniel R. Gerard, MS, RN, NRP

Daniel Gerard is the EMS coordinator for the City of Alameda FD and serves as the Vice President of the International Association of EMS Chiefs (IAEMSC). He is currently working on his doctorate. He is a recognized expert in EMS system delivery and design, EMS/health service integration, and service delivery models for out of hospital care. Gerard has worked with the Centers for Medicare and Medicaid Services on EMS integration into accountable care organizations.

Scot Phelps, JD, MPH

Scot Phelps is a paramedic and paramedic educator whose previous positions include New Jersey State EMS director, assistant commissioner of health for Emergency Management for the City of New York, associate professor of public health at Southern Connecticut State University, assistant professor of public administration at Metropolitan College, and assistant professor of emergency medicine at the George Washington University School of Medicine.

Barbara J. O’Neill, PhD, RN

Dr. O’Neill is an associate clinical professor at the University of Connecticut School of Nursing. Her research includes an international study on violence against paramedics.

Kathleen A. Handal, MD

Dr. Handal is an emergency medicine physician, educator, author and podcaster with an extensive background in all aspects of EMS worldwide.

Paul Maniscalco, PhD(c), MPA, MS, EMT/P, LP

Paul M. Maniscalco has over 40 years of public safety and emergency management response, supervisory, management and executive service and presently serves as a senior executive consultant to several governmental bodies and private sector organizations. Previously he has held an academic appointment as lead research scientist and principal investigator with The George Washington University – Office of Homeland Security-Center for Emergency Preparedness and Resilience and also served as a faculty member and subject matter expert to the Louisiana State University-National Center for Biomedical Research & Training-Academy of Counter-Terrorism Education. Maniscalco is president emeritus of the International Association of Emergency Medical Service Chiefs and is also a former president of the National Association of Emergency Medical Technicians. He worked for over 20 years in the New York City Emergency Medical Services as a deputy chief, instructor and paramedic.

Richard A. Bissell, PhD, MS, MA

Dr. Bissell is a retired professor at the University of Maryland Baltimore County, Department of Emergency Health Services, where he taught and researched in the area of emergency public health. His work in disaster epidemiology and public health preparedness covered more than a dozen countries. He also contributed to the National Disaster Medical Teams and FEMA through the production of training materials and research leadership.