At least in the US, EMS serves in four primary capacities:
- 911 Emergency Medical Response: In this setting, we are the intersection between public safety and emergency healthcare. We respond to 911 calls, assess our patients, provide some stabilizing treatments, and (usually) transport to an emergency department. Our training focuses overwhelmingly on this role.
- Interfacility Transfers: In this setting, we monitor and transport a sick patient from one healthcare facility to another. EMS treatments are rarely needed and we functionally are something akin to a hospital bed combined with a taxi. Surprisingly, our training spends very little time on this line of work and yet it is commonplace outside of municipal EMS agencies.
- Special Events/Standbys/First Aid: While there may be a transport component to this work, most of it involves being a medical resource for medical needs at some kind of an event. Medical needs are typically minor, and care typically fits within the scope of a typical first aid class. There are occasional exceptions—many of the sickest patients I cared for were athletes participating in Ironman races—but by and large, this is primarily about handing out bandaids and OTC meds and being available in case an attendee starts having trouble breathing, chest pain, or worst-case scenario codes.
- Community Paramedic/Mobile Integrated Health: This fourth role is becoming more widespread, and typically augments a 911 EMS system with the addition of a service that essentially blends traditional paramedic practice with home healthcare and social work. In this capacity, paramedics have proven they can solve a number of problems that traditional transport ambulances and home health cannot, in part because of our training and mindset, and in part because of our scope of practice and licensure.
There are other practice areas as well—industrial paramedics, travel/expedition medicine, and paramedic techs in hospitals or other medical facilities come to mind. But they are much less common and more focused on individual paramedics versus the system structure as a whole.
Why does EMS matter?
EMS is expensive. Ambulances are expensive, and ambulance rides are costly. So why is EMS important? Why not just call an Uber, which often has faster response times and is definitely cheaper?
Fundamentally, EMS is worth the added costs primarily because we’re able to immediately start critical, time-sensitive, life-saving interventions. We bring the knowledge, training, and equipment necessary for these treatments, and depending on the patient’s condition, delayed treatment while getting to the hospital could be extremely detrimental.
EMT-Bs are insufficently trained to provide necessary critical treatments
Sure, an EMT with an AED and a BVM could absolutely manage a cardiac arrest pretty effectively. And EMTs can apply tourniquets and pack wounds. But there are many treatments that are outside of the scope of most EMT-Bs and require further knowledge and training to be competent at. EMTs can’t typically start IVs and administer parenteral medications (outside of IM epinephrine and IN naloxone in some cases). They can’t recognize lethal dysrhythmias, differentiate between different causes (and necessary treatments) for serious shock, and aren’t adequately trained for advanced/invasive airway management beyond placing an i-gel or King supraglottic airway.
EMT-B is the EMS career entry point
EMT-Basic is rarely more than a semester-long course and could easily be completed in a month (with a relaxed full-time schedule). It’s more than a first-aid course (but not much more!) and provides a comprehensive introduction to the world of EMS for someone with no background at all.
This level of training is the bare minimum for someone working on an ambulance1. And this is arguably enough training for someone who is transporting interfacility patients who are abundantly stable and whose primary reason for needing an ambulance is something like being unable to sit up.
EMT-B is not enough
The standard makeup of most ALS ambulances is an EMT-B and a paramedic. Functionally, this is the bare minimum. The paramedic can handle more complex cases while the EMT-B can handle the lowest-acuity calls, assist on other calls, and drive the ambulance. However, this puts the paramedic at a huge disadvantage. Advanced procedures can only occur one at a time. The paramedic has to continually switch between a global, team lead perspective and a task-focused perspective, a skill that is challenging for experienced paramedics and is rarely intentionally discussed or practiced in initial education.
Advanced EMTs (formerly known as EMT-Intermediates) have more education and a broader scope of practice. They are able to offload many interventions from the paramedic and honestly should represent the minimum certification level on a 911 ambulance.
There are quite a few EMS systems that run all paramedic crews. While this makes scheduling, training, and designing protocols simpler, it does come with some major downsides. The biggest downside is skill dilution because each paramedic is now doing fewer of the key critical interventions per year. A robust high-fidelity simulation program paired with a regular, recurring cadaver lab session can mitigate some of this skill dilution but is expensive and complex.
- Yes, I know “ECA” or “EMR” is traditionally the lowest level EMS-certification, but that is aimed at first responders, not transporting ambulance personnel, and I’m choosing to ignore it almost entirely in this post. ↩︎