JEM

Current emergency medical services workforce issues

in the United States

Brian J. Maguire, MSA, EMT-P, DrPH

Bruce J. Walz, PhD

IntroductIon the number of patients treated by EMS personnel

Emergency medical services (EMS) providers are each year in the United States. In order to estimate
a vital component of our nation’s healthcare work- the national call volume, data were collected from the
force. EMS personnel care for millions of critically ill 2002 EMS Magazine “State and Province Survey.”12
and injured patients every year, and many have rec- Each state that listed both a population and a total
ognized the need to help reduce injuries and illnesses EMS call volume was included. Call volume per year,
in their communities1-4 and to provide additional care per one million of population was then calculated for
at the patient’s home.5 EMS personnel are some of each location (Table 1). The state with the lowest call
the first responders to disasters, and they may also volume per million was North Dakota, with 48,589.
help prepare their communities for possible disas- Alabama was the state with the highest call volume,
ters.6 Since September 11, 2001, their responsibilities at 175,429 calls per one million of population. The
in this area have been dramatically increasing; these average yearly call volume per one million of popula-
added responsibilities have been largely underfund- tion was 109,356 (95 percent confidence interval, CI =
ed, and little effort has been made to determine how 109,288 to 109,423). Extrapolating the data to the
these changes will affect the EMS infrastructure.7 entire US population of 285 million in 2001,13 we find
Although the nation depends on EMS as never before, a total yearly call volume of 31,166,337 (95 percent
the future of the workforce is at considerable risk. confidence interval, CI = 31,146,978 to 31,185,696).
This paper describes the major issues currently Medline searches found no reports or data docu-
affecting the EMS workforce in the United States. menting the number of patients treated per call or the
Historically, human resources have been recognized proportion of calls that resulted in patient contact,
as a major area of concern for EMS.8,9 In 1996, the treatment, or transport. Therefore, we developed an
National Highway Traffic Safety Administration estimate based on data acquired using a standard web
(NHTSA) sponsored a taskforce to develop the EMS search engine (Yahoo), which we used to search for the
Agenda for the Future.10 The Agenda proposed the terms EMS, statistics, and transport. Six localities were
development of 14 EMS attributes. Human resources found that provided data on both responses and trans-
was one of those 14 priority areas. The Human Re- ports. One state in the EMS Magazine survey included
sources section described six objectives, which included data on total call volume and number of patient trans-
the need for adequate training, the importance of collab- ports; that state, Mississippi, is included. Table 2 illus-
orative relationships with academic institutions, and trates that 2,530,834 calls resulted in 1,613,170 trans-
the importance of occupational health research.11 ports; an average of 64 percent of calls resulted in a
patient transport. The Montgomery County web page
MEtHodS (http://www.montcopa.org/eoc/MCEMS/Statistics/
Call volume and patients treated emstat.htm) also indicated that 9 percent of their
No published reports were found documenting total calls were for patients who were seen by the

Journal of Emergency Management 17

Vol. 2, No. 3, Summer 2004
table 1. State population, call volume per year and calls per year per one million population (n = 25)
State Population call volume calls per one million population

AL 3,990,221 700,000 175,429

CT* 3,300,000 450,000 136,364

DE† 666,200 77,400 116,181

FL 16,400,000 1,575,000 96,037

ID 1,293,953 75,889 58,649

IN 5,577,100 750,000 134,478

KS** 2,600,000 241,546 92,902

KY 3,900,000 625,000 160,256

ME 1,200,000 210,000 175,000

MA* 6,016,425 400,000 66,485

MN 4,919,479 390,000 79,277

MS 2,844,658 313,402 110,172

MO 5,233,857 433,000 82,731

NE*** 1,700,000 109,172 64,219

NV 2,214,813 249,485 112,644

NH‡ 1,200,000 98,000 81,667

ND 638,000 31,000 48,589

OK 3,200,000 366,444 114,514

PA 12,281,054 1,400,000 113,997

RI 990,000 132,792 134,133

SC 4,012,012 688,956 171,723

SD 696,004 48,000 68,965

VT 580,000 52,386 90,321

WI 5,100,000 500,000 98,039

WY 493,000 39,000 79,108

total 91,046,776 9,956,472 109,356

** estimated call volume; † Delaware estimated a 7 month call volume of 45,150; population estimate is from 1990;
** Kansas call volume estimate from 2000; *** Nebraska call volume from 1997; ‡ New Hampshire estimated calls at
** 95,000 to 100,000.

EMS crew but refused further medical aid. Based on would greatly increase the number of patients treat-
these data, we estimate that 70 percent of EMS calls ed each year by EMS providers.
result in some level of treatment. Therefore, based on
the available data, it is reasonable to estimate that Number of providers
EMS providers treat 22 million patients per year in Estimates of the number of EMS providers in the
the United States. If the state’s statistics only reflect United States have ranged from 150,000 to over
emergency or “911” ambulance calls, then adding rou- 800,000.14-18 Data from the EMS Magazine survey were
tine and critical care transport via ambulance and air analyzed to estimate the number of EMS providers in

18 Journal of Emergency Management

Vol. 2, No. 3, Summer 2004
 table 2. total calls, total patient transports and percent of calls transported,
selected jurisdictions, 1991 to 2003 (n = 7)
total patient Percent
Service Period total calls
transports transports

Montgomery County, PA (118) 2002 63,469 39,465 0.62

Iredell County, NC (119) January to July 2003 5,667 4,261 0.75

Seattle - King County, WA (120) 2001 165,255 69,136 0.42

Hemphill County, TX (121) 1996 to 2000 1,844 1,311 0.71

Houston, TX (122) 1991 to 2001 1,833,930 1,132,750 0.62

Richmond, VA (123) 1999 to 2001 147,267 114,281 0.78

Mississippi (124) 2001 313,402 251,966 0.80

total 2,530,834 1,613,170 0.64

the United States. Table 3 illustrates the number of rEvIEw of tHE lItEraturE
EMS personnel per category (e.g., EMT, paramedic) This section reviews the current literature on EMS
and the total number of EMS personnel per state. All workforce issues. Medline searches were conducted
50 states and the District of Columbia are included. on all available years, using the term emergency
The total number of EMS personnel is found to be medical services, along with workforce, occupational
891,570. Of these, 154,187 (17 percent) are paramedics. injuries, occupational fatalities, ambulance crashes,
These data are limited in a number of ways. For training, research, stress, and personnel. This section
example, it is not clear if the states counted individ- focuses on the findings in eight areas: demographics,
uals in more than one category, and it is possible occupational hazards, work hours, training require-
that some individuals may be certified in multiple ments, salaries, stress, fire departments in EMS, and
states. There is also the possibility that many people research.
work on ambulances without EMS certification (e.g.,
drivers). The proportions of paid and volunteer per- Demographics of the workforce
sonnel are unknown; the only report related to such Thompson published one study that specifically
proportions stated “in rural areas, approximately described the demographics of EMS personnel com-
three-quarters of rural prehospital EMS providers pared to their communities. In that study of rural
are volunteers.”19 EMS agencies and their communities, no significant
In 2003, the data indicate that there were approx- difference was found between the EMS personnel and
imately 900,000 EMS personnel in the United States. the community for race, sex, marital status, house-
Of these, approximately 180,000 were full-time work- hold size, home ownership, housing costs, and in-
ers. Much like the growing demand for emergency county employment.21 Chng et al.22 compared rural
medicine physicians,20 the demand for EMS person- and urban EMS providers in Texas. They found that
nel is expected to increase. In fact, the Bureau of urban personnel were younger, more educated, were
Labor Statistics predicts that “Employment is pro- more likely to be compensated (i.e., to be paid EMS
jected to grow faster than average, as paid emer- providers), and they reported a lower level of burnout.
gency medical technician positions replace unpaid What little information is available related to gender,
volunteers.”15 race, age, and marital status among EMS personnel

Journal of Emergency Management 19

Vol. 2, No. 3, Summer 2004
 table 3. EMS personnel, 50 states and district of columbia
data from 2002 EMS Magazine survey (n = 51)

State first responder EMt EMt-1 Paramedic other* total personnel

AL 5,756 2,297 2,495 10,548

AK 3,500 900 200 4,600

AZ 8.357 171 2,801 11,329

AR 5,580 339 1,387 7,306

CA 60,000 119 12,000 72,119

CO 13,361 997 3,454 17,812

CT 17,694

DE 600 850 132 1,582

DC 3,500 11 500 4,011

FL 25,063 14,910 39,973

GA 50 150 6,200 4,000 10,400

HI 471 344 815

ID 438 2,618 780 314 4,150

IL 19,934 1,500 6,000 500 27,934

IN 9,029 13,387 1,483 2,254 26,153

IA 2,504 6,135 1,203 1,805 2,698 14,345

KS 1,023 6,173 2,985 10,181

KY 2,740 11,251 1,396 15,387

LA 11,152 4,150 441 1,694 17,437

ME 200 2,660 750 725 4,335

MD 11,439 15,172 710 2,091 29,412

MA 17,170 536 1,923 19,629

MI 11,709 12,914 1,773 6,093 32,489

MN 16,609 9,606 307 1,752 28,274

MS 1,739 243 1,295 3,277

MO 7,000 3,000 10,000

MT 2,345 3,110 293 225 5,973

NE 7,243 227 533 8,003

NV 1,903 4,911 2,340 911 10,065

NH 365 2,199 900 528 3,992

NJ 20,900 13,000 33,900

* Other does not include MDs, RNs, PAs, dispatchers, etc.

20 Journal of Emergency Management

Vol. 2, No. 3, Summer 2004
 table 3. EMS personnel, 50 states and district of columbia (continued)
data from 2002 EMS Magazine survey (n = 51)

State first responder EMt EMt-1 Paramedic other* total personnel

NM 648 3,104 1,077 893 5,722

NY 13,136 37,945 4,806 4,297 60,184

NC 2,803 11,692 1,795 3,734 6,873 26,897

ND 1,632 354 320 2,306

OH 20,729 3,407 10,863 34,999

OK 22,526 6,517 1,327 1,400 31,770

OR 3,946 1,286 2,258 7,490

PA 5,506 27,125 11,769 44,400

RI 2,145 1,890 225 4,260

SC 2,095 771 2,451 5,317

SD 2,896 276 283 3,455

TN 3,283 4,904 3,113 3,285 223 14,808

TX 26,107 4,044 15,242 5,273 50,666

UT 7,184 1,741 872 434 10,231

VT 1,390 833 81 814 3,118

VA 2,310 23,044 2,921 4,417 32,692

WA 2,014 13,020 790 1,522 17,346

WV 644 4,115 1,705 3,360 9,824

WI 2,900 12,500 2,047 2,566 20,013

WY 2,178 687 82 2,947

total 127,876 509,128 58,093 154,187 24,592 891,570

* Other does not include MDs, RNs, PAs, dispatchers, etc.

comes from a variety of sources. EMS personnel in Approximately 4.5 percent of the EMS personnel in
the United States tend to be mostly male,23-25 these two studies had graduate degrees.
Caucasian,25 35 years of age, on average,25,26 and
most are married.25 An Iowa study found that 81 per- Occupational hazards
cent of personnel at EMS-only agencies had some col- The national rate for occupational injuries calcu-
lege or a college degree compared with 51 percent at lated by the Bureau of Labor Statistics for 2000 was
Fire/EMS agencies and 49 percent at Fire-only agen- 6.1 injuries per 100 full time workers, per year. In
cies.24 The study also found that 19 percent of the that same year, it found that the industry with the
EMS-only personnel had a bachelor’s degree com- highest rate of occupational injuries and illnesses was
pared with 7 percent of the EMS/Fire personnel.24 “meat packing plants”; in that industry, there are
Brown25 found the median experience for EMTs was approximately 25 injuries and illnesses for every 100
2.17 years compared with 9.12 years for paramedics. workers, per year.27 Only two papers present data

Journal of Emergency Management 21

Vol. 2, No. 3, Summer 2004
that might be used to estimate the risks for EMS. The effect of work hours on physician residents has
Gershon et al.28 found that there were 220 injury or been recognized by the Accreditation Council for
illness cases among a population of 197 EMS workers Graduate Medical Education and resulted in new
in 1992, and Schwartz et al.26 found that there were guidelines limiting the work hours of residents.55
approximately 45 injury and illness cases per 100 full- Other workers, such as pilots56 and commercial driv-
time EMS workers in 1990. These data indicate that ers,57 have legal limits on their work hours.
the problem is potentially very serious. One paper
looked at occupational fatalities among EMS personnel Training requirements
and found that the rate of fatality per 100,000 EMS Although one study found that 55 percent of rural
workers was 12.7 per year.29 In comparison, the rate EMS volunteers quit because of training require-
was 14.2 for police and 16.5 for firefighters; the nation- ments,58 EMS personnel generally embrace training,
al average for 1995 (a midpoint of the studies) was and many are believed to be interested in pursuing
five.30 Ambulance collisions have been found to be a sig- additional training, such as “expanded scope EMS.”59
nificant hazard to EMS personnel,29,31-33 as well as a This training allows providers to perform advanced
major source of litigation.34-37 Other occupational health clinical interventions, such as suturing and prescrib-
hazards include: assaults,38-41 infectious disease,42,43 ing limited types of medications. Expanded scope per-
needlesticks,44,45 back injuries,46 and hearing loss.47 sonnel may, instead of taking a patient to a busy and
expensive emergency department, perform some lim-
Work hours ited interventions, allowing the patient to arrange for
Although work hours have been found to influence follow-up care with a private physician or clinic at a
EMS job satisfaction,48 a precise estimate of the number convenient time.
of hours worked by EMS personnel is not available.
However, there are indications that employer-mandated Salaries
hours may be excessive. Reports indicate that some One study found that as of 2000, the average
employers, typically based in fire departments, have salary for a paramedic was approximately $38,000.60
shifts of 24 straight hours or more.49-53 Although such However, the Bureau of Labor Statistics estimates
shifts may be acceptable for fire personnel, who may get the median EMT and paramedic salary in 2000 as
called out on few occasions during a 24-hour shift, these $22,460.61 In comparison, Bureau figures for the
long shifts may be much more problematic for EMS per- same year report a median salary for firefighters
sonnel, who may be assigned to many calls during a 24- between $29,316 and $39,477;62 $39,79063 for police;
hour period. NHTSA data suggest that approximately $44,840 for registered nurses;64 and $61,910 for
100,000 crashes per year, including 1,357 fatal crashes physician assistants.65 Brown et al.25 found that
and approximately 71,000 injury crashes, involved EMTs had an average salary of $23,350, while the
drowsiness.54 It is reasonable to conclude that drowsi- average for paramedics was $37,282. Monosky66
ness from extended shift lengths increases the risk of found that the average starting paramedic salary
ambulance crashes and occupational injuries for EMS among respondents to a 2002 national survey was
personnel. This increased risk may also extend to citi- $32,420. One author concluded that only paramedics
zens in the community, as well as off-duty personnel in the northwest and south central regions of the
driving home after an extended shift. United States earn enough to afford a monthly mort-
In addition to the issues related to drowsiness gage payment for a 2,000 square foot home.67 Another
and operational safety, there are concerns in the survey found that many EMS workers earn salaries
areas of medical competency and quality assurance. near the poverty level and lack health insurance.68
For example, medical errors have been found to be a
significant problem in hospitals, which is a more con- EMS and fire departments
trolled environment than the practice arena for EMS. Although some fire departments have provided

22 Journal of Emergency Management

Vol. 2, No. 3, Summer 2004
ambulance services since at least the 1960s,69 an and 17 states report having an EMS injury preven-
increasing number of fire departments have taken tion program.75 Finally, EMS personnel have an
over local EMS services in recent years. The increasingly important role in monitoring the health of
International Association of Fire Chiefs recently the community76-78 and taking on other new roles.79-84
published the results of a study that “demonstrate Research is an important component of address-
that a growing percentage of fire departments are ing EMS problems85 and developing new initiatives.
providing ambulance transport, in addition to the This may be an ideal time to develop unique research
more traditional first response services.”70 Most models,86 but the success of future EMS research
remarkable was the finding that 94 percent of depends on increased research quality.87-88 It will also
respondents were now providing some level of EMS require dedicated researchers, funding, better infor-
in their communities. mation systems,89-91 the development of research skills
Anecdotal reports from many fire departments that among EMS personnel, and a focus not only on clini-
are providing EMS indicate that firefighters are often cal interventions but also on the evaluation of inte-
forced to work in EMS until openings become available grated EMS systems.92-94
on fire apparatus.71 The lack of research leaves open
the possibility that turnover is much higher among fire- dIScuSSIon
fighters than among personnel in EMS-only agencies Emergency medical services personnel have
(i.e., a greater proportion of firefighters may choose not developed a unique set of experiences and abilities
to recertify as EMS providers), and that fire depart- related to patient care, and they have also demon-
ments may be more likely to staff advanced life-support strated their abilities in community health initia-
units with personnel not trained to the full paramedic tives. At the same time, low salaries and changing
level.71 If these initial findings are indicative of a larg- training and certification requirements, along with
er trend, the future EMS workforce may be comprised a risk of occupational hazards, threaten the future
largely of workers who have little interest in providing of EMS services.
EMS, who have relatively little experience, and who EMS is evolving to take on a number of new roles.
have less training than current paramedics. A logical extension of these findings is that EMS pro-
Consolidation of EMS and fire departments may result fessionals can reduce the number of medical emer-
in a decrease in personnel available for disasters. It gencies in the community, facilitate the availability of
could also cause a conflict in roles for such incidents, if specialized care, play an important role in communi-
the firefighters are needed for fire duties and are thus ty health education, improve community health, and
unavailable for patient care. help reduce costs for healthcare in the United States.
Finally, this fundamental transformation of a In addition to having a significant influence on
healthcare delivery system that treats 22 million healthcare, this evolution is a crucial next step in the
Americans each year is being done in the absence of maturation of the EMS profession.
any published literature related to the involvement of
local medical direction or the larger healthcare com- concluSIon and rEcoMMEndatIonS
munity. In addition, no studies have been found on Since September 11, 2001, communities have
the national health impact of this transformation to become increasingly reliant on EMS personnel, espe-
fire department-based service. cially in areas such as disaster response and monitor-
ing of disease outbreaks. In addition, EMS profes-
New frontiers sionals have been increasingly involved in a variety of
Harrawood et al.72 demonstrated how EMS per- community health initiatives that may have helped
sonnel were able to help cut the pediatric drowning reduce healthcare costs and improved the health of
rate by 50 percent in one community. There is an in- the community. At the same time, EMS personnel are
creased interest in primary injury prevention,1,2,73,74 under increasing pressure from the demands of their

Journal of Emergency Management 23

Vol. 2, No. 3, Summer 2004
work and the hazards associated with the occupation. rEfErEncES
Perhaps most significant is the increased willingness 1. Garrison HG, Foltin GL, Becker LR, et al.: The Role of
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