Seven Hard Truths About EMS That Will Make You Better

Having worked in EMS for over two decades now, I’ve come to grasp a few hard truths that, once you accept, can improve your jobAmbulance Crew experience tremendously. I’ll warn you at the start that this post lacks much of the feel good vibe of much of my writing. A lot of what I’m about to tell you is harsh. It might be easier not to say it. But I wish someone had told me these things a long time ago. It took me a good portion of my career to figure some of these things out. And I think a good deal of success in the EMS world hinges on coming to terms with these hard truths.

1) Bad employers rarely, if ever, become good employers.

It doesn’t stop us from showing up to work in the morning and it certainly doesn’t stop us from complaining about it, but the hard fact is that any EMS agencies are managed poorly and they will continue to be managed poorly. If you’re hoping that the new management consultant firm or the next big managerial retreat will produce sweeping changes in the status quo, I’m sorry to burst your bubble but it isn’t going to happen. At that next management retreat, most of what your manager’s talk about will be how to get you to be more productive with their same crappy management style. You might get a new vision statement, but don’t expect a lot of change.

Most management teams aren’t really interested in improving working conditions or becoming better leaders. They have two primary concerns. They want to know how to improve productivity and they want to know how to improve morale. So they basically want you to work harder and be happier while you are doing it. They aren’t interested in creating the sweeping changes that you are wanting. That isn’t to say that there aren’t very well managed EMS organizations. There are great organizations, both public and private, that have inspired and creative leaders who want their agencies to be on the cutting edge.

The best way to work in an organization like that is to go out and find it and then work there. The pace of change in dysfunctional organizations is glacial. If you’re waiting for mediocre leaders to become great leaders, you’re going to have a very long wait. If you really want better working conditions, go find them yourself.


2) You will be paid whatever the market will accept. (And you are the market too.)

Back when I was a teenager I remember hearing people say, “Can you believe that the garbage man is paid better than a teacher? We care more about the garbage than our children’s education!” Today, twenty-five years later, people say, “Can you believe the sanitation worker makes more money than a teacher? We care more about garbage than our children’s education!” Nothing has changed and it won’t change in the next twenty-five years either. I know this because we pay people whatever the market will bear.

We don’t decide what to pay garbage men or teachers because of our feelings toward garbage and children. Our feelings have nothing to do with it. We pay them what the market allows. If we could pay garbage men five dollars an hour less and still have a ready supply of garbage men, we would. The problem is that when we pay them less, they stop showing up to work. They do a very hard, physically brutal, filthy job that is soul-sucking and non-glamorous and they only do it because they can make good money with no barriers to entry.

If you pay teachers five dollars an hour less than the average sanitation engineer, they still show up in droves to do the job. As long as people show up to do the job, the pay will remain unchanged. When people send their kids to school and there’s nobody qualified to teach them, there will be a referendum to start paying teachers more money. Regardless of what people might say on Facebook about the military holding bake sales, if someone marginally qualified shows up to teach their kid, they will have little motivation to pay them more money.

The same is true for your job…even more so. Many people will do your job for free! It’s true. As long as there are volunteers in communities willing to be EMTs and paramedics for free on their off time, the community will likely pay nothing for a full time ambulance crew. Until people call 911 and nobody shows up, paid EMS won’t even be a blip on the radar. Here’s a future salary increase potential calculator for you. If you make eight dollars an hour and your employer needs five more employees and he interviews nine people and hires five. In ten months you will still make….eight dollars an hour.

Unfortunately, even if people stop showing up for the job, your employer will likely just institute mandatory overtime until he or she can fill the gaps at the current market value. You may even suffer the humiliation of learning that a brand new employee makes more money than you do.

Honestly, the best predictor of increased wages is having another ambulance service in town that pays substantially more. That is one positive predictor of a future wage increase. It doesn’t matter how much people care about their heart or their family. Forget about the idea that worth-equals-pay. You are paid fair market value based on supply and demand.


3) Your knowledge and skills will not improve without purposeful practice.

helping victims by merine corps archives flickrWe get this idea that experience equals skill. It isn’t true. There are many, many EMS employees that were awful ten years ago and today they are still awful. They haven’t improved with experience and you won’t wither. You will improve because you make a conscious effort. I don’t mean attending the required C.E. classes and looking up the occasional prescription medication. I mean consciously seeking to broaden your knowledge base and get better at the skills that you are performing poorly.

This might seem obvious, but it isn’t. Most folks sit around thinking that after running a year or two of ambulance calls, they will be far superior to their more info

current self. Your brain is wired to convince you to do nothing uncomfortable that might change your status-quo. Your brain is built for efficiency. It chooses the path of least resistance. This is how you are able to filter millions of irrelevant bits of data and focus only on the important things every minute of every day. It’s also the reason that your brain will choose to read Harry Potter (again) instead of a paramedic textbook. You can get better, but you have to consciously decide it. You have to choose it every day.


4) Very few people will encourage you to be remarkable.

On that note, most folks aren’t remarkable and they don’t want others around them to be remarkable. If you work with unremarkable people, don’t expect them to cheer your efforts to become remarkable. They won’t. They will question why you, an EMT, are reading a paramedic textbook. Or why you, a paramedic are reading a physician’s desk reference. They will question and mock and ridicule you and they will offer to let you borrow their Harry Potter book. They don’t do it consciously, but inside, they secretly don’t want you to be any more remarkable than they are.

I don’t want you to be down on everyone else, but I do want you to recognize that, if your plan is to become remarkable, you have to do it on your own. There are a rare few individuals in this world who are good at helping lift other people become more. For most of us, our default mode is to quietly want others to remain exactly as they are right now. It’s a scarcity mindset.

Do you plan on advancing your career? You need to take the initiative. Do you want to attend classes, learn a new skill, qualify for a promotion, spend more time with family and friends, quit smoking or become more fit? You need to stop waiting for permission. You’ll need to take the initiative. If your dream is dependent on anyone else doing anything, you are on permanent hold. Stop waiting for some person or condition external to yourself. It’s time to begin.


5) Being nice is not a substitute for being competent.

I say that and I’m really big on being nice. If you’ve read my blog for any amount of time, you know how big I am on being nice. But it isn’t a substitute for being good. When someone hands you their sick baby, they aren’t critically concerned with how nice you are. They are hoping and praying that you are good at what you do. They could really care less if you are nice enough to fix their child’s problem. They are hoping that you are good enough to fix their child’s problem. Nice is a bonus, but good is essential.

So that you don’t misunderstand…being nice and kind and friendly is like a force multiplier. It makes everything you do easier and it makes our job immeasurably more worth doing. However, don’t use your nice-guy / kind-girl status to justify not knowing how to do your job. You don’t get a pass on competence because you are sweet and hold people’s hands. The hard truth is that people pay you to know how to do your job. If you choose to put on the uniform and call yourself an EMT or a paramedic, you have a responsibility to know your protocols, your skills and your job.


6) EMS providers who suck tend to suck because we allow it.

In just about every place I’ve ever worked, there have been low performing employees. The interesting thing is that, regardless of the organization, everyone always seemed to know exactly who the low performers were. Isn’t it true? If we gave everyone at your place of employment a pencil and paper and said, “Who sucks at their job the worst? Make me a list.” Just about every list would be identical. Wouldn’t it? So why do individuals continue to suck shift-after-shift, year-after-year? The reason is because we let them. We allow it. You and me both.

There is nothing we seem to be more afraid of than simply having an uncomfortable conversation. When faced with telling an individual that we feel their skills are inadequate, we shrink. You’re no different. The last time you worked with one of those people on your list, you didn’t say anything either.

When they did those things that make their care substandard, you looked the other way. We lack the social courage to make inadequate prehospital care unacceptable. And as long as we do, it will persist. It won’t be fixed by education, higher standards or better hiring practices. It won’t be fixed by quality assurance or better educators. While they all may play a role, it will end when we decide that it is no longer tolerable.

7) Prehospital medicine is not designed to be a long term career option.

emt cot instructions taberandrew flickrSome people decide to be waiters and flight attendants and river rafting guides for their whole lives. But those jobs weren’t designed for that and those who choose that option tend to pay for it. The same is true for prehospital ambulance service. It’s a job that demands a plan-B. You may have a long run and you may have a short run but it’s likely that your body and your life circumstances will decide when your run is over. It will likely be when your heart is still in the game (if you’re lucky).

I’ve watched it happen over and over again. People who design their lives to move through EMS find it a useful experience. People who design their lives to be EMS get eaten alive. This work will wear you out. High call volume, sleep deprived, system-status-management operated EMS wears away at you like water over stone. Its effect is invisible but it is real. You need to be moving toward something or you’ll just keep showing up year after year until one morning you have a stroke while noshing on a breakfast burrito, siting at a street corner post.

Your experience in EMS will be invaluable as you move on into one of thousands of possible next options. Gain the value. Learn the job well. Be remarkable. And then ride off into your sunset. I wish you luck.


  1. I have written about many of these in one form or another, but obviously without the eloquence or clarity that you bring. Thank you.

  2. Once again you crush it! Well done. Thanks.

  3. Very well spoken

  4. Your Hard Truths about EMS is indeed startling and shocking revelation. Private companies and the local, state, and national level authorities should now wake up from their deep slumber and improve the nagging issues plaguing EMS.

  5. Skip Kirkwood says:

    I was with you until #7. That one is true only if you make poor choices in the beginning. If you make the choice to stop getting educated when you get your EMT or PM card; if you make the choice to work for a bad agency; if you are unwilling to move to another community to take advantage of an advancement opportunity; if you’re financially irresponsible and get yourself in to debt so that you MUST work 90 hours per week to make ends meet, then you will not have the flexibility to make EMS a career.

    On the other hand, if you get educated, if you refuse to work for an agency that doesn’t treat its employees well’ if you keep yourself geographically mobile; if you don’t get financially jammed up, then you too can have a great career in EMS. I know – I’ve done it, and so have lots of people that I know. Which means only – that you can too. It is possible. The power lies in YOUR hands.

  6. Don Goldrup says:

    I agree with all the points but #7. Back in 1979 (OMG!) I decided to follow my passion rather than my pay check. Hello middle class living! But because I followed my passion I became involved. I embraced change and still do. I take the opportunities to positively effect my work place at both a micro and, less frequently, a macro level. I critique after every call and change or review accordingly. My yearly CME choices with Base Hospital reflect that critique process. And after 34 years with 10 more to go I still love going to work! I feel someehat compensated for those first 20 years of crappy pay by the high level of job satisfaction I got from embracing change in myself and in the industry. No one will carry me to retirement because I plan to stride across that line on my own. And I am very encouraged by the high number of younger medics with a growing post secondary education, positive attitudes to change and career planning and a passion for the job and being good at it. That being said pay attention to points 1-6 so you can soften the impact of #7 because it does eat medics up to be unaware and or uninspired about the day to day work they do!

  7. Natalie Arenovich says:

    Well said!

  8. Diane cooper says:

    Love the insight! You bring up very valid points! I agree with Don Goldrup and Skip above about #7- you can make it a career if you chose to! I had the pleasure of working with Don when I was a new medic (18 yrs ago- gasp!), and I plan to continue on this path as well…. I agree with the rest though!