And the Experience Gap May Be Making It Worse

By Scott Ash

For the Paramedic Hive

For years, we’ve called it an EMS staffing shortage.

I’m beginning to think we’ve been calling it the wrong thing.

“Staffing shortage” sounds administrative. It sounds like empty boxes on a schedule, overtime texts going out at six in the morning, another recruitment class starting next month, or a supervisor trying to figure out how to keep one more ambulance on the street.

But there comes a point when a staffing problem becomes something much bigger.

When the ambulance is ready, the equipment is stocked, the 911 call is waiting—and there aren’t enough paramedics to put in the truck—we have crossed that line.

This is becoming a public-safety crisis.

We Don’t Just Need More Paramedics. We Need Them to Stay.

Almost every conversation about the EMS workforce eventually arrives at the same conclusion: We need more paramedics.

We do.

But maybe we’re asking the wrong question.

Instead of asking how we can recruit more people into EMS, we should also be asking why so many experienced people are leaving it.

Consider what we ask of a paramedic.

Work nights. Work weekends. Miss holidays. Pick up overtime because somebody called out and there’s nobody else to cover the truck. Deal with violence, death, infectious disease, sleep deprivation, bad backs, bad knees, and things that follow you home whether you want them to or not.

Then walk into a stranger’s house at 3:00 in the morning and make decisions that may determine whether that person lives or dies.

We expect paramedics to interpret ECGs, manage airways, administer powerful medications, recognize shock, treat major trauma, resuscitate children, and make complicated clinical decisions in places never designed for medicine.

A bathroom floor.

A wrecked car.

A parking lot.

A bedroom.

The side of a highway.

Yet the compensation, career opportunities, and professional recognition in many EMS systems still don’t match that responsibility.

Eventually, dedication runs into reality.

People have families. Mortgages. Retirement plans. They want to see their kids. They want their bodies to still work when they’re sixty. And they want to know that after twenty years of becoming very good at what they do, there is somewhere for their career to go.

When other healthcare professions can offer that, we shouldn’t be shocked when paramedics leave.

The Experience Gap

There is another part of this crisis that worries me just as much as the empty ambulances.

We are losing experience.

When a paramedic with twenty or thirty years on the street retires or leaves the profession, the agency doesn’t simply lose one employee.

It loses thousands of patient encounters.

It loses the medic who has seen the “stable” patient suddenly become unstable.

The medic who knows that the monitor may look acceptable while the patient absolutely does not.

The medic who has made mistakes, learned from them, and spent the next twenty years preventing younger clinicians from making the same ones.

Most importantly, we lose the people who teach the next generation.

A veteran retires on Friday.

A newly graduated paramedic takes that position on Monday.

From a staffing perspective, the vacancy has been filled.

From a clinical perspective, something very different has happened.

That isn’t an insult to the new paramedic. Every veteran medic once stood beside an ambulance wondering whether they were ready for what was coming next.

The difference was that many of us entered EMS surrounded by people who had already been there.

Experienced partners. Field training officers. Supervisors. The crusty old medic in the next unit who somehow knew you were in trouble before you did.

They taught us the things no textbook could.

What happens when new paramedics increasingly find themselves working with other new paramedics?

Who says, “Slow down. Something doesn’t fit here”?

Who recognizes the subtle change in the patient’s face?

Who has seen this before?

That is the experience gap, and hiring alone won’t fix it.

Experience cannot be fast-tracked.

It takes calls.

It takes mistakes.

It takes mentorship.

Most of all, it takes time.

But We’re Trying to Make Paramedics Faster

That creates another uncomfortable problem.

When agencies cannot find enough paramedics, pressure naturally falls on the educational pipeline to produce more of them.

More students. More programs. Faster completion.

But paramedic education isn’t an assembly line.

We can teach medication dosages.

We can teach algorithms.

We can teach someone how to interpret an ECG or perform an airway procedure.

Clinical judgment is different.

Knowing when to do something is harder than learning how to do it.

Knowing when not to do it may be harder still.

If we respond to a staffing crisis by lowering educational expectations or rushing clinicians through the process, we haven’t solved the problem.

We’ve simply moved it from the staffing office to the back of the ambulance.

We need more paramedics.

But we need educated, competent, mentored paramedics who are given the opportunity to become experienced ones.

The Cycle Feeds Itself

This is where the problem begins accelerating.

Vacancies create overtime. Overtime creates fatigue. Fatigue contributes to burnout. Burnout drives people away.

Their departure creates another vacancy.

Then somebody else works the overtime.

Eventually an ambulance goes out of service.

The truck may still be sitting in the station. It may have a monitor, medications, oxygen, and everything necessary to handle an emergency.

But without a crew, it isn’t an ambulance.

It’s a very expensive box with flashing lights.

And the calls that unit would have answered don’t disappear.

They move to another crew.

That ambulance travels farther. Its call volume increases. Its coverage area gets bigger.

Then another call drops.

And another.

Eventually the public sees the consequence:

It takes longer for someone to arrive.

A cardiac arrest doesn’t care that two ambulances couldn’t be staffed that morning.

A stroke doesn’t know the nearest available ALS unit is coming from another district.

A critically ill child doesn’t understand that the ambulance normally covering the neighborhood is holding a patient at an overcrowded emergency department.

Physiology doesn’t care about staffing problems.

The clock keeps running.

This Is Mocking Time

That is where this issue connects directly to the argument I make in Mocking Time: How Paramedics Save Minutes, Lives, and The Crisis Behind Who Will Answer the Next Emergency Call.

Paramedics spend their careers trying to buy people time.

We buy the heart attack patient enough time to reach the cath lab.

The trauma patient enough time to reach an operating room.

The overdose patient enough time to breathe again.

The stroke patient enough time to reach definitive treatment.

Sometimes all we can give someone is another five minutes.

But sometimes five minutes is everything.

And here is the contradiction:

The profession that spends its existence buying time for everyone else is running out of its own.

Not enough time between calls.

Not enough time to recover.

Not enough time to properly educate new clinicians.

Not enough time for veteran paramedics to mentor them.

And eventually, not enough paramedics to get there in time.

That is where the staffing crisis and the experience gap become inseparable.

Someone Will Come

There is an unwritten promise behind 911.

Call us.

Someone will come.

Most people never think about what it takes to keep that promise. They shouldn’t have to.

But ambulances don’t save people.

The people inside them do.

Someone has to get into that truck at the beginning of the shift.

Someone has to answer the call.

Someone has to walk through the door everyone else may be running out of.

And somebody has to know what to do when they get there.

That requires more than staffing.

It requires experience.

It requires education.

It requires working conditions that allow people to build careers instead of simply surviving shifts.

And yes, it requires compensation that reflects the responsibility society has placed in their hands.

Wages, education, schedules, hospital delays, burnout, career development, and professional recognition aren’t separate from patient care.

They determine who will be there to provide it.

The Clock Is Already Running

EMS has always measured time.

Response time.

Scene time.

Transport time.

Door-to-balloon time.

Time without oxygen.

Time without circulation.

We understand better than most that minutes matter.

Maybe we need to start looking at our own profession with the same urgency.

Because the warning signs are already there.

Ambulances we cannot staff.

Veteran paramedics leaving.

New paramedics entering systems with fewer experienced clinicians available to mentor them.

Crews working overtime because nobody else is available.

Coverage areas getting larger.

And patients waiting longer.

In Mocking Time, I ask a question that sits at the center of the book:

Who will answer the next emergency call?

That question becomes a little less rhetorical every time an experienced paramedic walks away and another ambulance is taken out of service because there is nobody available to staff it.

We should probably figure out the answer before the public has to.

Because somewhere tonight, someone will dial 911.

The clock will start.

And they will assume someone is coming.

We need to make sure they’re right.

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Scott Ash, NRP
Author, Mocking Time: How Paramedics Save Minutes, Lives, and The Crisis Behind Who Will Answer the Next Emergency Call

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