Emergency Medicine’s Original Sin


By Marion Renault

Lindsey Kaczmarek gets called an ambulance driver more often than she gets called a paramedic. “That’s absolutely not what I do,” she told me. What she does do is show up when someone needs medical help, figure out what’s wrong with them, and do whatever she can to help them survive the trip to the hospital—in her case, the Mayo Clinic in Rochester, Minnesota.

The primary symptom for one in three 911 medical calls is simply “pain,” but during any given shift, Kaczmarek might attend to a heart attack, a stroke, a car crash, a labor and delivery gone wrong, a mental-health crisis, a shooting, or an elderly patient suffering from a severe urinary tract infection. “If they’re not breathing, I will breathe for them,” she said. “If their heart’s not beating, I will be the heartbeat for them.”

The job of providing emergency medical services, or EMS, often resembles medical detective work, with limited clues, no specialists to consult, and very little, if any, of the sophisticated equipment available to doctors and nurses. But even though emergency medics—a catchall term used throughout this story for paramedics, emergency medical technicians, and emergency medical responders—handle tens of millions of calls in the United States each year and make life-altering decisions for their patients every day, they remain all but excluded from institutional medicine. “You’re basically like a glorified taxi,” says Sarayna McGuire, a Mayo Clinic emergency physician who has studied pre-hospital health care.

The misconception that emergency medics provide transportation, not medicine, leaves them to cope with all sorts of indignities. “They’re used to being second-class citizens,” says Michael Levy, the president of the National Association of EMS Physicians. In one hour—during which they may respond to several 911 calls—the median paramedic or EMT makes a little more than $17.

That’s half the hourly pay of registered nurses and less than one-fifth the pay of doctors—if they’re paid at all. During the pandemic, emergency medics were literally enclosed in rolling boxes with COVID-19 patients. But in some states, they were not prioritized alongside other essential health-care workers for the first round of vaccines. After delivering their precious cargo to a hospital, in many cases they don’t learn the final diagnosis, or whether their patient ever makes it back home.

That medicine treats emergency medics like disposable, low-wage workers instead of the health-care professionals they are isn’t just unfortunate for the workers themselves—it also leads to less than optimal care for the rest of us on the day we may need it most.

The divide between health-care workers who respond to medical emergencies and those who treat patients in brick-and-mortar clinics is not new. In the 1800s, most accident victims were rushed to their homes, where they awaited medical care from private physicians. Hospitals started to staff their own 24/7 emergency departments only in the mid-20th century, in part thanks to the advent of lifesaving measures such as antibiotics, defibrillation, and blood transfusions.

By the 1960s, a loose network of unregulated emergency medical systems had sprung up around the country. Undertakers and law-enforcement officers provided the bulk of hospital transports—known as “you call, we haul” missions—in the back of police cars, hearses, or delivery vans. These makeshift responders often had little or no formal medical instruction. “It was a little bit of the wild West,” says Chris Richards, an emergency-medicine physician at the University of Cincinnati.

In the late ’60s and early ’70s, in response to growing concerns over traffic fatalities, the Department of Transportation—not the Department of Health and Human Services—developed a structured national EMS system, codifying the idea that emergency medics are drivers, not health-care workers. But the field has evolved significantly since then. Today, some emergency medics can dispense medications, and ambulances can house heart monitors and ultrasound machines. Over time, training and accreditation requirements have grown more and more rigorous. Still, in the eyes of some hospital staff, medics belong as much to today’s medical establishment as police officers and undertakers did in the 1960s.

Many of Remle Crowe’s EMT runs in rural Ohio ended with a dissatisfying reminder of her place in medicine’s hierarchy. “I would drop [patients] off at the hospital and they would disappear,” she told me. As she sped off to the next call, she’d wonder about her last pickup, and what happened to them beyond the emergency-room doors. “There was no way of knowing,” Crowe said.

For the most part, EMS providers don’t learn whether the split-second decisions they make—say, whether to intubate someone—ultimately help their patients. Only about one in three EMS agencies reports having any access to electronic, patient-specific medical information. Many hospitals refuse to share any outcome data with EMS, claiming it’s a HIPAA violation (legally, it’s not). Ultimately, even in the most clear-cut of cases, if a patient dies in the ambulance, an emergency medic may not learn the cause of death, or whether there was anything they could have done differently to change the outcome. “They’re kind of flying blind,” says Michael Sayre, the medical director of Seattle’s EMS.

Leaving emergency medics out of the loop doesn’t only turn their jobs into repeated chronic cliff-hangers. It also keeps them from improving the care they give to their patients, experts told me, robbing them of the opportunity to learn which of their instincts are correct and which to avoid. “Without creating this feedback loop, you really can’t get better,” Sayre says. “Of course medical errors happen because of that. You didn’t have enough of the puzzle pieces.” Few other fields, especially in the world of medicine, demand that its professionals tolerate working in a feedback-free environment. What if a chef never tasted a final dish? What if a teacher wasn’t allowed to grade tests? Would a lawyer be okay with never hearing a verdict? “If you don’t know if you’re bettering patients,” Kaczmarek said, “how do you keep coming to work?”

Some don’t. Emergency medics routinely struggle with high rates of burnout and job dissatisfaction, as well as PTSD and other mental illnesses. They are regularly bitten, punched, or otherwise assaulted by their patients, enduring a rate of occupational violence that is about 22 times higher than the average for all other U.S. workers. Altogether, the low pay, the absence of performance feedback, and the chronic mental and emotional toll “sends the message that no one cares about you and your work,” Crowe said.

The treatment of emergency medics as chauffeurs and not clinicians—as a profession of nonprofessionals—means that not enough Americans choose this career. While nurses and doctors generally stick around in the field for decades, the average age for an emergency medic is just 34, and about 80 percent leave the job after seven years or less. This affects the quality of medical care provided: Data suggest that more experienced EMS clinicians save more patients and lead to better health outcomes. Retention issues in EMS are so widespread that some states and counties are plagued by staffing shortages and, in turn, delayed emergency care. “In many places the turnover in this workforce is very high,” Sayre says. “People accumulate these mental injuries that don’t heal, and they don’t work in the field long enough to become truly excellent.”

As emergency medics continue to be undervalued, their work has never been more valuable. We needed them, and badly, during the pandemic, as 911 call volumes skyrocketed. We need them to respond to the urgent health needs of the country’s growing population of elderly people, who are more likely than in the past to suffer from several chronic conditions and take a dozen-plus prescriptions. We need them on the scene of mass shootings and drug overdoses. We need them as our planet continues to warm, leading to natural disasters, bouts of extreme weather, and infrastructure collapses. America’s health-care system ignores emergency medics at its own risk—and all of ours.


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