This is something we’ve really needed to address in our profession for a long time, with sadly little progress.
During one of the great Pinnacle EMS sessions last week, an EMS chief from a major urban fire agency explained why they switched away from dual-role FF/Medics to flex-staff daytime ambulances in his department.
He said that when they recruited for FF/Medics, the applicants all looked like the rest of the sworn department members, who did not look like the rest of the community.
When they opened of the flex staffing to non-sworn personnel, the applicants looked more like the rest of the community.
It’s THAT kind of thinking, along with EMS agencies offering training scholarships for paid training and employment post-graduation, that may start to bend the diversity curve in our profession!
From low pay to workplace culture, obstacles litter the path to diversity in EMS
By Akila Muthukumar
Aug. 1, 2022
A single mother, Tashina Hosey quit her job at a Pittsburgh post office when she was assigned to work a seventh consecutive day just as her second daughter was about to be born. Desperate to find her next paycheck, she stumbled upon a free 10-week emergency medical technician course.
Called Freedom House 2.0, the program trains people like Hosey – unemployed, single parents, low income – following in the footsteps of the original Freedom House, a pioneering Pittsburgh ambulance service staffed by predominantly disadvantaged Black residents that was at the vanguard of efforts to modernize the delivery of pre-hospital care in America in the 1960s and 1970s.
Emergency medical services have since become predominantly white, as well as mostly male, in Pittsburgh and nationally. Programs like Freedom House 2.0 have sprouted across the nation in an effort to diversify EMS. As of 2000, less than 5% of certified EMS professionals were African Americans, and that proportion remained until 2017. As of 2019, it had increased slightly: non-Hispanic Black people accounted for 8% of EMTs and 5% of paramedics.
When the race of EMS crews doesn’t match the population they serve, studies show inequities in care proliferate – strokes are overlooked in Black women, and Black children are less likely to receive pain medications for long bone fractures. There are even differences in hospital transport destinations for Black and Hispanic patients in comparison with their white counterparts.
“A lot of those health inequities: stroke recognition delays, trauma care delays, and pain control differences, start to go away when you have a workforce that looks similar to your patient population,” said Ben Weston, medical director of the Milwaukee County Office of Emergency Management.
Yet the diversity efforts face big challenges. EMS is notorious for low pay, long hours, limited career-advancement potential, and high turnover; many services are staffed by volunteers looking for experience before going into firefighting, police work, or medicine. Gallows humor and bullying disguised as banter are part of the culture in many EMS workplaces, and in a 2021 survey, 61% of female EMS workers said sexual misconduct was a major issue in the industry.
During her 10 weeks in the Freedom House 2.0 program, Hosey woke up at 6 a.m. in her apartment on a street with nothing but a Rite Aid and “heavy, heavy, heavy drug activity.” She’d pack diaper bags, bottles, and leftover dinner for lunch before waking her children up from the bed she shared with them.
“They call it a two-bedroom but I’m gonna say it was one and a half because the other one was not possibly big enough to be a bedroom,” she said.
Battling heavy traffic in her white 2014 Chevy Malibu, she’d drop her kids off at daycare before driving to the Hill District to learn about injuries, medications, and triage skills from 8 a.m. to 4:30 p.m. five days a week. After retracing her morning commute, she’d finish errands and sometimes only begin studying at 11 p.m. Still, she loved ride-alongs and began to think being an EMT “is something I can do.”
Upon graduation, however, Hosey did not take the EMT licensing exam, even with the program covering all fees and offering a $250 stipend. In fact, of the 30 graduates from the first four cohorts of Freedom House 2.0, only one is an EMT. Of the 22 who are employed, 10 are patient care technicians, five are medical assistants, three entered other allied health fields, and three became community health workers, including Hosey.
“They were starting out at maybe $14 [hourly pay],” Hosey said. “With me being a single mom with two children and a car and rent and all types of bills, it just didn’t seem like something that would be beneficial to me. They do 12-hour days … it would have never worked.”
Instead, she helps other single mothers move out of mice-infested homes and navigate the intricacies of obtaining housing subsidies. The regular hours, remote-work option when her kids are sick, and increase in pay allowed her to purchase a 2,474-square-foot, three-bedroom home with a basement and attic – luxuries she never imagined having before Freedom House.
Before Freedom House, police officers and morticians used to transport patients, but the death of the Pennsylvania governor from a heart attack en-route to the hospital in 1966 cast a spotlight on avoidable deaths. In Pittsburgh, Freedom House saw an opportunity to improve care for its neighborhood while providing training and jobs for its poor, unemployed Black residents.
After completing a 32-week, 300-hour course, 25 paramedics previously deemed “unemployable,” most of them Black men, were assigned to two ambulances. They were pioneers of CPR, intubation, and IV administration in the field and helped pave the way for national standards for pre-hospital emergency care.
But within a few years, the city’s EMS crews became almost entirely white.
“EMS started in Pittsburgh on the backs of African American men and women from the Hill District,” said Sylvia Owusu-Ansah, the diversity and inclusion director of the National Association of EMS Physicians. “A new regime came in the early ‘70s that basically, through the acts of racism, eliminated probably the most elite, astute paramedics that were there at the time.”
The city terminated funding of the Freedom House service and built a new paramedic force from scratch. Driven by police officers eager to maintain control of ambulances, the Freedom House crews were split up, despite the city originally agreeing not to do so. Those with criminal backgrounds were fired or reassigned non-medical work, and tests on material they had not been taught were used to dismiss others. Their replacements were all white, and white employees with less experience began to take on leadership roles. By the late ‘90s, Pittsburgh’s paramedic program was 98% white.
Owusu-Ansah said the picture nationally is similar. EMS is clearly “very much an old boys club,” especially in EMS-fire services, she said. “I’m pretty much on the national committee of every EMS organization that exists out there, and over 90% of the time, I’m one of the few women, I’m the only person of color, and I’m the youngest person.”
Because EMS in most places is a part of the fire or police agency, it has a similar culture and draws recruits from the same pool of applicants. “There’s a lot of fraternity involved in the way of ‘my uncle did this’ or ‘my grandfather did this,’” Owusu-Ansah said.
Much like Hosey, Douglas Randell – now division chief of EMS in Plainfield, Ind. – was married with a young kid trying to “make ends meet” when he joined an EMT program through a scholarship for disadvantaged students.
“When you have the exposure of something generation after generation, it almost becomes an expectation that you follow the path,” he said. “For Blacks, especially in urban areas, we didn’t have that exposure.”
There is also a widespread perception that EMS is a part of law enforcement, and that deters Black applicants and others from communities that have long been victims of police violence. Meg Marino, director of New Orleans EMS, turned on her Zoom camera mid-interview to show how her uniform and badge look like a police uniform. Even small visual cues like wearing a pride pin or Black Lives Matter shirt can increase patient trust in EMS providers, she said.
While the paramilitary structure of EMS promotes organization and high performance, it comes with deep-seated cultural values such as not questioning authority and “toughing it out” that may also make the job less appealing.
“We can do all the recruitment in the world” but it is meaningless without changes to workplace culture,” said Jordan Rudman, a former EMT who is now an emergency medicine resident physician at Beth Israel Deaconess Medical Center in Boston. Referring to the hierarchical structure of EMS agencies and cases of sexual assault, he said, “It’s pretty hard for me with a straight face to say: come work here. It’s gonna be great.”
Hosey saw first-hand the difference a diverse workforce, and its absence, can make in the way patients are treated on ambulances in low-income neighborhoods in Pittsburgh. Once on a ride along, Hosey remembers the team visited a mental health facility that was “almost like a jail.”
“The guy we picked up was a Black guy and you can tell that he was suffering from some type of mental illness,” she said. “But they [the EMTs] chose not to listen to him. It was just like ‘shut up’ and ‘you don’t know what you’re talking about,’” she said.
“I wasn’t an EMT at the time so I couldn’t pinpoint what the issue was, but I was vocal about the way that they chose to talk to him,” she said, adding that the EMTs were receptive and apologetic.
Diversity can improve communication with patients, whose accounts are often as useful to ambulance crews as clinical examinations. A bilingual EMT can be invaluable, especially since translators are not practical given the need for speedy treatment.
Even without perfect provider-patient racial concordance, a more diverse workforce can indirectly benefit patients. Randell says conversations he has with white providers in the station – about barber shops, soul food, and his favorite TV shows – makes them a bit more comfortable with treating patients who don’t look like them.
“When we go into a house and it is predominantly Black, I am the lead person because I know the environment,” Randell said. When someone asks for albuterol for their asthma in a poor neighborhood, he says he has “a level of compassion” and is willing to believe they couldn’t afford to get it filled while someone without his background might think the patient is just abusing the system.
Alongside Freedom House 2.0, EMS agencies across the country – in New Orleans, Chicago, Milwaukee, Durham, N.C. – are implementing efforts to diversify their workforces, but it can be slow-going and providers of color feel the extra work of promoting diversity frequently falls on them.
With a million-person county, 125,000 EMS encounters per year, and 14 fire-EMS stations, Milwaukee’s service is one of the largest in the United States. In early 2020, it found that race and ethnicity status of patients was recorded less than 50% of the time, which made it difficult to study inequities in care. “The data was garbage,” said Weston, the county emergency management medical director. After making it a required field in the patient care records system, he said, the agency was able to identify and show providers specific disparities in patient care.
“It’s not just data from other systems, but showing that right here in Milwaukee County, our system also has disparities in how we care for patients,” Weston said. Rather than making blanket statements about improving patient care, this focuses the conversation on how to improve care for patients from disadvantaged racial and ethnic groups. The issue is framed at the population-level so providers don’t feel like their medical competence is being called into question, nor that they are being attacked for bias.
Joshua Parish, assistant chief of EMS in the Milwaukee Fire Department, said traditional recruitment efforts involve highlighting the job – the fires and trucks – at career fairs, which attracted people who were willing to commit immediately.
Now, when speaking with someone from an underrepresented group, he tries to “anchor our recruiting messaging in what my target audience already understands.” He asks people what they like in their current job, what differentiates a job from a career, and how money factors into their family’s current situation. He gives them time to think about the decision.
He’s hyper-intentional about visual images: a feminine silhouette or a child wearing a hijab on flyers, websites, and photos can serve as psychological cues for inclusivity “without having to say ‘we’re inclusive,’” he said. Younger firefighters – who have dreadlocks and cornrows and get their hair done – are serving as a recruiting tool for the next generation to enter into this space, he says.
EMS certification is equivalent to an associate’s degree, and Parish said learning so much content quickly can be a barrier to entering the profession. For non-university-educated students unfamiliar with anatomy, or without any exposure to Latin, making sense of medical prefixes is not easy. Parish worked on making the EMT curriculum more accessible to under-resourced students by finding ways to teach basic numeracy and health literacy.
“This is so much harder than I thought it would be,” he said. “I was sitting in some high school classrooms and I realized that that’s where the deficit was.” The training program started teaching students structured note-taking and implemented academic probation for those with less than a B average, which led to students seeking additional help; though labor intensive for the leaders, it was beneficial to push students.
Now, the firefighters he is recruiting and promoting are the most diverse the department has ever seen; over 50% of new hires in the last five years have been women and people of color, but it will take time for that diversity to be reflected in leadership.
“[People] who just got promoted today, that’s because I hired them seven years ago,” Parish said. “They’re going to be my cultural trendsetters. So it’s my job, when they want to do something out of the norm and they get crap from our old guys to go, ‘No, that’s cool. Let them roll.’”
Workers are evaluated using objective metrics like the speed and accuracy of taking patient vital signs, Parish said, as opposed to an officer “telling you that you did a bad job because they think you did.” He said he assigns the “old guys” to work alongside colleagues from different backgrounds — say, a younger woman of color. After a while, he added, the older workers will accept that “people who look like her and sound like her can be EMTs.”
In New Orleans, EMS Director Marino said her agency has blinded hiring decisions and promotion reviews in an attempt to overcome unconscious bias or overt instances of candidates being excluded because of an “ethnic name” on a resume.
She said she’s not deterred by pushback from some veteran employees. The old guys’ pejorative whispers about the “diversity agenda,” she predicted, will be phased out by a workforce that wants to include maternity pants for pregnant providers, ask questions about pronouns for trans patients, and make diversity a core part of their agenda.