Doing the Job: Paramedics, EMTs, and the Crisis in Rural EMS
Complex funding and staffing challenges have hampered rural EMS for years. Will elected officials finally step up to help those doing the job?
↓ scroll down ↓
In thirteenth-century Florence, groups of laborers from the city’s wool-and-textile trade donned vermilion robes and identity-masking hoods and carried the sick and injured to medical attention. Or, quite often, to graveyards.
Known as the Fratelli della Misericordia, or Brothers of Mercy, they transported their patients on rudimentary stretchers crafted from canvas or leather slung between two poles.
Their concealed identities reflected a Christian devotion to service, humility, and charity, values they deemed godlier than riches or recognition.
This earliest of ambulance services was strictly volunteer. No payment was accepted. Any reward would come, they believed, in the next life.
Though it’s not directly linked to the establishment of emergency medical services (EMS) in the United States, it’s an example of the volunteer, community-based response that, beginning in the late 1960s, became the norm in rural Berkshire County towns.
But the realities of modern working life, extensive training requirements, and rising costs mean it’s no longer possible to rely solely on volunteers to staff ambulances and deliver the most advanced prehospital medical care.
Where the Brothers of Mercy once carried makeshift stretchers by hand, today’s EMS providers arrive in expensive, technology-laden ambulances that serve as emergency rooms on wheels.
And while those medieval volunteers had no special skills beyond strong arms and backs from carrying heavy loads of raw wool, present-day paramedics train for several years and can perform many of the same lifesaving procedures as emergency room physicians.
All of that costs money. And with the disappearance of the longstanding “volunteer subsidy,” today's rural EMS needs more financial resources than what reimbursement from public and private health insurance can provide.
Today’s EMS also requires trained, experienced paramedics and emergency medical technicians (EMTs) who are paid appropriately and treated well enough to stick with an often-stressful career. But many are leaving the field, and not just because of pandemic-era burdens.
For these and other reasons, advocates say that rural EMS needs urgent attention—particularly from elected officials at the local, state, and federal levels who have, in the past, not done enough to help.
It was early on a brisk, overcast Saturday this spring when I lost track of how many 911 emergency-response calls I had been on with the paramedics and EMTs of the Southern Berkshire Ambulance Squad.
Over many weeks, there were trips to seniors feeling dizzy, people with chest pain, shortness of breath, seizures and sudden collapses, unexplained abdominal pain, possible strokes, assorted falls and lift-assists, whacks to the head, car and motorcycle accidents, drug-rehab complications, and many patient transfers between hospitals, nursing homes, and rehabilitation facilities across the region.
In homes and at schools and on roadsides, I witnessed a teenager’s dislocated knee popped back into place, oxygen administered to someone with COPD, a baby with days-long diarrhea comforted, and five EMS responders care for a woman in her thirties who had crumpled to the floor of a grocery store, awake but unable to speak or move.
After we transported a motorcycle-accident victim to Berkshire Medical Center, I saw a paramedic brief an assembled trauma team of doctors and nurses under the bright lights of an emergency-room suite.
And one morning I watched as an eighty-nine-year-old woman answered a paramedic’s questions about her symptoms with a resigned shrug. “I’m old!” she said with a laugh and wry smile.
Each incident was different. But all unfolded in a familiar pattern: A dispatch tone shrieked over the radio in Southern Berkshire’s staff lounge, where on-duty paramedics and EMTs in their navy-blue uniforms might be completing patient-care reports from an earlier call, eating a meal, talking about recent dispatches, studying giant textbooks, scrolling their phones, or watching movies on a large-screen TV.
They all hear the information broadcast by the regional 911 dispatch center in Pittsfield or from the Great Barrington Police Department. But no eyes widen. No one runs. There’s no pounding soundtrack or fast camera cuts to ramp-up tension. Instead, a pair of emergency medical providers walk down a hallway to the garage, climb aboard their rig, open the large overhead door, and roll out. This all takes less than a minute.
The ambulance’s lights flash and its siren wails as needed to clear traffic from the road. On arrival, first responders from local fire and police are usually already there—sometimes appearing in large numbers, seemingly out of the ether—to secure the scene and pass along initial information. The EMS crew works calmly and with focus, engaging with both their patient and, often, concerned family members.
Paramedics and EMTs from Southern Berkshire tend to a woman who collapsed at a local grocery store.
Paramedics and EMTs from Southern Berkshire tend to a woman who collapsed at a local grocery store.
When I asked Southern Berkshire’s Mike Clapp, a paramedic with nearly forty years of experience, how they manage these sometimes-charged situations, he said, “It’s their emergency, not mine.”
That’s not to say they don’t act quickly or without concern—they do, and with an unfailingly compassionate stretcher-side manner. But Clapp’s statement sums up the difference in perspective: EMTs and paramedics respond to emergencies all day, every day. They’re trained to do a job, assess a human being, and provide care in sometimes harrowing situations. If we’re lucky, the rest of us experience these emergencies rarely—if ever. Our “don’t freak out” muscle is far less developed.
Unpredictability is both the appeal and the challenge of the job. Providers never know what each call might bring. “It’s twenty different things at once, and you can’t get overwhelmed,” explained Katie Boeckmann, a full-time nurse who still picks up a weekly shift as an EMT-Advanced at Southern Berkshire. She told me that, in an ideal world, she’d prefer to be a full-time EMT but went to nursing school because it pays better. “If I could be an EMT instead of a nurse, I would do it any day,” she said.
Katie Boeckmann, a nurse who also works part-time as an EMT-Advanced.
Katie Boeckmann, a nurse who also works part-time as an EMT-Advanced.
When it’s quiet back at Southern Berkshire’s headquarters in Great Barrington, someone on shift might be dubbed that day’s “white cloud” for bringing metaphorically clear weather and an uneventful shift. Other times, a “black cloud” could be playfully ribbed for a day or night of back-to-back 911 calls and inter-facility transfers. Those transfers not only ferry patients from Fairview Hospital, in Great Barrington, to Berkshire Medical Center, in Pittsfield, but also to distant, higher-level care at hospitals in Springfield, Hartford, Albany, and even Boston. (FYI: It’s considered bad form and bad luck to utter the word “quiet” during a shift that’s qui—er, not busy.)
Long drive times to higher-level trauma centers and better cardiac and stroke care often strain ambulance resources in the Berkshires, taking crews and rigs out of service for extended periods. That puts pressure on mutual aid from ambulance providers further afield, which increases response times. In some cases, it may even necessitate the use of more expensive helicopter transport, even for non-critical-care cases, to keep ground ambulances available for local 911 calls.
On that Saturday morning when my call-counting skills failed me, our first case of the day involved a pneumothorax, or a collapsed lung. That’s when the chest cavity fills with air and prevents the lungs from fully inflating. It can develop from blunt or penetrating trauma, a chronic medical condition, or occur spontaneously in an otherwise healthy person.
The emergency solution? A procedure called “needle decompression” to quickly release the air, create space for the lungs, and keep oxygenated blood flowing through body and brain—a top priority during patient transfer from scene to emergency room. It’s an invasive procedure that Massachusetts’ scope-of-practice regulations specify can be performed by paramedics but not EMTs.
“Do you want to try?” someone asked me.
“Sure,” I said.
Wearing blue surgical gloves, I picked up a fourteen-gauge, three-and-a-quarter inch hollow needle. One end had a sharp, angled point, while the other was fitted with an orange screw cap.
With many eyes on me, I pressed my fingers around the ribs, searching for the bone-free intercostal space and its layers of soft tissue. Once I found the right spot, I removed the needle’s safety cover, positioned the tip, and then plunged it downward.
The needle hit bone and stopped—a rookie mistake. I pulled it back and tried again, but once more struck nothing but rib. Finally, on the third go, the glistening silver needle slipped easily past resistance. I held it firmly in place and unscrewed the orange cap. Air escaped with a satisfying hiss.
“You’re hired,” someone yelled. Much laughter erupted.
If you’re horrified that a random person was allowed to stab a medical instrument into a patient’s rib cage—perhaps to (illegally) illustrate the crisis-level shortage of paramedics and EMTs in the Berkshires and beyond—you, too, can breathe easier.
In this case, the “patient” was a foot-long plastic tub filled with Styrofoam and duct-tape-covered balloons. On top was a rack of defrosted pork ribs—store-bought and more typically destined for the grill. Covering the ribs was a yellow chamois cloth like those used to polish a car’s finish to a bright shine. Together, the materials simulate the resistance met when inserting a hollow needle through skin, muscle, tendon-like fascia, and past sensitive bundles of arteries, veins, and nerves into the human chest cavity.
Southern Berkshire's chief of operations, paramedic Kevin Wall, at left, during a refresher training on needle decompression. Flight paramedic and instructor Dean Stockley is standing at right.
Southern Berkshire's chief of operations, paramedic Kevin Wall, at left, during a refresher training on needle decompression. Flight paramedic and instructor Dean Stockley is standing at right.
No lives were at stake. We weren’t treating a patient in the back of one of the squad’s three ambulances enroute to a hospital. Instead, a half-dozen of us were gathered around a conference table at Southern Berkshire’s tan-on-tan operations building and garage in Great Barrington, across a large parking lot from Fairview Hospital. I was there to observe a day of refresher-training on needle decompression, intubation, and techniques to create an emergency airway in someone’s trachea. EMTs and paramedics must complete continuing-education coursework like this to be recertified every two years. It also helps them maintain proficiency in what are called “high risk, low volume” medical procedures.
The class that day was led by Dean Stockley, a cheerful, Berkshires-born flight paramedic and prehospital-medicine instructor. During a break, he told me that while a student at the John T. Reid Middle School, in Pittsfield, he saw a medical-transport helicopter land in the parking lot. After that, he said, “I always wanted to be a flight paramedic.”
As I’d learn over the coming months, for many it was just that kind of interaction with EMS that led to their career choice. Dawn Josefski, who oversees the paramedic- and EMT-training programs at Greenfield Community College, told me, “At some point in their life, they’ve had to intersect with healthcare or EMS for themselves or family members.” Those experiences might be positive or negative, she said, and “either one of those are reasons people want to get into [EMS] and make a difference.”
Tragically, Josefski knows first-hand. As a child, in 1973, she was by her father’s side when he suffered a fatal heart attack. It was during the early days of EMS, and the oxygen tank on the ambulance that arrived to help didn’t work.
Josefski became a volunteer EMT, then paramedic, and finally an educator, combining her interests in medicine and teaching. The two-year paramedic program she runs in Greenfield is one of just a handful offered throughout western Massachusetts, and that lack of convenient training options is among the key challenges facing EMS in the region.
And the laughter after someone yelled, “you’re hired?” A knowing, world-weary response to persistent understaffing that can leave providers exhausted and sleep-deprived from too many overtime shifts, worrying about stretching paychecks to cover the high cost of housing in the region, and generally feeling—to use a term thrown around by the EMS crowd—“crispy.” That can mean burnout—from emotionally challenging work, grueling schedules, insufficient pay, ongoing training requirements, non-emergency “junk calls,” overnight patient transfers, managing the “frequent fliers” who summon ambulances too often, and dealing with higher levels of anxiety, post-traumatic stress, and general distress than the public at large.
Josefski told me that the culture and work environment of an EMS agency influences how well people manage that emotional toll—and whether they stay in the field. “Where you work is the biggest thing I’ve seen,” she said. In the best situations, EMS is like a family. “When you are with somebody in god-awful situations, it does create a connection,” she said. “There’s a sense of pride, that I’m doing a job that’s not an easy job.”
Among those laughing around that plastic-tub-and-pork-ribs patient was A.J. Anderson, a thirty-nine-year-old paramedic who has been Southern Berkshire’s training director for the past five years. Good-natured and conversational, he’s a constant presence in the building. And he’s usually easy to find—his unmistakable, staccato laugh echoes through the hallways.
Born and raised in Great Barrington, Anderson was sixteen when he saw EMTs arrive in an ambulance to help his grandfather, who was having trouble breathing. “I was hooked,” he told me. His mother worked as a nurse at Fairview, so health care was in the family. He’s been in EMS for fourteen years, a paramedic for ten.
A.J. Anderson, a paramedic and Southern Berkshire's director of training, completes paperwork between calls.
A.J. Anderson, a paramedic and Southern Berkshire's director of training, completes paperwork between calls.
One morning I rode along with Anderson on a 911 call to help a man in his sixties exhibiting stroke-like symptoms and confusion. As the man lay nearly motionless on his bed, Anderson asked a series of basic questions—name, age, day of the week—but he couldn’t respond. A family member told Anderson about the man’s recent back surgery, said his confusion had been ongoing for a couple of days, and provided a list of his medications. Vitals were taken, a cardiac monitor attached, and more questions asked. (Tests later confirmed spinal meningitis.)
Once in the ambulance—which required carrying him on a stretcher through a narrow doorway and down steep outdoor steps—his cardiac rhythms were reviewed and an intravenous port inserted into his arm. Anderson drew blood for tests to be done at the hospital, saving the ER team a few tasks and a few precious minutes. While en route, information was relayed to the hospital over the radio.
In a routine I’d witness countless times, an intake staffer met us outside of Fairview’s emergency department and led the crew and patient to the ER suite. The man was transferred to a hospital bed from Southern Berkshire’s hydraulic Stryker-brand stretcher—a $70,000 piece of equipment that enables easy transfer into and out of an ambulance, helping to prevent once-common back injuries among EMS providers. Other equipment like the cardiac monitor—itself a $50,000 tool—can be securely attached to the stretcher.
Paramedic A.J. Anderson and EMT Tess Fedell tend to a patient in the back of their ambulance.
Paramedic A.J. Anderson and EMT Tess Fedell tend to a patient in the back of their ambulance.
In the ER, Anderson gave a verbal hand-off report that recapped everything that happened from dispatch to delivery. He was clear, informative, and didn’t refer to his notes while rattling off a lengthy list of patient details. (EMTs and paramedics often write information on a strip of silver duct tape stuck to their thigh to keep it from getting lost.)
“They’re going to take good care of you,” Anderson said, offering a final word of encouragement he often gives to patients as the emergency-room physician and ER team take over.
Back at Southern Berkshire’s garage, we talked in the ambulance while he repacked gear and restocked supplies. He described a passion for immersing himself in medical-journal articles and podcasts and marveled at all the information available, for free, just a few clicks away. Learning more is integral to his role as director of training, which for him seems equal parts vocation and avocation. “I’ve always been taught that if you have information, it’s your responsibility to pass it on to others,” he said.
In addition to working with new hires, he regularly leads training sessions for Berkshire County paramedics, EMTs, firefighters, and first responders. In one session held in April at the Great Barrington firehouse, he guided a couple dozen participants in the room, along with many more via Zoom, through updates to the Massachusetts treatment protocols that inform on-scene medical decisions. He supplemented the dense, text-heavy PowerPoint slides with insights from his field experience, adding valuable context and depth to the state-issued guidelines.
Anderson typically works two 24-hour shifts per week, each starting at 8:00 a.m. That means overnight downtime in one of the squad’s four upstairs bedrooms. Time between calls is spent in the comfortable, home-theater-style recliners in the staff lounge. There’s also a full kitchen, dining table, and three large television screens: Two display the location of the squad’s ambulances and details of recent dispatches, while the third is reserved for movies. (Although not required by medical-privacy laws, I won’t disclose the names of the films we watched over a couple of months. But suffice it to say they tend toward entertainment that requires little cognitive effort, providing a certain relief from the intensity of the job.)
Southern Berkshire's staff lounge.
Southern Berkshire's staff lounge.
The squad currently has nearly thirty employees: An evolving mix of full-time, part-time, and per diem EMTs and paramedics. They’re paired up and scheduled with a goal of staffing two ambulances 24/7 with a paramedic and EMT, known as an “advanced-life support,” or ALS, crew. Kevin Wall, the squad’s operations chief and a paramedic for more than thirty years, told me they’d like to fully staff a third ambulance to meet growing demand for non-emergency inter-facility transfers—a service that currently provides roughly half of the squad’s revenue. But 911 response comes first, Wall said, so any non-emergency transfers get in line behind those calls.
Early in his career, Anderson thought he wanted what he described as “a big-city EMS experience.” But today, he’s happy to be living and working in a safe community while raising his six-year-old son. “It’s nice to be able to work in your own community,” he said. “Especially on those days when you’re tired.”
Having discovered how much he enjoys treating patients, Anderson said that if he could go back in time, he might pursue a career as an advanced medical practitioner and perhaps go to medical school. But he’s content with how things turned out. “Everything happens for a reason,” he said, without noticeable wistfulness or regret.
When he started out, colleagues told him he’d need something—a hobby or other distraction—to counter the emotional intensity of EMS work. He blew off the advice, he said. But during the pandemic, he found himself drifting into his wood shop and losing himself for hours.
Anderson describes the funding, staffing, and other challenges of modern EMS as “this whole mess.” The field needs to evolve, he said, with things like advanced-degree opportunities and more career options for paramedics. That includes being able to work for twenty years and retire with a pension—just like those who work for municipal police and fire agencies.
He told me about providers who work sixty to a hundred hours a week to make a living. “We have a lot of people who leave this job because of burnout,” he said. “It’s a vicious circle of being shorthanded, understaffed, and underpaid.”
So why do it? “Because I love it. I like taking care of patients,” he said. “It’s all the stuff around it that wears me out.”
November, 1967:
A bungled emergency response and the founding of a volunteer ambulance squad
At three o’clock on a cold Sunday morning in November, 1967, a car sped east through the town of Egremont and over the border into neighboring Great Barrington. Moments later, it swerved off the two-lane highway, knocked over a utility pole, hit a tree, sideswiped a fence, and struck a second tree before careening back onto the roadway. The vehicle was totaled, its front end crushed.
The cause was speed and alcohol: At a court hearing a few days later, a judge fined a twenty-five-year-old Great Barrington man named Floyd Joslyn seventy-five dollars for driving under the influence and driving to endanger. It was a typical-for-the-time wrist-slap for an offense now punished more severely.
Joslyn and a passenger, twenty-year-old Preston L. Tinker, Jr., walked away from the wreck with minor injuries. But Tinker’s girlfriend, an eighteen-year-old Egremont woman named Laurel Grahn, was left in critical condition.
When the police arrived, Grahn was unconscious and bleeding inside the car. Officers called for an ambulance and doctor from Fairview Hospital, located just a few minutes away. (The hospital began providing ambulance service in 1938 thanks to a donation from a local veteran’s group.) It arrived more than a half-hour later with only a driver, an orderly, and Margaret Harvey, a nurse.
The police, already frustrated by the slow response, refused to move Grahn to the ambulance without a doctor present—concerned, they would later say, about liability. So it was after 4:30 a.m. when the hospital’s chief of surgery and later head of its emergency department, Dr. E. Morgan Vigneron, finally arrived on scene. He had been at the hospital, he said, waiting for the ambulance.
Grahn was pulled from the wreck, placed on a stretcher, and loaded into the ambulance for the short trip back to Fairview. But the ambulance wouldn’t start. The driver, a maintenance hand from the hospital, had turned off the engine but left the headlights blazing to illuminate the accident scene. The battery was dead.
A few passersby helped roll the ambulance back onto the highway. And then, in a remarkable scene, a police car nudged it from behind while the ambulance driver tried to jump-start the engine by popping it into gear. Inside, Grahn lay unconscious, jolted repeatedly as the police car pushed the ambulance for almost a mile of jump-start attempts. Eventually they gave up. Grahn was moved to the back of Vigneron’s station-wagon and the doctor drove his own patient to the hospital.
An image from the Berkshire Courier showing a Great Barrington police car pushing the stalled ambulance.
An image from the Berkshire Courier showing a Great Barrington police car pushing the stalled ambulance.
All told, Grahn didn’t arrive at Fairview until more than two hours after the accident. She was later transferred to the intensive-care unit at Pittsfield General Hospital, where she remained in a coma past New Year’s Day, 1968.
Details of the slow, clumsy response filled news stories and newspaper editorials. Angry finger-pointing spread across the community. The responding police officers, led by a Great Barrington patrolman named Arthur Cottrell, called Fairview’s service “inept,” complained about “unqualified” drivers, and called on the hospital to “maintain and equip a serviceable ambulance to go to accidents accompanied by a competent doctor when requested by the police.” Cottrell didn’t stop there: “It’s about time someone besides the police start caring about the lives and the safety of these people coming back drunk from New York State,” he fumed.
The hospital responded without apology. “If anyone is to be criticized,” said Fairview’s administrator, Burton H. Morrell, “it is the police department.” He quickly announced plans to shutter the ambulance service entirely at the end of the year. It was likely a relief: Morrell had long complained about the hospital’s responsibility for the ambulance and bristled at frequent grumbling about response times. A decade earlier, he told a reporter that running the service, which answered around fifteen calls each month, was “a headache” and “a public-relations problem.”
A group of thirty nurses wrote an open letter defending Harvey—a nurse who worked in Fairview’s maternity department for forty years before retiring in 1984—and mocking frivolous police requests for an ambulance for minor injuries like “a child’s cut finger.” Dispatching the ambulance, they wrote, meant “a maintenance man must leave his work and a nurse must leave her patient.” But they would carry on, the nurses wrote, “even though we are smeared continually.”
The weekly Berkshire Courier newspaper published a detailed account of the accident that included Cottrell’s sharp criticism. It followed up with strongly worded editorials. One noted that Fairview had just raised millions of dollars from the community to pay for a major expansion and argued the hospital should return the favor by improving its ambulance service. (Earlier, Cottrell had complained, “A lot of money was spent on making a fancy hospital. It’s time some was spent on a competent ambulance service.”)
In another editorial, the paper suggested creating what would become, in just a few months, the Southern Berkshire Volunteer Ambulance Squad. In fact, the Courier helped seed the ground by publishing a detailed profile of a similar service in nearby Copake, New York.
Great Barrington’s veteran fire chief, M.T. “Mort” Cavanaugh, soon took the lead in organizing the new volunteer ambulance company. He suggested locating it at a garage on the Fairview Hospital grounds.
At a public meeting just before Christmas, Cavanaugh said “if we get enough volunteers, it will only mean a few hours a week for each man.” Twenty-five volunteers immediately signed up to help. The fire chief estimated that “thirty men” were needed, but women joined, too: One of the earliest volunteers was ninety-two-year-old Elsie Huntley, who had spent twenty years as a school nurse.
Plans were made for first-aid classes, acquiring necessary equipment, and establishing a nonprofit organization. Southern Berkshire was operating by the spring of 1968 with a new ambulance and enough volunteers to staff a nightly 6:00 p.m. to 6:00 a.m. shift.
Despite Morrell’s earlier threat, the hospital continued to provide daytime ambulance coverage during what it said would only be a transition period. But Fairview would play a role for decades: Into the 1980s, its emergency department managed ambulance dispatch and the hospital sometimes provided sleeping quarters for Southern Berkshire’s night-shift volunteers. And today, a Fairview emergency-department physician provides medical oversight for the squad, and the hospital supplies, at no charge, all of the three dozen medications carried by its paramedics.
To pay its bills, the new service relied on charitable donations from individuals and community organizations. (Requests for donations to Southern Berkshire quickly became a common feature of local obituaries.) The new company also introduced a subscription service: For five dollars a year, residents from Stockbridge to the Connecticut border received free emergency-ambulance rides, while others were charged fifteen dollars plus a mileage fee for each trip.
With little payroll expense, funds were ample—and sometimes flowed in the opposite direction than they do today. For instance, in the fall of 1978, Southern Berkshire donated emergency equipment valued at $35,000 in today’s dollars to first responders in the towns it served. The donation included oxygen tanks, portable suction units, ventilation masks, and other first-aid supplies. Additionally, it provided the Great Barrington Fire Department with a “Jaws of Life” rescue tool, which cost nearly $40,000 when adjusted for inflation.
An undated photo of Southern Berkshire volunteers that hangs on the wall of its headquarters in Great Barrington.
An undated photo of Southern Berkshire volunteers that hangs on the wall of its headquarters in Great Barrington.
Its founding and early growth aligned with key historical milestones in EMS. First, in 1966, was the publication of the revolution-spawning “Accidental Death and Disability: The Neglected Disease of Modern Society” by the National Academy of Sciences, which recommended national standards for ambulance services and training of medical responders. That was followed by the federal Highway Safety Act, also in 1966; the 1967 launch of the groundbreaking Freedom House Ambulance, in Pittsburgh, staffed largely with Black men from an economically challenged neighborhood who became the nation’s first well-trained urban paramedics; and federal seed funding to establish regional EMS systems that was provided to the states through the Emergency Medical Services Systems Act, which Congress passed in 1973.
The public also came to expect rapid emergency-medical care thanks to the swashbuckling adventures of paramedics John Gage and Roy DeSoto, characters in television’s “Emergency!” The show, which followed the fictional Squad 51 on medical-rescue calls in Los Angeles, aired on NBC from 1972 to 1979. It also inspired many to join the field, including Wall, Southern Berkshire’s operations chief. “As cliche as it sounds, I did watch that show,” he told me. “Johnny and Roy were a big influence back in the day.”
A 1972 publicity photo for the NBC show, "Emergency!"
A 1972 publicity photo for the NBC show, "Emergency!"
Growth and change at Southern Berkshire also mirrored the evolution, improvements, and increased regulation of EMS at the state and federal levels: Adding volunteers with the new EMT certification in the 1970s; accreditation per new state requirements in 1977; more advanced ambulances every few years; and in 1992, a $250,000 building expansion that added the upstairs bedrooms for crews working overnight.
Southern Berkshire remained a primarily volunteer service for nearly five decades. But in 2014, in response to national trends and the need for a higher level of prehospital care for the region’s aging population, the squad made the leap to a full-time, paramedic-level service. The change was also nudged along by the expanding, county-wide Berkshire Health Systems (BHS), which needed paramedic-level crews for a growing number of ambulance transfers from Fairview, the small hospital in Great Barrington it acquired in 1985, to Berkshire Medical Center, in Pittsfield. That’s where BHS has centralized many of its medical, diagnostic, and surgical services.
As the professional staff expanded, volunteer EMTs also drifted away—which meant hiring more paid staff. The squad’s annual payroll expense increased five-fold, from $190,000 in 2012 to $1.25 million a decade later, according to federal tax filings.
Ambulances parked in the squad's garage this summer.
Ambulances parked in the squad's garage this summer.
When I first spoke to Jim Santos, the squad’s board president and a longtime volunteer, he explained how that leap in expenditures is at the heart of today’s rural EMS challenge. “We have two major problems: staffing and funding,” he told me in March. “We need one to support the other, and we need both of those to survive.”
Southern Berkshire is a regional EMS service that provides 911 response to six towns in southern Berkshire County and paramedic-level intercept service to three more. And staffing two advanced-life-support (ALS) ambulances, available 24/7 with a paramedic and either a basic- or advanced-level EMT, is a fixed cost regardless of the number of the number of 911 calls or inter-facility transfers completed each day, month, or year. “We’re paying our people to be here whether they do something or not,” Wall, the operations chief, explained. “It’s to be ready to respond.”
The origins of today’s EMS funding challenge reach back half a century to the days of less-safe cars and more serious accidents on the nation’s highways. It began when the 1966 Highway Safety Act did two things: Created an agency that would soon become the National Highway Transportation Safety Administration and tasked it with overseeing EMS, and linked grants of federal highway funds to a state’s efforts to meet new federal EMS guidelines.
As health insurance companies started covering ambulance rides, they classified the service as transportation rather than health care. Today, those insurance reimbursements—particularly from the federal Medicare program for seniors and state-based Medicaid services, like MassHealth, for those with modest incomes—don’t cover the cost of running a paramedic-level ambulance service in rural areas like the southern Berkshires.
Wall shared data that showed while Southern Berkshire’s average bill for service in 2023 was $1,832.26, the average reimbursement was only $606.27. The low Medicare reimbursement rate when compared to higher payments made by private insurance helps pull down that average: With an aging population, more 911 responses are for seniors who rely on that federal program for health coverage.
Another complicating factor is that if a responding crew provides medical care to a patient, but there’s no transport to a hospital, the ambulance provider often doesn’t get paid a dime. (Medicare does not pay anything for these “treat-no-transport” calls.)
For example, one 911 call I rode along on this spring to the small town of Alford was to aid a woman in her eighties who reported feeling weak. Southern Berkshire’s response included a half-hour of assessment, connecting her to a twelve-lead cardiac monitor to check for heart issues, and evaluating whether recent medication changes might be the culprit.
In the end, she declined to be transported to the hospital for additional examination. In many cases, that means no bill and no payment.
Last year, sixteen percent of Southern Berkshire’s 1,585 responses to 911 calls did not include transport, according to data it provided. (In 2023, it had a total of 2,328 calls, including 743 inter-facility transports.)
EMT Justin Bona, left, and paramedic Craig Crawford, at right, with a patient during a 911 response to a fall and head injury. Bona is a former Great Barrington firefighter who plans to become a nurse.
EMT Justin Bona, left, and paramedic Craig Crawford, at right, with a patient during a 911 response to a fall and head injury. Bona is a former Great Barrington firefighter who plans to become a nurse.
Because the health-care system in the United States is headache-inducingly complex, and how it’s funded is—to use a technical term—kind of messed up, there are a host of proposals to provide higher reimbursements, eliminate surprise bills, and ensure consistency for both patients and providers.
Accurate data on the true cost of ambulance service is crucial for policymakers. To address this need, the federal Centers for Medicare & Medicaid Services (CMS) have initiated a comprehensive cost analysis through the newly established Medicare Ground Ambulance Data Collection System. Authorized in 2018 but delayed by the pandemic, the project aims to provide a clearer picture of current ambulance-agency expenses. Providers hope this effort will lead to substantial increases in Medicare reimbursement rates.
The funding model is closely tied to the staffing challenge because it is responsible, in large part, for low wages for EMS workers—especially when compared to other health-care professions. “There’s a critical need for EMTs and paramedics not just here, but everywhere,” Santos told me. “And it’s not a well-paid profession, because of the way we’re reimbursed. You don’t have the funds to give people what they deserve.”
“There’s no hope for EMS in the reimbursement model.”
That’s true across the country. “Every state has some variation of the same problem,” Andy Gienapp, the deputy executive director at the National Association of State EMS Officials (NASEMSO), told me recently. He’s a longtime paramedic-turned-EMS administrator who spent a decade as Wyoming’s state EMS director and now has a bird’s eye view of challenges facing rural EMS across the country.
The current model that funds ambulance services won’t do, he said, particularly in rural and sparsely populated areas where the longtime “volunteer subsidy”—the free labor of community first-responders and volunteer EMTs—has disappeared. “There’s no hope for EMS in the reimbursement model,” he said flatly. “There simply isn’t enough money to take care of it.” (Gienapp told me he believes the most economical model in rural areas is a hospital-owned ambulance service. Certain critical-access hospitals can be reimbursed by Medicare at one-hundred percent of actual ambulance costs if the hospital owns the ambulance service.)
To help attract and retain employees, Southern Berkshire has increased salaries over the last couple of years: An eight-percent increase in 2023 and another bump that took effect last month. Wall said that basic EMTs now earn between $20.21 and $30.05 an hour, based on experience; advanced-level EMTs earn $22.60 to $33.58, and paramedics $27.50 to $40.88.
EMT Kevin Brown on a call in March. He's currently training to be a paramedic.
EMT Kevin Brown on a call in March. He's currently training to be a paramedic.
Santos told me that competition for staff among EMS agencies in the Berkshires also puts upward pressure on wages—normally a good thing, but difficult to absorb when the funding model remains both inadequate and static. That includes competition from fire departments that may hire their own EMTs and paramedics, many of whom serve in dual roles as firefighter/paramedic or firefighter/EMT.
And because the educational pipeline creating new EMTs and paramedics is anemic, and many are leaving EMS altogether, the squeeze is growing. (In 2016, prior to the pandemic, a federal report projected a need for an additional 40,000 paramedics and EMTs nationwide by 2030.)
The skyrocketing cost of housing in the southern Berkshires has made attracting EMTs and paramedics even harder. “We have a brand new EMT who’s spectacular, great employee, wants to be here,” Wall told me. “But he cannot find anything near here that he can afford.”
Wall, who lives east of Pittsfield in Hinsdale, said that half of Southern Berkshire’s staff currently live outside the communities they serve. Many commute from the Pittsfield area and further north. Some reside as far away as Northampton and Agawam to the east. One longtime paramedic has even traveled from Torrington, Connecticut—an hour southeast of Great Barrington—for the past decade.
These funding and staffing issues are driving the squad’s recent requests for municipal subsidies. From 1968 until a few years ago, the six towns that today rely on Southern Berkshire for primary, paramedic-level, 911 ambulance response—Great Barrington, Egremont, Alford, Sheffield, Mount Washington, and Monterey—were not required to pay anything. (Mount Washington made an annual donation of $1,500.) That meant there was little need for town officials or residents to understand the EMS funding model, the difference between paramedics and EMTs, or the emerging crisis. Like many town fire departments, the ambulance was generally understood to be a service staffed by unpaid, community-minded volunteers. And many assumed it always would be.
A map of Berkshire County showing Southern Berkshire's service area. (Image via sbvas.com)
A map of Berkshire County showing Southern Berkshire's service area. (Image via sbvas.com)
In early 2020, just weeks before the pandemic began, Southern Berkshire officials made the rounds to town boards to explain the changing EMS landscape and to seek financial help. It didn’t go well, and the first reactions were often strong and negative. Members of Great Barrington’s Finance and Select Boards, for example, at first declined to make any contribution. They sharply criticized the nonprofit service for its financial problems, lackluster fundraising, and failure to better explain its operations.
That reaction was understandable, Santos, the ambulance company’s board chair, told me. “They had ambulance service free for fifty years,” he said. “No one ever thought of it. So it [was] new to them.”
While fire departments and law enforcement are widely seen as deserving of taxpayer support—including ample state and federal funding—EMS often falls into a gray area, at least among elected officials. “For some reason, when we turn to the folks who are serving us in our most dire hour,” Gienapp, from the national EMS organization, told me, “It’s ‘oh, well, wait a minute.’ We get a little hesitant about putting tax dollars towards that.” He said there’s also a hard-to-dispel misconception that EMS is “a cash cow” because of insurance payments, but few understand how the full, complicated picture.
That was certainly the case in Great Barrington in 2020. During hours of presentations and discussions over multiple days, some members of the Select Board suggested their town was a “profit center” for Southern Berkshire because of Fairview Hospital and several nursing homes in town. Therefore, they argued, other towns should cover any budget shortfall. One member suggested the town could take over the ambulance service and run it themselves. Another said the hospital and Berkshire Health Systems should pick up any financial slack.
When I asked Gienapp how rural towns across the country have approached fixing their EMS issues, he stressed the need for outside expertise. While some in small-town government may think they can tackle these complexities on their own, in his experience that’s not been enough. “You’ve got to have way more big brains in the room,” he said. “And people who know how this business works.”
Since those rough initial conversations in 2020, the six towns have since used pandemic-relief funds to help Southern Berkshire pay for a new ambulance. They also now contribute an increasing annual subsidy to support the squad. But not without complaints, ongoing tension, and calls to find a different model for municipal assessments. (In 2024, the towns’ payments represented roughly a quarter of Southern Berkshire’s annual two-million-dollar budget.)
Town | 2023 Subsidy | 2024 Subsidy | Population |
|---|---|---|---|
Alford | $27,275 | $37,016 | 499 |
Great Barrington | $151,293 | $205,236 | 7,117 |
Egremont | $45,144 | $61,267 | 1,374 |
Monterey | $51,669 | $70,122 | 1,073 |
Mount Washington | $8,793 | $11,933 | 133 |
Sheffield | $65,826 | $89,335 | 3,329 |
Southern Berkshire’s board of directors has been exploring possibilities for several years, including some kind of municipal affiliation to gain access to additional grant funding and improved employee benefits. But Santos said it could still take a couple of years to identify and implement substantial changes.
After rotating through several chiefs of operations, both permanent and interim, in recent years, last year Southern Berkshire hired Wall, someone with decades of experience managing ambulance services, large and small, across the Commonwealth. It also brought on new staff with experience in health-insurance-related administration to improve its reimbursement rates and financial processes, and also stepped up its fundraising efforts.
These days, when Santos appears in front of town boards there’s little argument from Southern Berkshire about the need for a new road forward amid an EMS crisis that’s not confined to the Berkshires. “We understand that because we’re thinking the same thing,” he told me. “We can’t keep going the way we are right now and survive financially,” Santos said.
Indeed, those who manage EMS services have long warned policymakers that continuing to kick the rusty, dented, long-ignored EMS can down the road is not an option. At least, as one experienced paramedic told me, if you still want skilled help to arrive quickly, at 3:00 a.m., when you or a loved one is having a heart attack, stroke, or can’t breathe.
That urgency has rekindled a broader EMS regionalization conversation now underway in many communities across the southern and central Berkshires—one that has Southern Berkshire, as the largest, already-regional ambulance provider at its center.
But who will provide leadership and rally the political will to make needed and costly changes at the local, state, and federal levels is perhaps the most significant question. Locally, when a 2019 consultant’s study recommended a new integration of fire and EMS services across southern Berkshire communities, including those covered by Southern Berkshire, it was discussed briefly and quickly shelved. Municipal officials showed little appetite for pursuing a broad, regional solution for fire or EMS—much less both—that would require a substantial investment of local tax dollars. And, perhaps most of all, they were uninterested in changing how they’ve always done things, even in the face of an accelerating crisis.
At least, that’s the explanation provided by William “Smitty” Pignatelli, the longtime state representative for eighteen communities in the central and southern Berkshires, who will retire from the legislature in January. When we first spoke about rural EMS in March, he was frank. “Town leaders have to make some tough decisions for the next generation,” he told me over lunch at a Great Barrington diner. He suggested that regionalization is the only way forward. “These fiefdoms have to be broken down. If we’re not doing that, we’re not thinking long-term,” he said.
A few weeks later, during a meeting of elected, fire, EMS, and health-care officials from his district that have gathered monthly since late winter, Pignatelli, a Democrat, put a sharper point on it. Standing in front of three dozen people at Lenox Town Hall, he said, “Any community that thinks they can do this on their own, long term, should leave.” No one did. A few moments later, he said—to laughter—“It’s nice to not run for re-election. I can say what’s on my mind, finally.”
A gathering of town, fire, and EMS officials at Lenox Town Hall in April, 2024.
A gathering of town, fire, and EMS officials at Lenox Town Hall in April, 2024.
It was a revealing moment that made clear how long these problems have been around and the sticky politics involved. In fact, Pignatelli said essentially the same thing—but without the ultimatum—five years earlier. During an event at the Great Barrington firehouse to discuss the 2019 consultant’s study—which itself was undertaken following similar monthly meetings of the Southern Berkshire Regional Emergency Planning Committee in 2018—he told many of the same officials, “We’ve got to do something different here, folks. It’s ridiculous.”
Also evident at the 2019 meeting was the impact of Berkshire Health Systems’ (BHS) concentration of services in Pittsfield. Heather Barbieri, who directs emergency management for Fairview and has played a key role in Pignatelli’s new working group, highlighted the small hospital’s growing, sometimes-unmet need for inter-facility transfers. “At the hospital, we were noticing that we weren’t able to get an ambulance to go to another hospital,” she said in 2019.
Pignatelli told me that he believes his vision for EMS regionalization is workable and that oft-raised concerns by small communities can be addressed. “We can maintain [our towns’] identities, enhance services, and save taxpayer money,” he insisted. He said that a regional EMS system linking all eighteen communities “could be a model for the state.”
Given the longstanding resistance even to smaller shared-services agreements between Berkshire County towns, Pignatelli knows it will not be easy. “Ripping the band aid off is going to hurt,” he said.
State Senator Paul Mark, a Democrat who since last year has represented fifty-seven communities in four western Massachusetts counties, including all of the Berkshires, and previously spent a decade in the state House of Representatives, told me that as a small-town resident, he understands the concerns. “There can be a fear that if we join with other communities, especially communities that are a little bigger, we’re not going to get the attention we feel we need or deserve,” he said. “But I think it’s time that we start to realize we’re often not getting the attention we think we deserve right now. And by banding together with other communities, where possible and for the right purposes, we’re going to do ourselves a favor in the long run.”
The EMS regionalization tea leaves may soon get easier to read: Pignatelli has asked the eighteen towns in his district, along with each of the region’s EMS providers and Berkshire Health Systems, to join a more formal task force. The group plans to seek state-grant funding for another year-long study that will collect updated data and propose options for a regional EMS system. Unlike the 2019 effort, this one will leave the related problems facing volunteer fire-and-rescue services for another day.
The study will likely be done by consultants from the Edward J. Collins, Jr. Center for Public Management at UMass Boston, which has taken on similar projects, including a regional EMS study for the town of Northfield in Franklin County.
Any proposals that emerge will require voter approval. If past is prologue, convincing all towns to agree to the myriad, often-complex details of a multi-town agreement encompassing capital expenditures, funding models, and service-delivery terms won’t be easy. And the memory of last year’s failure of an eight-town, two-school-district merger in the same region—after more than three years of work—is still fresh.
In the meantime, a number of communities are pursuing their own—sometimes heated—conversations about smaller EMS collaborations. Monterey’s Select Board, which has long complained about its municipal contribution to Southern Berkshire, has tasked its fire chief with designing its own fire-and-EMS plan. A working group of officials from Stockbridge, West Stockbridge, and Richmond began meeting last month to explore the outlines of a shared fire-and-EMS system. Further north, the larger communities of Lee and Lenox, which have their own municipal paramedic-level fire-department ambulances for 911 response, are spending $37 million and $25 million, respectively, on new public-safety complexes that will house police, fire, and EMS. And in October, the town of Becket will launch its own 24/7 paramedic-level ambulance service following voter approval, last May, of a $582,000 expenditure for salaries and expenses. (Becket’s service will also respond to 911 calls in the geographically large but sparsely populated town of Washington.)
At this stage, it’s unclear how these efforts will align with a “hub-and-spoke” layout in a single, region-wide EMS system. And whether any new facilities built over the next couple of years to house ambulances and staff will be in locations considered optimal for such a system. Another key question is whether staffing all-new entities is feasible when there’s already a shortage of EMTs and paramedics.
Any proposed models that come out of a new task force are likely to include elements of what several towns in nearby Franklin County have done: Regional, municipal-linked services that are supported in part by local taxpayers with oversight structures that include town officials.
One example is South County EMS, which was the first regional, municipal-based, paramedic-level EMS service in Massachusetts when it was formed just over a decade ago. It serves Deerfield, Sunderland, and Whately—with a combined population of around 13,000—and is managed by an oversight board that includes representatives from each town. It was also created after a multi-year, consultant-led study and implementation process.
This year’s discussions about the future of EMS in the Berkshires have revealed not only the stubborn parochialism noted by Pignatelli but also that many residents know very little about how EMS works. “It’s a very misunderstood profession,” explained Wall. He described that fog of misunderstanding as three-fold: “What we do, how we do it, and how’s it’s paid for,” he said.
Indeed, often overlooked in these conversations about ambulance-response times and municipal budgets and assessment schemes and number of calls per town and disappearing volunteers and insurance reimbursement and cost of new ambulances and hub-and-spoke regional systems and, and, and, and—are the lives and careers of the people actually doing the job. Because in the end, any EMS system—whether urban or rural, single community or regional, relying on private or municipal or nonprofit providers—is only as good as the skill, experience, and commitment of those who staff it.
During my time riding with Southern Berkshire, I met a staff that is a mixture of young and old(er), newbies and experienced hands, lifers in the field and others who work part-time as EMTs while holding other jobs as diverse as voice-over actor, emergency-room attendant, and manager of horse stables at a wellness resort.
Some, like paramedic Mike Clapp, are nearing retirement after four eventful decades in the industry. He’s done a lot: Directed of EMS for Baystate Health in Springfield, worked for the state’s EMS regulator, taught courses, and with his wife, Deb, helped lay the groundwork for regional EMS agencies in Franklin County that use the shared-municipal model that may be the path forward in the Berkshires. He also worked on experiments in mobile-integrated health in Holyoke and Springfield, where paramedics provide routine, non-emergency preventative and follow-up care in home settings—something many see as an important part of a sustainable future for EMS and a path to lower health-care costs.
Paramedic Mike Clapp, at front, and EMT Kevin Brown care for a patient.
Paramedic Mike Clapp, at front, and EMT Kevin Brown care for a patient.
Clapp projects a calm, sometimes-cynical irreverence mixed with a deep passion for the work. When I first met him in March, I asked how long he’d been doing the job. “Too long,” he said quickly. But he soon softened and deftly walked a listener out into the weeds of EMS history, treatment protocols for trauma patients, and the complex intersection of EMS, rural hospitals, and the modern health-care system.
At Southern Berkshire, he’s constantly dispensing thoughts, opinions, and jokes—on EMS and other topics. He doles out heaps of advice to new EMTs and those working to reach the paramedic rung. He knows it’s a tough field. “Career paths are limited,” he told me. “I tried to escape several times but was unsuccessful,” he joked, describing detours that included going back to college, at forty, to earn a degree in English, and once taking a job in a sleep lab. He always returned to work as a paramedic. But without those diversions, he said, “I probably would have burned out. Crashed and burned.”
Others, like nineteen-year-old EMT Jake Aloia, a recent graduate of Simon’s Rock at Bard College, are just starting out. But Aloia already has ideas about how the field can evolve and wrote his senior thesis on EMS. A self-described adrenaline junkie, he told me that he likes both the cognitive challenge and the unexpected twists and turns of the job. “You never know what’s going to happen when you clock in to work,” he said.
EMT Jake Aloia
EMT Jake Aloia
That work is not easy: EMTs and paramedics must simultaneously manage complicated scenes and patient complexities, often in an emotionally charged environment with lives at stake. With few details when they leave the garage, on scene they quickly collect and weigh information, staunch bleeding, ease pain, make treatment decisions, monitor cardiac rhythms, start I.V.s, draw blood, administer medications, manage airways, send info ahead to a receiving emergency department, and finally deliver their patient and a detailed status summary to a waiting team of doctors and nurses.
After a rough call or a bad outcome, they might walk away shaken, leaning on friends and colleagues to process what they saw. Sometimes that includes second-guessing decisions made under pressure and what they might have done better. Some turn to therapy, or EMS threads on Reddit, or to after-action counseling resources made available through regional EMS programs. But they can’t unsee what they’ve seen. Many told me that managing those emotions is central to surviving—much less thriving—in EMS.
In the rural regions of western Massachusetts, dramatic “lights-and-sirens” calls are far less frequent than what Hollywood portrays on screen as the daily diet of urban EMS providers. Steven Wall, a twenty-three-year-old paramedic who works for Southern Berkshire and other services across the region—and son of Kevin—told me that in his experience, nine out of ten calls are routine. “‘Today I picked up an eighty-year-old who was nauseous’” doesn’t sound extremely exciting, he said. “It’s not like what people see on television.”
But intense calls can happen at any time. Tess Fedell, a part-time EMT who works one twelve-hour shift each week at Southern Berkshire, was fresh out of training five years ago when she began volunteering with town-ambulance services in the small community of Sandisfield, where she lives, and in neighboring New Marlborough. It wasn’t an easy start. “The first calls in my first two weeks were the most horrible I’ve seen,” she told me one afternoon in April as we sat in Southern Berkshire’s staff lounge. One was at the scene of a high-profile murder-suicide and house fire in Sheffield that killed five people, including three young children. Another was a serious roadway accident where a man was ejected from his car and grievously injured. As she described the graphic details, she said, “It was shocking, as a human, to see that.” Fedell told me that in that moment, she thought, “I don’t know how I’m ever going to be able to deal with this.”
But she has—in part thanks to her work with Southern Berkshire. That connection was established during one of those dramatic emergency calls when Southern Berkshire sent an intercept—a paramedic-and-EMT unit that assists other ambulance services when an EMT-only crew needs help providing more advanced medical care. She was impressed with their ability and collaboration as they worked with those already on scene. “They made me feel more confident,” she said. And she soon began working with them.
EMT Tess Fedell on a call in Great Barrington.
EMT Tess Fedell on a call in Great Barrington.
Of those early months after achieving certification, Fedell echoed what others described as an abrupt-if-expected transition from classroom to the field. “It’s just not the same as seeing it in front of you and being responsible for a person’s life,” she said.
Kaileen Wolfe, a freshly minted EMT-Basic from Sheffield, where she has been a volunteer firefighter, started at Southern Berkshire this spring. She summed up that transition another way: Once you pass your EMT certification exam, she said, “You’re certified to learn.” Over several weeks, I saw Wolfe on her first outing driving a box-truck ambulance, answering pop-quiz questions from colleagues overseeing her three-month orientation, and listening to feedback from those supervising her training.
Kaileen Wolfe, a new EMT-Basic at Southern Berkshire.
Kaileen Wolfe, a new EMT-Basic at Southern Berkshire.
In Massachusetts, the training and certification requirements for EMTs and paramedics are overseen by the Massachusetts Office of Emergency Medical Services (OEMS), part of the state Department of Public Health. EMTs complete a state-approved training program, which typically involves about one hundred fifty hours of classroom instruction, practical skills training, and clinical experience. The focus is on patient assessment, emergency care procedures, and handling trauma and medical emergencies.
Paramedics in Massachusetts undergo much more extensive training and education compared to EMTs. Paramedic programs typically require around fifteen hundred hours of instruction, including advanced coursework in pharmacology, advanced airway management, cardiology, and medical procedures. Their training also involves significant clinical and field internships, including rounds in hospital departments including the ER, labor-and-delivery, surgery, and pediatrics. (Advanced EMTs are certified after an additional four hundred hours of clinical training.)
The main differences between what EMTs and paramedics can do lie in the scope and complexity of medical procedures they are authorized to perform. EMTs provide basic life support (BLS) and are trained to administer CPR, perform basic airway management, provide oxygen, control bleeding, and assist with certain medications like epinephrine auto-injectors. Paramedics, on the other hand, have a broader skill set that includes advanced airway management (such as intubation), administration of a wide range of medications, intravenous (IV) therapy, cardiac monitoring, and performing complex, invasive medical procedures.
For both paramedics and EMTs, though, it wasn’t just Covid-era burnout that led many to leave the field. But leaving they are. According to data from OEMS, in each of the last two years nearly twenty percent of Massachusetts-licensed EMS providers didn’t complete their biannual re-certification.
Those numbers are of particular concern to Mike Woronka, the president and CEO of Action EMS, based northwest of Boston in the town of Wilmington. His company provides 911 ambulance service in communities in Massachusetts and New Hampshire. Action is part of the ambulance landscape in the Berkshires, sharing responsibility for 911 emergency-medical response in Pittsfield with another private company, County Ambulance.
A longtime paramedic who oversees a staff of nearly three hundred and fifty, he’s brought a data-driven focus to addressing his company’s staffing and other challenges. He said hints of staff burnout first appear as increased use of sick time, more requests for mental-health days, and higher injury rates.
“The people in the field right now are so dedicated, but they’re also really stressed,” he told me when we first spoke earlier this summer. “They’re really overworked, and they need a break. And they need to know help is coming.”
At Action, Woronka hired a consultant to help his staff understand generational differences among his employees. He found that younger EMTs and paramedics are seeking a better work-life balance, something older EMS workers might scoff at, he said. “We need to turn this into a profession where you don’t have to work sixty, seventy, eighty hours a week to make ends meet,” he said.
Action EMS President and CEO Mike Woronka speaking at a meeting of Berkshire County EMS officials in June.
Action EMS President and CEO Mike Woronka speaking at a meeting of Berkshire County EMS officials in June.
Woronka said the recertification data from OEMS backs up what he’s seeing on the ground and drives what he thinks needs to happen. “These are questions that we should be asking as an industry: Why are the recertification rates so low? Why are we not recertifying one hundred percent? Let’s start asking the ‘whys’ and start working toward collaborative solutions,” he said.
In the Berkshires, those possible solutions include addressing stress caused by understaffing by spinning up more conveniently located training programs, particularly at the paramedic level. Currently, the closest paramedic programs are in Greenfield and Springfield, both a long drive from the Berkshire County jobs, homes, and families of the region’s EMTs.
Students attend an EMT training course offered earlier this year at three locations in Berkshire County, including at Southern Berkshire. A grant provided no-cost training for up to twenty students: Sixteen enrolled, twelve completed the course, and to date nine have become certified EMTs.
Students attend an EMT training course offered earlier this year at three locations in Berkshire County, including at Southern Berkshire. A grant provided no-cost training for up to twenty students: Sixteen enrolled, twelve completed the course, and to date nine have become certified EMTs.
Southern Berkshire EMT Crystal Marcantel is currently enrolled in Greenfield Community College’s paramedic program while working full-time. Twenty-four-hour shifts enable days off to attend classes in Greenfield and for the hundreds of hours of clinical rounds she began this summer. At Southern Berkshire, in-between calls she’s often spread out with large textbooks, yellow highlighter in hand. How does she juggle a full-time job and full-time paramedic training? “If I take sleep out of it…” she said with a laugh.
EMT Crystal Marcantel, foreground, oversees new EMT Kaileen Wolfe as she installs an oxygen tank.
EMT Crystal Marcantel, foreground, oversees new EMT Kaileen Wolfe as she installs an oxygen tank.
Pignatelli’s working group recently formed a committee to explore ideas that include a new, stand-alone training entity in the Berkshires. Paramedic training closer to home could make a difference, though it may take several years to line up funding, hire staff—there’s a statewide shortage of certified instructors, too—and meet substantial accreditation requirements.
This month, Action EMS received a $1.3 million workforce-development grant to train up to 90 new paramedics and EMTs in eastern Massachusetts. Woronka said he worked with state officials for more than two years to secure the funding.
Still, Woronka said state leaders need to do more on both funding and staffing. “This problem has been coming over decades and policymakers have essentially been blind to [it],” he said. He argues that OEMS is too small, underfunded, buried inside the Department of Public Health, and without the authority or resources to advocate for changes.
“This problem has been coming over decades and policymakers have essentially been blind to [it].”
When I asked OEMS about solutions under consideration to aid rural EMS, a spokesperson sent the following statement: “The Department of Public Health (DPH) is committed to ensuring that all residents of and visitors to Massachusetts have access to high-quality EMS health care no matter where they are in the state. DPH is aware of staffing challenges that face ambulance services and takes part in identifying potential solutions through a working group with the Executive Office of Health and Human Services and other stakeholders, while also encouraging people to use urgent-care centers when appropriate.”
The agency didn’t provide details or proposals under consideration by the working group. When I asked Gov. Maura Healey’s office about its budget, legislative, and regulatory agenda regarding EMS, a spokesperson also referred me to the administration’s Executive Office of Health and Human Services, which did not respond to multiple requests for comment about its working group or its EMS-related agenda.
The OEMS spokesperson said the agency recommends that rural communities consider regional solutions, and pointed to a regulatory change made last year to help with staffing. It allows, in some cases, ambulances to be staffed only with a driver trained in first aid and one EMT-Basic to provide patient care, instead of a minimum of two EMTs. (Several paramedics I spoke to said this is not optimal, particularly for cardiac and stroke patients in rural communities located far from a hospital.)
Mark, the state senator, met with Southern Berkshire officials last year and is seeking a one-time earmark of $75,000 from the legislature to help pay for new equipment. He said the Healey administration has generally encouraged towns to pursue shared-municipal services but said he’s not aware of anything the governor has done that’s specific to rural EMS. “I just think [EMS] needs money,” he said, pointing to a need for “more predictable, more steady, and more reliable” funding. But he doesn't have a particular fix in mind. “What that’s going to look like is a great question,” he said.
Mark also told me there’s been little legislative action because the state’s population is overwhelmingly urban and EMS systems in those areas don’t face similar challenges. It’s another example, he suggested, of rural needs getting less attention from a legislature with far more representatives from urban communities.
Others have a different view. Even better-funded, higher-volume, urban EMS systems, including in the Boston area, are struggling with staffing, Action’s Woronka told me. “The challenge [in Boston] is the same challenge as in the southern Berkshires. It’s just on a wider scale,” he said. “Nobody in the industry is immune from what’s going on. If Boston EMS is the most highly funded EMS system in the state, why are they struggling to put [ambulances] on the road?”
At times, the problem appears to be urban, rural, and suburban. In January, in the Boston suburb of Winthrop—where Action provides two ambulances for 911 response—no ambulances were available to respond to a two-year-old girl suffering cardiac arrest. At the time, both of Action’s ambulances were transporting other patients, and no others were immediately available via mutual aid from other providers. The toddler was eventually transported in the town fire chief’s car to Massachusetts General Hospital where she was pronounced dead.
An OEMS investigation said Action acted properly when it sought help via mutual aid and noted the EMS system was “taxed” at the time. It recommended improving communications for mutual-aid calls. It was a high-profile incident that many thought would light a fire under legislators and state officials. But to date, it appears that little has changed.
For his part, Pignatelli says he supports designating EMS as an essential service, something done in other states and often promoted by advocates here as a positive step. “It’s foolish that we don’t,” he told me earlier this summer. But he’s less enthusiastic about substantial or ongoing state funding for EMS, except perhaps to finance capital expenditures like building construction. In late winter, he told his working group that he doesn’t see “a Beacon Hill solution” to the EMS problem.
State Representative William "Smitty" Pignatelli (D-Lenox) at an EMS working group meeting in June.
State Representative William "Smitty" Pignatelli (D-Lenox) at an EMS working group meeting in June.
Gienapp, from NASEMSO, said the essential-service designation is “meaningless” unless it comes with specific requirements and additional funding. “I think that there are a lot of states who have passed an essential-service law who are walking around patting themselves on the back thinking that they did a really great thing,” he told me. “If all a state statute says is, ‘We, the people of this state, think EMS is super-important, should be readily available, and it’s essential for our way of life in fill-in-the-blank state, and everybody should do something about it,’ then you’ve got nothing,” he said. “That and six bucks will get you a cup of coffee at Starbucks.”
According to a database maintained by the National Conference of State Legislators, among the fifteen states plus the District of Columbia with an essential-services designation for EMS are many statutes that describe it as important but don’t require public funds be spent to support it. “That’s the way it still is in most of America, even in states that have passed an essential-services law,” Gienapp said. But when it comes to much-needed funding, he said, “Everybody gets to walk away and say, ‘Not me. Not it.’”
Outside of Massachusetts, some states have taken far bolder steps to help rural EMS. Over the last few years, the Maine legislature has convened two blue-ribbon EMS commissions that issued substantial reports featuring dozens of recommendations to help stabilize and sustain its EMS system. The legislature also spent an initial $31 million to help shore up EMS services across the state and promised future action and support.
In Minnesota, another state where rural EMS agencies face crisis-level shortfalls, the legislature approved $30 million in aid for EMS agencies in late May. It was one product of a bipartisan legislative EMS task force created late last year that has held hearings across the state.
A few states are considering legislation to give municipalities greater authority to set rates for ambulance services covered by private insurance, and to establish a minimum reimbursement rate at roughly three times the current Medicare rate.
Paramedic Craig Crawford reviews an EKG printout while transporting a patient.
Paramedic Craig Crawford reviews an EKG printout while transporting a patient.
There are a few Massachusetts officials calling for more action here. The attorney general, Andrea Joy Campbell, issued a report last fall that examined ambulance service in the state as well as consumer-protection issues like surprise “balance bills” sometimes sent by ambulance companies to those with private health insurance. (A federal law banning those bills exempted ambulance service.)
Campbell’s report pointed specifically to Maine’s emergency appropriation and called for “consideration of structural changes in EMS response to better align needs in smaller communities that may struggle to meet costs of readiness and adequate staffing, including state support of regional services.” (A spokesperson for Campbell said they had no update on any state action taken in response to her recommendations.)
A lone Massachusetts state representative, Democrat Bill Driscoll, who represents two communities south of Boston, introduced legislation early last year to create a Maine-like task force. It would have a broad mandate to examine the full range of EMS-related issues statewide and provide recommendations within six months.
While the bill didn’t advance, his task-force language was approved as an amendment during the House’s budget debate this year. But ultimately the proposal was rejected by the state senate as part of a bundle of amendments that were voted down as a group. (Mark told me via email that he supports both the task-force bill and an essential-services designation that would include consistent funding for EMS.)
At the federal level, legislation that would require Medicare reimbursement for “treat-no-transport” ambulance calls was introduced last year in both the U.S. House and Senate. But the bill, the Emergency Medical Services Reimbursement for On-Scene Care and Support (EMS ROCS) Act, has not advanced, and neither the House nor Senate versions are co-sponsored by anyone from Massachusetts.
A bipartisan House bill, the Supporting Our First Responders Act, was also introduced last year by New Jersey Democrat Rep. Andy Kim, the odds-on favorite to become the state’s junior senator after November’s election. It would establish a program to provide federal grants of up to $300,000 to EMS providers to help pay for salaries, vehicle purchases, and in support of community paramedicine and mobile-integrated-health projects. Each year, at least twenty percent of available funds under the program would be reserved for rural areas. No member of Congress from Massachusetts is currently among the bill’s thirty-two Democratic and Republican sponsors, who hail from twenty-two states and the District of Columbia.
Spokespersons for Massachusetts’ two Democratic senators, Elizabeth Warren and Ed Markey, did not respond to multiple requests for comment about the EMS ROCS legislation or any work they’ve done related to rural EMS. A spokesperson for Rep. Richard Neal, who represents western Massachusetts in Congress, did not respond to multiple requests for comment or reply to emailed questions. (Disclosure: In 2012, I was a candidate in the Democratic primary for Congress that Neal won.)
Amid the day-to-day issues in rural EMS—from the complex funding and staffing challenges to what many see as an urgent need for state and federal action—there are those like paramedic Artina Subklew who are EMS’s best ambassadors.
The first thing she said when I asked about her work as a paramedic could be emblazoned on a career-fair banner: “It’s kind of a dream job. I remember thinking, ‘You mean they pay people to do this?’”
Subklew is sixty-one. She changed careers in her late forties—from auto repair and boxing-gym trainer to paramedic. It started with an EMT class, then volunteering with EMS services in Connecticut, attending night school for paramedic training, an internship at Fairview Hospital, and finally a paramedic job with County Ambulance in Pittsfield.
When Southern Berkshire went paramedic-level in 2014, she was among the first hired to help spin up its new advanced-life-support service.
As we sat in the squad’s staff lounge one afternoon this spring, she told me the work is rewarding, challenging—and unpredictable. “We could have a day like today where we’re watching TV and relaxing,” she said, “and ten minutes from now it could be, ‘Do I reach into this car that’s tipped on its side and try to get that patient out or not?’”
Subklew knows well the emotional challenges that come with her work as a paramedic. “If there’s something special that [we] have, it’s that [we] can look at really ugly things and manage them while being able to stay professional and disengaged emotionally,” she said. “But that always comes in later. Because none of us are robots.”
Her longtime shift partner, Cindy Allard, has been an EMT for fourteen years. She used to work as an outdoor guide. “It was a lot of fun, but it just seemed like ‘Groundhog Day,’” she said, referring to the Bill Murray film about repeating the same day countless times. “I wanted to make more of a difference.”
Paramedic Artina Subklew and her longtime shift partner, EMT Cindy Allard.
Paramedic Artina Subklew and her longtime shift partner, EMT Cindy Allard.
Allard said she can remember almost every call she’s ever been on. “Sometimes I don’t remember the person’s name, or exactly where they live, but I can see their face and know what happened,” she said. “And I always, always, always wonder what happened to them afterwards.”
Memories of rough calls can linger. “These pictures stack up inside your brain from all of these things, and then eventually you get kind of overloaded with them, and you’re not letting any of it out,” Subklew said. She has a personal, first-hand understanding of how hard that can be.
That awareness is useful in her work as a continuous-quality-improvement (CQI) officer at Southern Berkshire. In that role, she reviews her colleagues’ patient-care reports to evaluate clinical decision-making and, she said, watch for signs of burnout. That might show up as unusual changes in behavior or even subtle shifts in report-writing style that indicate stress-related incidents and a need for additional support or intervention.
Overall, she told me, many people don’t understand what paramedics and EMTs do every day—and what they bring to their work. “The public perception is that they see us moving patients back and forth,” she said. “And they have very little understanding of how much training, and knowledge, and skills practice every single EMT has to go through. They may think of us as people who just grab and bring people to the hospital. What they don’t realize is that, in reality, we’re bringing the hospital to them.”
When I asked Dawn Josefski, who runs the paramedic and EMT training program in Greenfield, what she tells people considering an EMS career, she said, “Every potential student who wants to come into the program has to meet with me.” That’s when she asks a few questions: “Why do you want to do this? If you’re doing it for the money, then I would say there’s a lot of other health-care professions that will make you money,” she tells them. “It’s not all lights and sirens. It’s a lot about caring for another human being.”
For those who wonder why anyone is still attracted to a stressful career in EMS given current realities and what—if anything—will change, Josefski has an answer. “There are just some people—this is what they are built to do,” she said. “EMS is where they want to be.”
Kevin Wall agrees. “The only reason that I can see why people stay in this business,” he said, “is because they legitimately want to help people.”
∎ ∎ ∎
Bill Shein is editor of The Berkshire Argus.
Click here to sign up for the Argus e-mail newsletter. Occasional updates, no spam, unsubscribe anytime.
Support The Argus with a one-time donation or a voluntary paid subscription. With no advertising and no paywall, we rely on reader support to make this in-depth independent journalism possible.
Photos, videos, and story design by Bill Shein
Bellevue Ambulance photo: Public domain
Built with Shorthand
