The first thing you learn in Emergency Medical Services (EMS) training is what’s called  “scene safety and body/substance isolation.” In other words, when you arrive at the scene of a 911 call, you have to first determine whether it’s safe enough to reach your patient, and ensure that your body is protected from any hazardous fluids or gases in the vicinity. This concept is extremely important—in your day-long certification test, if you fail to start every scenario with “scene safety and BSI,” you fail the entire thing and go home. The logic is simple—you’re there to help the patient, but you can’t do it if you’re in danger yourself. If EMTs are going to provide good care, the EMTs have to be taken care of as well.

Unfortunately, the moment they finish submitting their incident paperwork, the principle is forgotten. Nobody cares about what happens to the EMTs until the next call comes in. It’s one reason American emergency services are steadily on the road to disaster.

In the United States, emergency medical response is carried out by a patchwork of different entities that vary from locality to locality. In cities, the Fire Department is often the first service on the scene of a 911 call, so they will do a lot of the heavy lifting for an emergency, with EMTs arriving close behind to do a secondary assessment and transport the patient. The fire department is tax funded, but the ambulance may be one of a dozen different private companies operating in just one municipality. A lot of cracks are filled in by local publicly owned services—not just firefighters, but also volunteer ambulances, which might get some of their money from taxes but ultimately rely on donation drives to keep the lights on. It helps to have these services, but they’re not very well-funded. In my hometown, manpower requirements were met by having police officers carry oxygen tanks and EMR certifications.

Nationwide, there is one massive monopoly, American Medical Response, which is kind of like the McDonald’s of EMS, since they have branches all over that are fairly decentralized but still linked to the same capital distribution system. AMR runs a massive share of private EMS services, with over 6,000 ambulances and even 12 fixed-wing aircrafts.

The private ownership model for ambulances is fundamentally at odds with its own purpose. In the beginning they were useful insofar as they were an ad-hoc option in a society that gave no thought to whether or not speed was important in treating an illness or injury. However, this jumble of organizations across the nation creates big problems beyond figuring out billing logs. A key problem is the cost of doing business. A single ambulance can cost somewhere in the $500,000 to $1 million range, so any ambulance company’s first priority is to reduce overhead as much as possible. Of course, if you read Current Affairs, you can probably guess what the implications are. They want to get the cheapest gear, the cheapest ambulances, and the cheapest workers. You will see EMS personnel make fast-food level wages, for what is ostensibly an extremely important job. Paying people by the hour in addition to having prohibitively expensive equipment means EMS corporations need to maximize the workload for a workforce that they keep as small as is feasible.

So, you have EMTs pulling 60-hour workweeks to scrounge together a rent check, which means their free time is spent recovering from work. They essentially exist to work. Their day-to-day schedules are often determined by manpower needs, so they often don’t know what their shifts look like from week to week, and every hour on shift is different from the last one. You could sit in the station for five hours before you get tasked out to transport someone from one hospital to another, or you could get a CPR call right as you punch in. You may get tasked to deal with a guy whose only problem is being stuck in the bathtub and feel frustrated as you listen to your partner units get dispatched to a car wreck.

The irregularity is just one reason that health problems are rampant in EMS. Overworked EMTs have random meal schedules, eat unhealthy food often, and are too tired to exercise.About 1/3 of EMTs work more than 40 hours a week, and the Bureau of Labor Statistics confirms that they have “one of the highest rates of injuries and illnesses of all occupations.” This has led to plenty of stories of EMTs and paramedics suffering health emergencies while they transport patients to the hospital. I know at least one EMT who had a heart attack while driving the ambulance(survived), and another one who was out for months due to pericardial tamponade. One of the most common injuries they get are back injuries due to lifting heavy patients- as a volunteer EMT every stretcher was battery operated, but in the private sector cost analysis demanded old fashioned pneumatic lever operated ones. We haven’t even talked about the psychological toll. The Journal of Emergency Medical Services reports “alarming rates of EMS provider stress and thoughts of suicide.” No wonder, then, that your average EMT lasts about two years before experiencing “burnout,” the psychological exhaustion that irreversibly damages your performance.

Recently, Nathan Robinson wrote about an incident he observed in a diner, where two EMTs were disdainful and uncaring towards a sick woman. She seemed to be homeless, a drug addict, or both, and passed out in the booth. When the EMTs arrived, Robinson said, they seemed to care little about her well-being, and were more concerned with figuring out who would pay her bill than with treating her.

I’m not going to justify their behavior. But it’s not necessarily a product of individually callous EMTs. It’s also a product of a medical system that creates indifferent and exasperated EMTs who are forced to work far too long for little pay. In the case of the woman Robinson described, the EMTs could well be fed up with her because they’re past their clock-out time after an intense shift. They ought to have treated her with dignity and respect, but I also know how they feel just from having to deal with my own anxiety on busy nights for the ambulance. Often EMTs have no idea they’ve hit burnout, and are bitter and judgmental of patients who present a far less urgent situation than the worst things an EMT has seen.

For all the cost-cutting and neglect, you might at least expect ambulance services to be affordable. Yet as anyone who has taken one knows, consumers pay fat stacks of cash to keep this system running. You can tell a lot about the American healthcare experience just from reading the Yelp reviews for American Medical Response. A sample:

• Charged us $1400 to take my wife two blocks to a radiation center. Then charged another $1400 back to the hospital. Corporate corruption at its finest!

• They deserve negative stars – an immeasurable amount of negative stars. Alas, I am forced to give them one star, to which they could never hope to aspire. AMR is a sham business that scams patients from the very first contact to the very last… [T]hey bill incorrectly, they overcharge egregiously, and they stress out already-sick patients more and more with every subsequent communication.

• I received a bill of $1212.50 for a 5-minute ambulance ride in which no help was given.

• AMR took her about 4 miles to the local hospital and we received a bill for $1857.00.  We have insurance but AMR is private and not in network for ANY providers! THIS IS ABSURD!
• Crooks. Fire truck chasers. Charged me $2.5k for five min drive to hospital and did not really need it. I didn’t even call them. Do NOT use unless your life depends on it.

The usual justifications for free markets fail completely when it comes to ambulances, since there’s no practical way for “consumer choice” to improve services. When you’re bleeding to death, it’s hard to comparison shop—not that you’re even offered a choice. As Harvard Law School’s Shailin Thomas wrote, ambulances function as monopolies, because “the patient faces a market with exactly one option.” Thus even though the ambulance industry itself is actually “quite diverse,” consumers have approximately zero power in the market. Moreover, the company that transports you is usually determined by the contract they strike with the town/city government, not you. You take whatever ambulance the dispatcher sends, and they already got the council to agree to what constituted an “acceptable” transportation fee.

Given the poor employment conditions, EMT culture should be fertile territory for left organizing. Unfortunately, the poor pay of EMTs has often been used as an argument against the improvement of other workers’ lives. You may run across a self-declared EMT on Facebook ranting in long paragraphs about how it’s outrageous that “burger flippers” should make more than him, since his job is so important, yet he’s so overworked and so underpaid. You’ll see memes like this one, comparing those who “demand $15.00 an hour for working a menial job at McDonald’s” to someone who  “makes $9.00 an hour saving lives and demands nothing.” It’s such obvious narrow and fallacious thinking, this idea that since EMTs are underpaid, everyone else deserves to be even more underpaid. One paramedic earning $15 an hour showed a better way of thinking::

[T]hese burger flippers think they deserve as much as me? Good for them. [I]f any job is going to take up someone’s life, it deserves a living wage. If a job exists and you have to hire someone to do it, they deserve a living wage. End of story. There’s a lot of talk going around my workplace along the lines of, “These guys with no education and no skills think they deserve as much as us? Fuck those guys.” … And that’s exactly what the bosses want! They want us fighting over who has the bigger pile of crumbs so we don’t realize they made off with almost the whole damn cake. Why are you angry about fast food workers making two bucks more an hour when your CEO makes four hundred TIMES what you do? … My company, as they’re so fond of telling us in boosterist emails, cleared 1.3 billion dollars last year. They expect guys supporting families on 26-27k/year to applaud that.

The very fact that EMTs make such terrible wages is all the proof you need that people don’t get paid based on the value of their contribution to society. It’s true you can train an EMT in a few months and it doesn’t require a college degree. But helping a little old lady who’s panicking about stroke symptoms is infinitely more valuable a service than all the hedge funds on earth. Show me an EMT that has joined the ranks for money and not a sense of altruism and I’ll show you a three legged Pegasus.

If we were to design a good EMS system, it would be fully tax-funded, and each town EMS department would be run by the EMTs themselves. They would either act collectively to optimize the place or elect officers to dictate orders. Ideally, to combat fatigue, they would only ever work 4-6 hours a day, 5 days a week. That would require a lot of manpower for 24/7 coverage, but better pay and reasonable hours would lure many highly capable people to the job. Of course, it would cost far more than the current system. But the current system is disastrous, and getting profit out of emergency services means no more thousand-dollar one-mile rides.

Capitalism struggles to fit emergency services into its overall structure. When it comes to basic services, corporations’ mandate to maximize profits and deny access creates complications, not the least of which is that the negotiating power between consumer and owner is lopsided. What’s more, it doesn’t even produce reliability: Ambulance services can go out of business and leave communities in the lurch, a problem that simply does not exist with the military or the post office.

Good emergency medical services are going to be expensive and unprofitable. The sheer cost of operating an emergency response service is why firefighting was ultimately turned into a public utility. In the beginning week of firefighter training, students learn that the Great Chicago Fire was the turning point that led to the extinction of private fire companies and the beginning of fire services as a widespread public utility. Chicago’s fire businesses found it far too expensive to keep and maintain the equipment and people necessary for a massive disaster, which they saw as too rare an occurrence to justify budgeting for it. The same could be said for ambulances. Republicans may finger wag about how EMTs can’t have better wages due to the sheer expense of the equipment. But in my opinion that’s just another argument for having everyone pitch in to fund it instead of hoping a few shareholders can gin up some extra revenue that might go to maintenance.

The first principle in EMT training is that there’s no sense trying to help someone if you can’t keep yourself safe first. Private ownership of emergency services ultimately endangers EMTs. Rather than fight other wage-earners over pay differences, first responders ought to decide among themselves how best to run their own organization.

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