Taylor Scott, Managing Editor
On March 31, Gov. Tony Evers announced that he had vetoed recently passed Senate Bill 89. The bill, introduced by Sen. Howard Marklein, R-Spring Green, would have made the National Registry of Emergency Medical Technicians exam optional for emergency medical responders. Marklein argued the bill would improve recruitment and retention for rural emergency medical services. Local EMS directors fell on either side of the issue, with an expert in prehospital emergency medicine arguing lowering the bar is never the answer.
The rural EMS bill, SB 89, was introduced by Marklein in February 2021. The bill passed the Wisconsin state Senate in April of last year, with the state Assembly following suit in January of this year and the bill ending up on the governor’s desk in late March.
The bill would have prohibited the Wisconsin Department of Health Services from requiring an applicant who is applying for certification as an EMR to register with or take the examination of the National Registry of Emergency Medical Technicians (NREMT).
Current DHS rules require an applicant for a license as an emergency medical services practitioner at any level, including an emergency medical responder, to be registered with the NREMT or to have completed the NREMT examination.
“I object to potentially lowering statewide educational qualifications needed to be certified as an emergency medical responder in Wisconsin,” said Evers in his veto message.
Evers noted the important work EMRs are doing in our communities while acknowledging the challenges facing EMS in the state. According to Evers’ statement, state aid to communities has gone down by more than nine percent since 2011, while public safety costs have increased more than 16 percent. Evers also noted more than half of EMS providers in the state are either operated exclusively by volunteers or through a combination of volunteers and paid staff.
Though he vetoed this bill, in his State-of-the-State address in mid-February, Evers announced an additional $27.4 million funds for training, a Medicaid reimbursement rate increase and one-time flexible grants funded through the federal American Rescue Plan Act for EMS programs.
Evers said there are provisions in the bill he was open to considering, specifically satisfying emergency medical responder certification requirements by having applicants demonstrate military service training, education or experience that is substantially equivalent to the course required for emergency medical responder certification.
“This effort could help further ensure our veterans entering our workforce after their service face fewer barriers to finding work,” said Evers. “I cannot support other provisions in this legislation that I am concerned would have negative, long-term effects on patient care by lowering educational and training qualifications.”
The next day Marklein expressed his disappointment in Evers’ veto.
“I am extremely disappointed that Gov. Evers vetoed my bill that would have helped rural EMS with recruitment and retention,” said Marklein in a statement. “I authored this bill with Rep. Travis Tranel, R-Cuba City, because our rural EMS squads told us that they needed some flexibility in order to have enough members to provide services in our small rural communities.”
Marklein said the bill was inspired by conversations he had with rural EMS volunteers.
“They told us this is what they needed,” said Marklein. “The governor isn’t listening to local people and the local volunteers who are working hard to save lives in our communities.”
Marklein also disputed Evers’ assertion that the bill would have lowered standards, saying he believed the bill gave individual departments the ability to decide whether or not the NREMT exam would still be required for credentialing in their specific department.
“Every EMR would still have needed to complete a DHS approved training course and pass all other applicable tests and hands-on experiences to receive licensure,” said Marklein.
Tracey Brent, Plain EMS service director, said she was hesitant to weigh in on the issue, fearing the bill has or may become political. Instead, she suggested, providing more incentive to volunteer.
“Instead of attacking the process for becoming a first responder,” said Brent. “We would be better suited to look at incentivizing those who give back to their communities.”
Brent says the few tax credits that exist for first responders is not enough.
“Volunteers give up a lot to serve their communities. They give up their freedom to leave town when on call, they leave their friends and families during the middle of dinner, holidays, and the middle of the night. They give up their life to serve others,” said Brent. “Making classes for first responders more accessible and more affordable is an area that would serve us better. Perhaps incentivizing taking the class is an option as well.”
Volunteerism is a dying craft, says Brent, with both recruitment and retention issues facing many EMS services and the situation becoming dire in our rural communities.
“When you or a loved one needs help, you dial 911 expecting someone to answer the call,” said Brent. “But what if there was nobody there to answer it?”
Brent says ambulance services in our area are in jeopardy of cessation without the continued involvement and volunteerism of members of the community.
“Having an ambulance service is a vital piece in what makes a community thrive, knowing that if you ever need help, help will be there,” concluded Brent. “Volunteer services will only last as long as there’s people to staff the truck.”
“We can’t just say, ‘we need more doctors, so… let’s skip spleen week or something…”
Dr. Michael Abernethy, clinical professor of emergency medicine at UW-Madison
Last year, when the bill was originally introduced, Tyler Tisdale, Arena EMS service director, said he believed the bill would help, but that it doesn’t solve the main issue of recruiting volunteers.
“It’s great to have EMRs,” said Tisdale. “But we still need at least one EMT with an EMR to minimally staff the ambulance while maintaining a legal crew.”
Tisdale says that Arena has the same problem that he believes is rampant across the state — recruiting people to become volunteer EMTs. Tisdale suggests the solutions lie in hiring full time EMTs, changing the requirements for incoming EMTs and providing better compensation for volunteers.
“We are aware of the time commitment one takes on when volunteering to be an EMT,” says Tisdale. “These individuals give up so much of their time in an instant to respond to an emergency and, in many situations, their efforts are not compensated as they should be.”
Both EMS directors agreed that more volunteers are needed and urged those interested to reach out to their local EMS program and sign up for classes.
“It’s a great cause,” says Tisdale.
Dr. Michael Abernethy, clinical professor of emergency medicine at UW-Madison’s School of Medicine and Public Health and the chief flight physician for UW Med Flight said he believes the bill would lower the standard of medical care.
“I think lowering the bar is never the answer,” said Abernethy, an expert on prehospital emergency medicine.
Having practiced emergency medicine abroad, Abernethy says the problem in the US is the divide between prehospital care and health care, with EMS being largely reliant on individual communities.
Abernethy uses the examples he sees of EMS programs and volunteers doing bake sales and pancake breakfasts “to keep the lights on.”
“I do work in other countries where they look at us and sort of shake their heads, why is there this divide?” says Abernethy. “Why isn’t there just this continuum of health care?”
Abernethy says the quantity and quality of care in the US is “all over the place.” He says in the UK paramedicine requires a four year college degree and is uniform, saying a paramedic in Edinburgh, Scotland would have the same training and medical education as a paramedic in London, England.
“[In the US] you can have everything from a four year degree to a two year degree to a one year certificate and now there’s programs, you can do it almost all online,” says Abernethy. “So the idea of any uniformity when someone says, ‘we have a paramedic’ here, I don’t know what that means…when I have a new graduate or a new paramedic, I have no idea what that means.”
Abernethy says that he considers a national registry test to be the bare minimum.
“So by having a national registry test, it minimally says ‘okay, they’ve probably met these standards,’” says Abernethy.
Though he believes there is value in looking into the possibility of using a grandfather clause to license paramedics that have equivalent experience in the field.
“[You] can talk about higher standards, and all that, but until the government recognizes that this is a problem,” Abernethy says, comparing the situation to other regulations enacted after loss of life. “Do people have to die because of lack of care for people to pay attention to this?”
As for solutions, Abernethy suggests moving EMS regulation at the federal level to be under Health and Human Services rather than under the Department of Transportation, where it is currently. He also suggests looking into a penny tax on a gallon of gasoline to put into EMS infrastructure.
He agrees that getting volunteers is the biggest issue facing rural EMS right now, but says it’s “absurd” that a critical service depends on volunteers and there needs to be better funding.
“I certainly understand, ‘Oh, my God, we don’t have volunteers and now we’re making more requirements and making it harder for them to do this when we should be making it easier,’ but we have to have standards,” says Abernethy. “We can’t just say, ‘we need more doctors, so let’s cut two years out of medical school or let’s skip spleen week or something,’ you can’t lower the standards, you got to fix the problem.”