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Organizing Emergency Medical Services

It Really Was This Easy

EMS companies are all very vulnerable to organization, because public opinion and perception of them is critical to their success and ridiculously easy to attack.

Ricardo Torres President & CEO - PSLC

12/19/2018

While I was still on the union side, before working with management to keep unions from penetrating the workforce, some of my favorite campaigns were in the healthcare industry: long-term care facilities, hospitals and First Response/EMS providers. These companies are all very vulnerable, because public opinion and perception of them are critical and ridiculously easy to attack.

Today, the shortage of healthcare workers is at an all-time high. Despite demand for EMTs and paramedics being projected to grow 15% by 2026, according to the Department of Labor, changes will have to occur in the industry to see these jobs filled. It will be interesting to see this unfold. I personally question this growth potential.

EMTs and paramedics have been in the news lately, both in the US and abroad. There have been some high-profile strikes and threats of strikes, most recently with the AMR threatening to strike in Seattle. Long work weeks, outdated equipment, insufficient training, low pay, and dangerous working conditions have been hotly fought-over topics in the EMS field for years, whether in union organizing attempts or contract negotiations.

While I held the position as a National Union Organizing Coordinator, I directed my organizers across the country to very methodical about which requests from workers to assist in their efforts to organize we would accept. I ran my department in a very systematic and structured way. Before we would even meet with the workers, they had to convince us that the group understood the dedication required of them for the organization to succeed. After that, the first meeting with the workers (in EMS or any other industry) was, as I described it, an interview. We told the workers up front what we expected of them and that we would pull our support at the first sign of weakness on their part. While I held this position, my goal was to have 25-30 active organizing campaigns ongoing at any time across the country.


I remember when I received an email from a paramedic from the Northwest region of the country. I spoke with the medic by phone, during which conversation she informed me that I was the third union that she had contacted for assistance as she was not satisfied with the initial meetings with the organizers on the ground. In return, I explained our ground rules to her and told agreed to meet with her and a few other supporters, but that they needed to keep quiet about the meeting because we did not what management to know about her reaching out to us. I told her to bring information about benefits, work rules, the employee handbook, work shifts and a list of employees, and to be prepared to let me know all the employees' issues.

One of my lead organizers, with a district located in the medic's region, arranged the meeting. A good first sign was that they brought all the requested information. Once again, my organizer laid out the ground rules and explained that every week would require advancement in support numbers and effort.

A glaring indicator of the unit's dissatisfaction with their work environment was the high turnover rate. This EMS provider's annual turnover rate consistently averaged 65%.


While writing this article, I ran across a 2018 study by the American Ambulance Association in an article by Greg Friese, Editor-in-Chief of EMS1.com. Per the article, the study concluded that there is a national turnover rate of 25% of full-time EMTs and 24% of paramedics. I initially questioned the study's results as 700 organizations were invited to participate in the survey, but only 119 responded. Of the participating organizations, one third were not-for-profit organizations, another third were for-profit organizations, and the remainder were municipal-based providers. Typically, the turnover in the public sector is much lower than the private. However, further review does show the crisis in the industry: at 25% turnover, these organizations are still facing an effective 100% turnover rate every four years. Having a revolving door that sweeps employees in and out over such a short period of time makes it very difficult to maintain positive morale among a group of employees charged with saving lives and have a positive impact to their communities.

Additionally, the rate of involuntary turnover is very low. Full-time EMTs were discharged at an average annual rate of 4%, and paramedics at 3%. This is due to the waves of shortages experienced by EMS providers that have culminated in near-crisis levels in parts of the US. Imagine being even just a marginally effective EMT or paramedic and being partnered with a horrible medic who is either completely lacking in skills or just so negative that you struggle to get out of bed each day knowing that you will have to work with this person. This very scenario is repeated across the country as so few companies are in a position that they cannot terminate poor employees because there are simply no quality replacements available. This is another morale killer that leads to high turnover rates and employee dissatisfaction. While this was not such a prominent problem when I oversaw EMS campaigns, it was still a problem that we took advantage of.


On the campaign in the Northwest, the turnover rate was causing extreme distress amongst the workforce and excessive overtime was causing both physical and emotional breakdowns. Management continually failed to address these problems.

Old vehicles were breaking down daily and the company's CEO constantly promised that he was working on buying more trucks and expanding the garage mechanic personnel. However, these were empty promises and the nothing was being done to alleviate the problems.

We began the campaign by having the Volunteer Organizing Committee (VOC) breakdown the workforce by known union supporters, management supporters, and those who they were not sure of. We also wanted to know about any and all relationships and dynamics between employees. The VOC was directed to start addressing the issues to everyone to see how they responded, but no mention of the union was to be made at this time, because we did not want the company to get wind of any organizing activity. We wanted the issues brought front-and-center and to get all the employees talking about how hard the job was and how little they received in compensation for all the hard work they performed in less than perfect conditions. These conversations also provided us with proof of whether there was enough support among the 400 employees in the unit to bother proceeding with our efforts.

The VOC was also to set up an informal "Committee of Concerned Employees" to start addressing solutions to known issues affecting the employees. This committee was to include well-known company supporters in order to make it appear non-threatening to management. Members of the VOC were instructed to falsely befriend all management and complement them on their willingness to meet with the "concerned" employees. This committee served the dual purposes of comforting management by making it appear that the employees were all pro-company and not seeking outside help, and to put the other employees in a non-threatening atmosphere of openly discussing their feelings about the working conditions and solutions needed to resolve them. This would also highlight management's failure to address issues themselves, instead "passing the buck" to the employees to come up with solutions.

The next meeting took place three weeks later. We learned that the VOC had convinced a non-suspecting, pro-company employee to lead the "Committee of Concerned Employees", set up a task group to search for solutions, and lead the conversations with the CEO to get his blessing to move forward with the committee. They also solicited supervisors' suggestions and convinced other departments' employees to participate. We were also able to get a better picture of the support landscape and solidify friendships and build trust with the other employees who would be needed to successfully launch a card-signing campaign; each shift and area would have to be covered by a member of the VOC to read reactions and drive discussions.

At this meeting, we instructed the committee to heighten the employees' expectation of success for the task group's stated goals, and to simultaneously appear to accept the continued excuses from the CEO and management on why they were unable to resolve even the most basic workplace issues. It was critical to keep the workforce's expectations high, as it engaged them during the initial staged of the process and ensured their outrage at management when their expectations were crushed by the company's incompetence and lack of progress.

During this time, 15 paramedics were forced to take leaves for work-related injuries, which forced everyone else to work even more hours. Once again, management promised to hire more EMTs and paramedics, but no progress was made.

By this point, the task group was where most of the employees took their complaints about working conditions. We intentionally set this scenario up so that complaints never fully reach the CEO and management. We were setting the situation up to reach a boiling point, and it was getting closer every day, while management continued to be oblivious.

One day, an ambulance was dispatched to a house where a man had died several days earlier and was discovered by his family. The man was obviously deceased as post-mortem processes had bloated him to several times his normal size. A family member demanded that they paramedic check the deceased man's pulse. For whatever reason, this request irritated the paramedic, who refused the request. The family member assaulted the paramedic, pushing him to the ground, and yelled at him. Later that day, the family member called the company and made a complaint, which resulted in the paramedic being suspending pending an investigation of the complaint. Even though it would not have hurt the situation to provide comfort to the family, it was obvious that the paramedic was facing burnout, was fed up with where he was in his career, and ignored the fact that in such times comforting the family is both the humane and moral thing to do. Although the request from the family member was not unreasonable, the suspension infuriated the paramedic's coworkers, many of whom had also been victims of abuse from the public. The suspension also gave the impression that management cared more about call volume than what the employees faced in the streets and in the hospitals they serviced.

Another EMT was fired after he fell asleep at the wheel while returning to the station. He wound up hitting a tree and being sent to the hospital. This was also perceived as a slap in the face to the other crews who were also enduring prolonged shifts.


Those of you readers who have run an EMS organization or worked with one in the past know that one of the biggest complaints is Dispatch. Dispatch is often perceived as having their favorite crews who receive the easier or most interesting calls, and their "not-so-favorite" crews who get the harder calls: bariatric patients, psychiatric calls, or wait and return calls.


Dispatch at this facility was deeply resented by the employees, ever though we learned from a previous dispatcher turned paramedic that most dispatchers did not intentionally target employees. The company was aware of the "perception" problem but felt powerless to address it. We also learned that there were certain dispatchers who did play favorites and dispatched calls in a "vengeful manner". In fact, one of these "vengeful" dispatches did not seem to understand that ambulances must be decontaminated after calls to ensure the health and safety of both the next patient and the medical personnel.

An EMT angrily entered the supervisor's office in front of other employees who were also getting off shift at the same time to complain of earlier abuse from a dispatcher. He informed his supervisor that one of his patients became sick and had a bowel movement during a possible heart attack. The patient was found with no clothes on and was being transported "priority 1". During the transport, the patient managed to transfer fecal matter through the inside of the ambulance and across the stretcher, creating a significant contamination to be "deconned". No EMT or paramedic ever enjoys this type of "decon", but tempers flared when the dispatcher told him he would have to go on another run prior to sanitizing the back of the rig. One member of the crew tried to explain that, not only was the inside of the truck contaminated and was unsafe for the patient, but he had gotten fecal matter on his clothing and needed to return to the station for a change of his uniform. The dispatcher had yelled at him over the air for all to hear and told him to pull the call anyway. When he addressed this with his supervisor, the EMT was informed that this was the nature of the business and, in a failed attempt to relieve tension, "... happens". He further blamed it on the shortage of people as they were behind on hospital pickups that day and felt they would be risking a client by not moving patients to open up bed space for a hospital.

As a defense against facing tragedy every day, EMS workers tend to develop a twisted sense of humor. So, of course, when the medic who was exposed to fecal matter met up with his peers, they made jokes at his expense for taking a run with fecal matter on him. The jokes quickly subsided after they learned the supervisor's response to his complaint, and since the dispatcher verbally attacked the medic over the radio, word spread like wildfire about how management cared more about clients than their own people. This righteous anger was even worse for management because the EMTs and paramedics all knew they were short staffed and believed that management should be doing everything possible to keep them happy. This did not make them happy. At all. Tempers were flaring.

My organizers were speaking with the VOC daily. We utilized the information they gathered on their peers while we compiled information on the part-time workers (some of whom only worked a few days per month). This data allowed us to target the employees we would reach out to. This was a critical step as we needed them to be able to relate to the negative working conditions, so we had their support when we pulled the trigger on the election campaign.

We also sought out the most senior EMTs and paramedics and befriended them. They would be the unexpected biggest motivators behind the "Committee of Concerned Employees". We used their egos to drive the effort, as they saw themselves as leaders. We exploited their self-perceptions to manipulate them into being unwitting tools to support our goal to organize the unit.

By this point, the unit was getting exhausted and upset at the lack of progress in improvements and lack of consideration from the CEO and his leadership team. The VOC began circulating a petition for a series of "town hall" meetings to discuss the issues the workforce was facing every day. Over 80% of the EMTs and paramedics signed the petition. Pro-company members of the "Committee of Concerned Employees" delivered the request for the meetings to the CEO, but the VOC intentionally "forgot" to give the petition to the pro-company advocates, so the CEO was not made aware of just how dissatisfied so many employees were.

Our calculations showed about 65% of the workforce would vote "yes" for a union, but we needed expand out lead. Our numbers were soft because the prospect of bringing in a union had not yet been introduced to most employees. I was also not happy about this level of support as I figured about 15% of the of workers would flip and not support the union, even if they signed a union signature cards, and that did not leave much meat on the bone for the election. Everything led us to believe that management was still in the dark concerning the organizing campaign, so we needed everything to coincide with the town hall meeting. We had to increase support for the "Committee of Concerned Employees" among the group our internal polling showed would be solid "yes" votes.

The town hall meetings were finally arranged but we still needed to work on expanding the VOC (while keeping it as small as possible to preserve secrecy). We needed to come out hard against the CEO and management at the meetings. We had been compiling infractions, hard complaints from meetings with management, and targeted complaints from workers. Presenting this at the town hall meetings heightened the emotional level and gave the employees the opportunity to directly address the CEO while their anger was fresh.

It had been a balancing act to downplay the frustrations of the EMTs and paramedics for the CEO and management while simultaneously herding them to trust and befriend the "Committee of Concerned Employees" members without tipping our hand that this was, in reality, a well thought out union drive. Prior to the town hall meetings, a few committee members met with the CEO to reassure that everything was under control. They also provided him with a few recommendations on what to say during the town hall meetings to alleviate any concerns the workers might have about their issues and how to solve them. Of course, these recommendations were actually designed to further infuriate the workforce, as we had led everyone to expect the CEO would come to them with real solutions to their issues.

The town hall meetings were a resounding success (for the union). The pro-union employees hit the CEO right between the eyes with issues he had no idea even existed. The VOC members perfectly executed our plan. We had different people in each meeting give emotional examples of the abuse they had to endure from their managers and the awful responses the CEO had to their concerns. The CEO was speechless, and the employees were indignant.

As we expected, the CEO attacked the "Committee of Concerned Employees". He had a bad temper and we knew he would explode when he realized he had been duped. He also attacked the supervisors and accused them of being part of the plot. While this was an unexpected bonus to the VOC members, as someone who took over 1,000 campaigns to election, did not surprise me at all.

After the meetings, we distributed prepared flyers listing many of the issues presented, along with union signature cards. We knew this would expose the CEO and management to ULP (unfair labor practice) charges when they overreacted. The first meeting was the most successful at advancing the movement. The VOC members present were kicked out of the building and two of the VOC members coming on to their shifts were told to go home. We did everything we could to get the CEO and management to violate the NLRA (National Labor Relations Act). We knew that the pressure we exerted left them in no frame of mind (or even gave them a chance, time-wise) to seek legal advice before the second and third town hall meetings.

Between the three meetings, we determined the company violated the NLRA over 15 times. Within two days, we had filed the charges with the NLRB (National Labor Relations Board). We also distributed copies of each charge to the employees to highlight how little the CEO cared about the employees. This also served to distract management and caused them to waste legal resources dealing with the charges.

We did not want to anger any neutral employees who might believe the "Committee of Concerned Employees" had pre-planned the attack on management, so the VOC members had been kept from participating in the committee. This allowed the VOC members to appear impartial. This was reinforced, when a few days before the town hall meetings, the VOC members told everyone they could that they did not trust the CEO but would give him one last chance to make things right at the meetings.

Most of the hospitals that this ambulance company supported were represented by unions. We took advantage of this by having union leadership in the hospitals direct their members to talk with the EMTs and paramedics when they brought patients into the hospital.

The employees were showing us that they were solid "yes" votes and continued to move in a pro-union direction. This included several of the "pawns" who were once hardcore pro-company employees. In fact, several of these wound up serving as our biggest mouthpieces, since they were so respected by their peers. They also provided quite a bit of sensitive information they had obtained from loose-lipped supervisors who had trusted so much in their so-called "most loyal" and "hardest" workers.

While preparing to introduce union signature cards, we obtained personal financial information on the CEO, his home address, and pictures of both his main home and his lake house. We obtained the information by utilizing relationships the VOC members had with janitorial and office staff workers. It was exploited it by passing it around to all the employees, further cementing the divide between workers and management.

In response to our efforts, the company hired labor consultants to hold meetings with everyone. This should have been an excellent move on the company's part, giving them a fighting chance, but it seemed they were unwilling to listen to professional advice.

The company and consultants held "captive audience meetings", in which the employees were to attend mandatory meetings and learn management's perspective on unionization. The meetings were not well attended. As the company already held frequent continuing educational meetings that were mandatory, the CEO decided to write up all employees who missed the captive audience meetings, just as if they had missed a continuing educational meeting. This was an expected bonus for us, as it further infuriated the employees.

The consultants also met with employees in the hospitals. Because the medics were often posted on the road, on calls, or in the hospitals and there was a lack of manpower, the hospitals were the best chance the consultants had to meet and communicate with the workers. Most of them refused to talk with the consultants, as they simple no longer cared. One member of the VOC managed to take pictures of the consultants and posted them in the medic rooms in most of the area hospitals. The photos and internal messaging from the VOC combined with the enormous uptick in union support made the consultants essentially useless. Some of the employees started making a game of laughing in the consultants' faces and taunting them. This is when I knew we had the upper hand.

This confidence was reinforced after the CEO held his last meetings with the employees (known as a 25th hour speech). A supervisor once again slipped up by relating something to an employee he was certain he could trust but was actually 100% supportive of the union. The supervisor let it slip that the CEO would show a short video on the history of the company that would include a picture of the employee (who had worked there for about 20 years). The employee made sure that the union supporters were ready. The union supporters took popcorn into the meetings in order to have popcorn fights during the video. This was done for two reasons: First, to show the last few workers who were still on the fence that the employees were not afraid of the CEO. Second, we never lost sight of the CEO's temper and genuine lack of empathy towards the employees. Once the popcorn started flying, the CEO had a meltdown and stormed out of the first meeting. He verbally attacked anyone with popcorn entering the following meetings.

Some of the statements the CEO made qualified as further ULPs, but we saved them as an ace in the hole if we had not calculated the projected vote count properly. Of course, we were not off. The EMS provider lost the election by a three-to-one vote with nearly 90% of the approximately 400 workers voting.


Of course, these days, I am not on the union side. My company partners with management to make sure that these outcomes do not become reality. When I shared this story with my Executive Vice President (who came out of the EMS industry, and was as one time involved in EMS unions), I felt that his response was worth sharing:

First, he stated that "EMS is currently facing a crisis bigger than I have ever seen." He was a firefighter prior to working for a private EMS company. He also stated, "In order to be a firefighter in my day, in the Detroit area, you pretty much had to have a paramedic license and you faced thousands of other applicants as you competed for a handful of openings. Today, if you have a paramedic license, it is far easier to get into the Fire Service because the shortage is so severe. That's where all of the good paramedics are going."

Next, he stated that while helping the union organize his former employer, he distinctly remembered an IAEP organizer from Maryland waiting for him at a hospital and walking right into his ambulance with a patient onboard to give his "sales speech". His partner signed an authorization card on the spot. Now that he is working with management, looking back, it is easy to understand how a medic can not only be so uneducated about the true costs of unions, but also allow a union organizer to violate the sanctity of patient care. (Despite the fact that even a brand-new medic should know better.) "The frustration and burnout that comes with being a road medic is a huge problem, even when fully staffed. In times of crisis like this, frustration and burnout can reach a fever pitch almost immediately."

His final response was, "There may be some horrible leaders in EMS, but most are amazing leaders who are stuck in an impossible situation." He believes the current EMS crisis is tied directly to an industry-wide problem where private EMS services are not receiving the compensation they are worth. The primary driver of this is that the government only pays minimum returns for patients with Medicare and Medicaid and EMS companies must be competitive with their wages. It is almost impossible for an EMS company to raise wages to what the general public believes EMTs and paramedics should be paid, or they will quickly run into the red and out of business.

Per the Bureau of Labor Statistics' (BLS) 2017 statistics, the median pay for EMTs and paramedics is $33,380 (or approximately $16.05/hour). With that in mind, remember that Basic EMTs made significantly less that Paramedics and the BLS combined both categories in their industry report. 

The industry must undergo substantial changes before CEOs and private owners can pay more and afford the costly capital equipment upgrades and the latest lifesaving technologies that today's medics need to do their jobs right. Until that happens, EMS is ripe for the picking by unions and, if you follow the NLRB petition logs, you will find that unions are indeed targeting EMS companies across the nation.

These problems existed when I was on the union side and in the EMS campaign I just discussed. It was an easy win then because the vulnerability was so high. Today, if put in the same circumstances, it would have been even easier to win, as these problems have only expanded.

The best solution if you are a leader in EMS is constant communication with your employees. Promote their value to your organization and be frank with them about the status of the industry. As my EVP told me, "Nobody goes to school to become a paramedic to become rich. They do it because they like the adrenaline (which fades quickly) and, most importantly, because of their compassion for human life." While they still hold this mentality is when you should be holding conversations about the industry; not after years of disappointments and a severe case of burnout.