Communities Must Address Racial Disparities in Emergency Medical Services

The recent conviction of two paramedics in the 2019 death of Elijah McClain has sent shockwaves through the emergency medical services (EMS) community. EMS clinicians and advocates fear that the jury’s decision signals a trend toward criminalizing medical errors and worry about the impact it will have on the profession.

The case also raised another issue, one that research consistently validates yet often gets ignored—racial bias in EMS care.

We don’t know exactly how race influenced paramedics’ treatment of Elijah McClain. But we know that he was Black. As were George Floyd, Tyre Nichols, and other men who died after interactions with law enforcement and EMS, like Earl Moore. Moore was 35 when two paramedics, now charged with murder, strapped him face down to the stretcher and treated him with an apparent lack of compassion or medical competence.

Just as racial disparities are known to exist throughout American health care—as well as in criminal justice, education, and housing, among others—they are also well documented in EMS. Multiple studies show that Black patients are less likely to receive pain medication from paramedics than white patients. Race also impacts which hospital an ambulance will take you to and how you’re depicted in the images in EMS textbooks. These inequities harm patients who, due to structural racism and other factors impacting their access to care, rely on EMS more than white patients. It’s literally adding insult to injury to insult, over and over again.

Studies outside of EMS have also shown that even today, many people, including medical professionals, believe in long-debunked theories about the biological basis of race. A study of medical students just a decade ago showed that many still held stereotypes, including the belief that Black people had thicker skin than their white counterparts. Not surprisingly, these racist beliefs led participants in the study to rate the severity of patients’ pain differently based on their perceived race. And there’s no reason to believe that these feelings aren’t equally pervasive in EMS.

Our colleagues aren’t all racists. In fact, one reason we believe the EMS profession must reckon with racial bias is because as white, male paramedics, we know what it’s like to make a quick judgment influenced by what someone looks like or how they talk to us.

We’ve also seen how the environment paramedics work in can compound these biases. Working long shifts and operating in stressful environments, paramedics face multiple factors that researchers say are conducive to cognitive bias and can contribute to medical errors—cognitive overload, distractions, bystanders or other responders, and exhaustion, just to name a few. In some cases, EMS clinicians perceive their own safety to be at risk and are under pressure to act quickly to protect themselves, the public, and the patient.

Not every instance of bias in prehospital emergency medical care occurs on camera, and many don’t lead to someone needlessly dying. Some may have outcomes with lesser impact, but impact nonetheless—a child remaining in pain longer than necessary, or a heart attack victim experiencing a delay in restoring coronary blood flow. These disparities impact care every day, in communities around the country. We don’t know of any EMS system that has examined its care by race or ethnicity and not found some discrepancies. The problem is, only a few communities have made the effort to look.

The evidence is clear and consistent. Unless communities take action, more patients will be harmed, and more paramedics will end up on trial.

We propose a few initial steps that EMS agencies, local government, and state regulators can take.

First, invest in quality measurement to see if the EMS system is providing high quality care to all residents—no matter what they look like, or what neighborhood they live in. Second, work to understand the mechanisms behind the disparities. Do providers have biases, or beliefs that impact their care? Are they relying too much on police to direct their medical care? Finally, work on implementing and evaluating interventions that have the potential to reduce or eliminate disparities, such as explicitly talking about race, diversifying EMS agency leadership and staff, and engaging with the community.

Some EMS leaders are taking action, but it’s coming too slowly. EMS agencies see tackling disparities as perhaps one other project to take on—after they’ve solved the funding and staffing crises affecting most agencies right now. It’s up to the communities they serve, the governments and taxpayers who fund them, and the patients who depend on their care to demand that EMS agencies no longer ignore these disparities.

As paramedics, we take pride in knowing that no matter who calls us, we’ll respond. It’s time to make sure that the care we provide once we get there is just as equitable.

Michael S. Gerber is a senior editor at Health Affairs. He previously worked as a paramedic.

Jamie Kennel, PhD, is a professor, paramedic, and department chair of the emergency medical services department at Oregon Health and Science University and the Oregon Institute of Technology. He is also the co-founder of Equity Analytics Group.

The views expressed in this article are the writers’ own.