Scarcity as Strategy

Editor’s Note: Tracey Loscar, BA, NRP, is Deputy Director of EMS for the Matanuska-Susitna Borough in Alaska and a member of the EMS World Editorial Advisory Board. This article is adapted from her presentation, “Scarcity as Strategy: Disruptive Leadership Lessons from Rural Alaska EMS,” delivered a the inaugural National EMS Management Association (NEMSMA) Leadership Conference in Washington D.C.

December 2025. Ice fog, 20 below zero. A chain reaction collision on the Knik Bridge, 37 vehicles. The scene is still accumulating patients on a surface that’s still compromising vehicles in visibility conditions measured in inches.

Back at dispatch the math is simple and brutal. We cover 25,000 square miles, roughly the size of West Virginia, with six to eight ambulances around the clock. For each unit committing to a scene like the Knik Bridge, 700 square miles go dark. There is no mutual aid waiting in the wings; anyone coming in is coming from home.

That wasn’t a worst-case scenario. That was a Tuesday morning.

I spent nearly three decades running calls in Newark before I came to Alaska and I thought I understood resource scarcity. The city had its own brand of chaos: urban, dense, violent, chronically underfunded. What I found in the Matanuska-Susitna Borough reordered my thinking about what scarcity means.

The Map Is Wrong

In 2023 the Maine Rural Health Research Center published the first national analysis of ambulance coverage gaps in the United States. The findings were sobering. 4.5 million Americans live in what the authors defined as an “ambulance desert,” more than 25 minutes from the nearest station. In the U.S., 82% of counties contain at least one such gap. It's good work; the field needed a baseline.

Alaska isn't on the map; it's never on the map.

That omission isn't just missing data; it reflects a flawed assumption embedded in the model itself that if you can draw a circle on a map, an ambulance can travel across it. In large portions of Alaska, and in meaningful stretches of my own service area, that assumption fails completely.

You can’t census-block an ice fog event. You can’t polygon a whiteout. 

The ambulance desert model describes a static problem: geographic, infrastructure-driven, solvable with more stations and more units. Build your way out. That’s not what we are. 

We are access- fragile. A system where access exists but is conditional. Weather-dependent, workforce-dependent, one variable away from failure. 

It’s not a desert; it’s  a cliff. 

Our system serves over 120,000 people with just one hospital perched on a handful of arterial roadways. The Parks Highway is the primary north-south corridor. You can drive it all the way from Anchorage to Fairbanks through some of the most magnificent wilderness on the continent. For long stretches through the Mat-Su Valley, it's lined on both sides with dead timber. The skeletal remains of thousands of black spruce trees killed by invasive beetles, turned into 30-foot matchsticks. A critical corridor running through a wildfire time bomb.

The 2018 Cook Inlet earthquake turned access to Anchorage into a real-time risk calculation. Katabatic wind events off local glaciers routinely produce hurricane-force conditions, shutting down power grids and movement across the valley, sometimes for days.

And then there’s the quieter version of the same problem. One ambulance, routine transport, icy road, a fatal crash. Within minutes, 25% to 40% of shift staffing is committed to coverage areas. They go dark. There is no neighboring county to call.

Leadership looks very different at the edge of a cliff than it does in the middle of a desert.

You Can’t Recruit Your Way to Experience

Recruitment and retention are the dominant operational crisis in EMS right now. The 2023 EMS Trend Survey found 95% to 96% of agencies reporting difficulty in both categories. Gen Z, now the fastest growing share of the workforce with average early career tenure of 1.1 years, is entering EMS in volume with limited field time and a well-documented resistance to institutional authority.

In a resource-rich system the response is time. Pair new providers with experienced ones. Assign lower acuity posts. Let exposure accumulate. We don’t have that option.

About half our workforce arrives with fewer than two years of field experience. Our average hire is 25 years old. The geography doesn't care. It places a critical patient 25 miles out at 0300, regardless of how long you've been certified.

Our answer was to build a compressed competency model: structured clinical exposure, deliberate high-frequency simulation, and accountable field mentorship. Not because it was ideal but because it was necessary. Systems that are forced to develop people instead of acquiring them build durable learning cultures. 

Protocols Must Match Reality

National protocol frameworks assume ALS arrival in under 10 minutes, transport to definitive care in under 30, with reliable medical direction access. Those are not our assumptions. Forty-five-minute transports (and longer) are routine. Weather may eliminate air support entirely. Extended pain management is standard practice. Airway decisions carry longer downstream consequences.

This doesn't degrade care. It produces clinicians who manage patients, not just package them. Building a clinical picture over hour(s), reassessing as interventions take effect, making decisions without an ED minutes away, requires critical thinking skills. It develops in direct proportion to how much time you spend doing it without a net.

Decision Authority Has To Move Down

In our system there is no slack to absorb a poorly stocked unit, a provider who skipped shift checks, or a supervisor who hoards decisions that should live at the field level. Operational discipline isn’t a cultural aspiration here; it’s a necessity. Each shift comes with the possibility of being cut off from the ability to re-supply for an extended period of time. 

When the supervisor is 40 miles out and communication is uncertain, a culture that requires escalation before every meaningful decision fails the moment conditions get real. Authority has to exist where decisions are made. That requires trust before proof. Push authority to the lowest operational level before it’s comfortable, not after something breaks badly enough to force it.

This is harder than it sounds. Not because of the providers, because of what it demands from senior leadership. Punishment cultures kill decision-making speed. Learning cultures build it. You can’t ask for ownership at the field level while modeling escalation at the top. The choice between those two organizational postures is a leadership choice, not a staffing or protocol question.

For a workforce that skews heavily toward Gen Z, distributed authority also happens to match what that generation actually needs and what keeps them. Not ambiguity. Clear expectations. Explicit rationale. Feedback close to the event rather than in the annual review. Visible stakes and work that asks for something real.

When people feel like they are part of something that demands something genuine from them, they stay.

What the Field Can Take Home

Most systems aren’t Alaska, but most systems are becoming fragile. Weather variability, workforce instability, hospital congestion, and system strain are introducing conditional access into environments that once assumed reliability. The cliff exists somewhere in your service area.  Here are four things you can choose without needing the frontier to force them.

Audit your comfort. Where has resource abundance insulated your agency from problems that are quietly getting worse? The work around has normalized for five years because you can afford to. The protocol passed its date because outcomes aren’t catastrophic enough yet to force the conversation. The escalation culture, where decisions that belong at the field level keep drifting upward because nothing has broken badly enough to stop it.

Comfort isn’t the same as function. Sometimes it’s a slow
accumulation of things you stopped noticing.

Map your cliff. Failure occurs at the intersection of resource constraints and access constraints, not at either one alone. Find that intersection before conditions do. Design for fragility rather than stability because stability is a condition you don’t control.

Most agencies don’t fail because they lack resources, they fail because they misunderstand how constraints combine.

Ask yourself:

• Where do my staffing gaps overlap with access delays?
• Where do my busiest hours overlap with my weakest coverage?
• Where does my least experienced provider face my highest risk calls?
• What happens when your communications fail at the same moment your units are most geographically dispersed?

Push decision authority down to a level where it’s not organizationally comfortable. Give authority before it’s fully earned. That’s not naivete; it’s operational design. Treat errors as learning events rather than punishment triggers. (Book recommendation: Turn the Ship Around by L. David Marquet)

Treat workforce development as infrastructure. The hire you make today is your competency floor for the next 20 years. Invest in onboarding. Build culture deliberately because it transmits whether you manage it or not. The only question is whether you’re the one managing it. Measure what you value. If development outcomes aren’t tracked, they aren’t valued and the mission suffers for it quietly until it doesn’t.

The cliff doesn’t announce itself. Weather doesn’t send ahead. Ice fog doesn’t call dispatch. A 37-vehicle pileup at 20 below is just another December morning until it isn’t.

What you build before the cliff is the only thing that matters once you’re at the edge. Resilience isn’t a response; it’s infrastructure.

Build for the cliff.   

For a list of references visit www.hmpgloballearningnetwork.com/site/emsworld/feature/scarcity-strategy. Look for the followup article "Training At the Edge" in our Fall issue.

About the Author

Tracey Loscar, BA, NRP, is the Deputy Director of Emergency Services in the Matanuska-Susitna Borough in Southcentral Alaska. Her adventures started on the East Coast, where she spent more than 25 years serving as a paramedic, educator, and supervisor in Newark, NJ. She is an inaugural recipient of the American Ambulance Association’s EMS Vanguard Award (2023) for her contributions to prehospital healthcare. An author, national speaker, and member of the EMS World Editorial Advisory Board, you can contact her at taloscar@gmail.com. She also puts out a periodic newsletter, which you can subscribe to at https://taloscar.substack.com/.