This week’s ask:

1. Is there a newer ambulance replacement guideline than Dan Fellow’s April 2016 EMS World article?

You can reply below or email michaelward@isu.edu.

Background to these lecture topics

EMS financing and vehicle/durable medical equipment procurement are volatile topics due to the pandemic and the DOGE-driven federal reorganization. I anticipate that both of these lectures will require major updates for the Fall 2026 semester.

11: Financing EMS

The 3300 lecture starts with review of the July 22, 2025 “The true cost of a 911 call: Breaking down EMS economics” by Matt Zavadsky pubished by ems1.com.

This replaces the 2019 NAEMT/AimHi webinar “How EMS is Financed” presented by Chip Decker and Matt Zavadsky. They describe the sources of revenue:

1. Fees For Service
2. Tax Subsidy
3. Other:
   • Grants
   • Special Assessments
     • such as a Tax Levy
   • Ground Emergency Medical Transport (GEMT) program
   • Subscriptions

A review of the payor types and their payment performance.:

• Medicare
• Medicaid
• Private Pay
• Commercial Insurance
• Other

Fees For Service: Deeper Dive

Describe how Centers for Medicare & Medicaid Services (CMS) differentiates Suppliers and Providers. Describe how ambulance services is identified as a supplier and its reimbursement implications. Briefly discuss the unique reimbursement opportunity for hospital-based ambulance services.

Scan the decades of documentation showing that the insurance reimbursement fails to cover the direct cost of an ambulance transport. Look at the additional “cost of preparation” for 9-1-1 services. Review February 17, 2025, PWW Advisory Group “Quantifying the gap between expenses and revenue for EMS services: Takeaways from the First CMS Data Collection Report on Ambulance Services to enhance service levels and reduce costs of service delivery” [https://www.ems1.com/ems-trend-report/quantifying-the-gap-between-expenses-and-revenue-for-ems-services]. Their conclusion:

The average revenue shortfall for all ambulance suppliers is 57% for every transport performed.

Tax Levies: Deeper Dive

Doing a deeper dive into tax levies. Start with describing the 1997 failure of the Seattle/King County Medic One Foundation tax levy vote. Review the narrow post-pandemic failure of many tax levy proposals for emergency ambulance service. Describe the efforts it took Canyon County Paramedics, Idaho, to get a tax levy passed in 2025 after two failures in 2024.

Ground Emergency Medical Transport (GEMT) Program: Deeper Dive

A federally funded state supplement payment program that is likely to be reduced or eliminated due to the current government reorganization. Review the March 11, 2025 PWW Advisory Group assessment of Texas GEMT and its national implications.

Fire Department takeover: Overstated revenue, understated costs, and ignorance of health care insurance reimbursement practices

Ambulance billing is complex. Many hospital-based EMS systems contract out for ambulance billing even when they do the rest of their medical billing in-house. Several of the largest fire-based ambulance services have faced significant penalties from CMS/US Justice Department due to improper billing practices. We will examine the financial issues of a fire department takeover of ambulance services, with 2025 examples from Sonoma County, California, and Evansville, Indiana.

Review the 2023 financial profile of AMR’s Multnomah County, Oregon, operations in light of a years-long fight over paramedic ambulance staffing. Discuss the failed effort of Santa Barbara County Fire Department’s effort to take over ambulance service from AMR in 2025 – and what to do with 35 never used fire department ambulances.

Wrap up lecture showing the PWW Advisory Group/NAEMT The “One Big Beautiful Bill Act” Potential Impacts on EMS: A Wake-Up Call for Financial Sustainability “living document” to highlight the potential revenue, human resources and tax implications of the OBBBA on the EMS system and EMS employees.

Required Readings/viewings

Zavadsky, M. (2025 July 22) The true cost of a 911 call: Breaking down EMS economics. ems1.com https://www.ems1.com/ems-management/the-true-cost-of-a-911-call-breaking-down-ems-economics

Reference: 2019 “Follow The Money: How EMS is Financed” NAEMT/AimHi [1 hour 3:34 minutes]

PWW Advisory Group. (2025 March 11). Analysis of 2023 vs. 2022 Texas GEMT Funding Distribution. https://aimhi.mobi/news/13473236

PWW Advisory Group and NAEMT (2025 July 17) Table of Major Provisions In HR1 That May Impact EMS. https://aimhi.mobi/news/13522232

Welsch, Nick.(2025 July 23) Santa Barbara County Fire Chief Announces Retirement: Hartwig Fought to Take Over AMR Ambulance Monopoly. Santa Barbara Independent. https://www.independent.com/2025/07/23/santa-barbara-county-fire-chief-announces-retirement/

12: Ambulance/Durable Medical Equipment Procurement

The 3300 lecture describes the procurement process for vehicles and durable medical equipment, highlighting the parameters that differentiate a Request For Proposal versus a Purchase Order.

Identify the special situation of ambulances and durable medical equipment, such as the KKK-A-1822 ambulance classification scheme and Federal Food and Drug Administration (FDA) certification of durable medical equipment operating in an out-of-hospital environment.

Brief review of our current supply chain position in the post-pandemic marketplace.

When To Replace An Ambulance

Review Ron Fellow’s description about the Richmond Ambulance Authority (RAA) fleet replacement goals:

• Maintain a fleet size capable to 133% of peak-of-day operations
• Replace after 150,000 to 250,000 miles
• Replace after 4 to 7 years

Describe the process and value of remounting Type 1 and Type 3 ambulance boxes on new trucks.

Individual Assignment: Construct a 3 year ambulance replacement plan for BengalCare Mobile Health. You inherent a fleet of 16 ambulances from Mercy 911, Mercy Transport, and Mount Pleasant Fire Department. Using Ron Fellow’s RAA guidelines, your subject matter expert provides a spreadsheet analyzing all ambulances.

BengalCare Mobile Health peak deployment is 12 ambulances, will need 16 ambulances to get to 133% peak-of-day. Of the inherited fleet of 16, only 11 are roadworthy. Using a state cooperative purchasing program price guide for new ambulance purchases and remounts, identify how you will update the fleet with the $375,000 budgeted for new/remounted ambulances each year?

Required Readings/viewings

“Wheeled Coach Walk-Around, FDIC 2024” (5:02 minutes)

Featured picture: Penn Township Ambulance Association. May 8, 2024.  Today, Chief Grant inspected Unit 228 at the REV Group, Inc. remount factory. Progress is on track for expected completion at the end of the month. The remount process avoids about $50,000 of expense versus purchasing a new modular box construction.

This week’s asks:

1. Has ambulance staffing gotten easier in 2025 than it was in 2020?
2. What is driving caregiver turnover today: workload (hours), work conditions, or pay?
3. Has the opioid overdose crisis created new high-demand census tracts beyond the high poverty communities?

You can respond below or email michaelward@isu.edu.

Background to this week’s lectures

Fifty years of ambulance operations, with changing reimbursement and expanded community expectations, make the original vision of two paramedics responding to a cardiac arrest by themselves quaint. Responding to a witnessed cardiac arrest is still a life-threatening situation where EMS can make a significant difference. It looks a lot different in 2025.

How units are deployed and what type of caregivers staff them have gone through many models. EMS 3300’s goal is to explain ambulance deployment and staffing, identify current issues, and provide examples.

While an Assistant Professor of Emergency Medicine at The George Washington University, I studied how Los Angeles City and Baltimore fire departments were handling the 1999/2000 crisis of overwhelmed paramedic ambulance demand. Unexpectedly, both departments recently received detailed third-party evaluations of their ambulance services – some of that research is included in these lectures. Finally, the students will determine how to deploy and staff BengalCare units for River and Sully counties.

9: Ambulance Deployment

The 3300 lecture starts with a 1968 UCLA public health research project: An Analysis of the Demand for Emergency Ambulance Service in an Urban Area. They analyzed the Los Angeles City emergency ambulance data from 1964-1967.

Emergency ambulances were provided by Central Receiving Hospital in the downtown area and commercial ambulance services that were supplemented by Los Angeles Fire Department (LAFD) ambulances in the San Fernando Valley. John C. Hisserich was one of the authors who used the same data in his public health dissertation, which took a deeper dive into urban emergency ambulance service demand determinants.

Using demand based on census tracts, we can show how poverty drives ambulance demand. Hisserich observed in his analysis, “Highest (ambulance) demands came from downtown, commercial (census) tracts inhabited by lonely, unemployed males who constitute the least mobile, most ‘hard-core’ poor in the city.” Of the 632 Los Angeles census tracts, 57 tracts generated 25% of the emergency ambulance workload (1964-1967).

These tracts are persistent. A 2020 economic development analysis showed that the 13 census tracts identified by Hisserich as part of the “skid row” areas have maintained a poverty rate of 79% for 38 years. Poverty is persistent, but the predominantly Black population is now predominantly Hispanic.

When LAFD was responding to 24 homeless encampment fires a day in Spring 2020, most of them were in the same census tracts. The 2023 Citygate LLC Los Angeles Fire Department: Standards of Cover Analysis identified two clusters of the top ten busiest engines, trucks, and rescue ambulances.

The individual unit-hour utilization (UHU) measures for these units significantly exceed 30 percent [UHU above 0.30] for long, consecutive hours at a time. The volume and simultaneous demand on the top 10 to top 28 LAFD stations is the highest Citygate has ever measured in a metro client.

The clusters cover most of the same 57 census tracts identified in 1968.

Heat Maps

Students are introduced to heat maps as a way to envision system-wide workload. Here is the heat map for the BengalCare Mobile Health ambulance service area:

System Status Management

Students are introduced to Stout’s System Status Management, also called Dynamic Deployment, by describing static and dynamic deployment. We preview Dale Loberger’s 2022 “System Status Management Strategies for Success” that was presented in the Fitch and Associates LLC Pinnacle Webinar Series.

Deploying the BengalCare Mobile Health Ambulances

BengalCare is replacing a combination of hospital and volunteer fire department ambulances that served River and Sully Counties. The heat map showed where the units were located:

Individual Student Assignment:

Required readings/viewings

Stout, J. (1983). System status management: the strategy of ambulance placement. Journal of Emergency Medical Services, 8(5), 22-32. http://emsmuseum.org/wp-content/uploads/2021/05/System-Status-Mangement-The-Strategy-of-Ambulance-Placement-22-32-1983-05-JEMS.pdf

Loberger, D. (2022 June 21). “System Status Management: Strategies for Success.” In Pinnacle Webinar Series. [58:04 minutes]

10: Ambulance Staffing

The 3300 lecture starts with a description of Unit Hour Utilization (UHU), one of the Stout metrics. Apply the metric when looking at LAFD and Baltimore ambulance workload at three points: 1999/2000, 2007 (after all of the changes made in response to the paramedic ambulance workload), and now – Baltimore (2021 FACETS assessment) and LAFD (2023 Citygate analysis).

Demonstrate the 2022 NASEMO Shift Schedule Fatigue Risk Analyzer and review the findings from the 2023 EMS Sleep Health Study.

Walk the student through a reorganization of a multiple-hospital-based EMS system that used UHU to document workload changes when combining three separate ambulance silos (9-1-1, interfacility, and dedicated township contracts) into a regional “first-come-first-served” ambulance system. BengalCare Mobile Health will be doing the same thing, folding the interfacility transports into the 9-1-1 service.

Describe the impact when an organization experiences a vacancy rate of funded positions that rises above 11% – that point when there are not enough remaining employees to cover the overtime needs. This leads to involuntary overtime and mandatory call backs.

Share the Wake County 2022 and Richmond Ambulance Authority 2024 experiences in resolving significant position vacancies.

BengalCare Ambulance Staffing

Students are provided with detailed historic workload data, showing a system-wide UHU of 0.41. Small Group Activity: Build a BengalCare Mobile Health work schedule:

Required readings/viewings

Patterson, P. D., Martin, S. E., Weaver, M. D., Brassil, B. N., Hsiao, W. H., Okerman, T. I., Seitz, S. T., Patterson, C. G., Messina, O. R., Herbert, B. M., & Robinson, K. (2023, January). The emergency medical services sleep health study (Report No. DOT HS 813 391). National Highway Traffic Safety Administration. https://rosap.ntl.bts.gov/view/dot/65893

(2022) Fatigue Risk Management in EMS Project Summary and Webtool Demo.

Featured picture: Just before 5:20 a.m. on Sunday, April 2, 2023, Long Beach Fire Department BLS 16 responded to a 9-1-1 call. The single-role “Ambulance Operators” were on hour 68 of a 72-hour tour, where they got between four to six hours of rest between about 57 responses. Both caregivers fell asleep, and the ambulance slammed into a power pole, a crosswalk sign, and a wall. The crew suffered minor injuries.

(4 April 2023) Long Beach unions say ambulance crash highlights staffing shortage. KCAL CBS. Accessed July 13, 2025: https://www.cbsnews.com/losangeles/news/long-beach-unions-say-ambulance-crash-highlights-staffing-shortage/

This Week’s asks:

1. Is there a newer video showing telecommunicator providing dispatcher CPR, using a tiered response protocol, to replace the 2018 Pitt County NC example?
2. Is there research looking at the impact of non-transport paramedic units (chase cars or paramedic-capable fire companies) on patient outcomes? Not looking at community paramedics.
3. Have other EMS agencies altered their response time goals using the same process that the Mecklenburg (NC) EMS Agency used?

You can respond in the comments or email michaelward@isu.edu

Background to this week’s lectures

Between 1999 and 2024 a core course in the Master’s of Emergency Health Services (EHS) at the University of Maryland Baltimore County (UMBC) was “EHS 640: High Performance EMS.” Stephen Dean was an early adopter of Jack Stout’s Public Utility Model for Pinellas County, Florida, and wrote the original course while a visiting professor at UMBC and obtaining his Ph.D.

Kurt Kruperman and Jon Washko, both adjunct faculty members at UMBC’s EHS, updated the course in 2010. Kruperman was getting his Ph.D. They obtained support from the American Ambulance Association, digitizing EMS Structured for Quality: Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service to use as the textbook. Wasko provided ambulance deployment and financial exercises.

In 2021, while working on my Ph.D., I updated the course. Unfortunately, the same post-pandemic economic forces that dismantled some high-performance public utility ambulance services also impacted EHS. We needed to go where the students and the funded research were. EHS morphed into the Department of Emergency and Disaster Health Systems (EDHS). EHS 640 is gone.

Many metrics from the Stout public utility model, such as unit hour utilization, dynamic ambulance deployment, and response time performance measurement, are embedded into the best practices of emergency service systems. Both lectures this week reflect the work I did for the 2021 EHS 640 course and my Ph.D.

6: What is “High-Performance EMS”?

The EMS 3300 lecture follows the origin story of economist Jack Stout starting as a Systems Analyst with the Arkansas Health Systems Foundation (one of the five 1972 Department of Health, Education, and Welfare EMS funded demonstration projects), to research fellow at the University of Oklahoma’s Center for Economic and Management Research – where the Public Utility Model (PUM) was developed.

The 1980s witnessed the creation of nine Public Utility Model EMS Systems, starting with Kansas City. The high-performance EMS (HP-EMS) body of knowledge comes from the dozens of Stout articles published in the trade magazine Journal of Emergency Medical Services from 1983-1989. Stout’s The Fourth Party organization became the focus for all HP-EMS development and advocacy.

We describe the six elements of HP-EMS as articulated by Jack Stout and Jerry Overton in 2002, and compare/contrast with the 2025 Academy of International Mobile Healthcare Integration (AIMHi) “High Performance System Design.”

We review three elements challenging the public utility model:

• Increased expenses and labor costs while reimbursements decline
• Inconsistent or negligent ambulance authority oversight
• Political pressure from fire department

Wrap up by evaluating how well Bengalcare Mobile Health aligns with the AIMHi HP-EMS System Design.

Required readings/viewings:

Richmond Ambulance Authority (2022) RAA-High Performance EMS. (2:18 minutes)

Stout, J. (1985a). Public Utility Model Revisited: Part 1: Origins. Journal of Emergency Medical Services (February), 55-58, 62-63. http://emsmuseum.org/wp-content/uploads/2021/05/Public-Utility-Model-Revisited-Part-1-_-Origins-55-58-62-63-1985-02-JEMS.pdf

Stout, J. (1985b). Public Utility Model Revisited: Part 2: 10 Essential Features. Journal of Emergency Medical Services (March) 71 – 74. http://emsmuseum.org/wp-content/uploads/2021/04/Public-Utility-Model-Revisited_Part-2-10-Essential-Features_1985-March-71-74-JEMS.pdf

Stout, J. (1985c). Public Utility Model Revisited: Part 3. Journal of Emergency Medical Services (May) 58-64. http://emsmuseum.org/wp-content/uploads/2021/04/Tulsa-Public-Utility-Model-Revisited-Part-3_1985-May-58-64-JEMS.pdf

Dean, S. (2004) Public Utility Model EMS. EMS World. 33(3) 87-91.

Bledsoe, B. (2003 December) EMS Myth #8: Public Utility Models are the most efficient model for providing prehospital care. EMS World.

Redlener, M., Buckler, D. G., Sondheim, S. E., Yeturu, S. K., Loo, G. T., Munjal, K. G., … Crowe, R. P. (2024). A National Assessment of EMS Performance at the Response and Agency Level. Prehospital Emergency Care, 1–8. https://doi.org/10.1080/10903127.2023.2283886

Multnomah County Ombudsman (2024 May) “County has longstanding contractual authority to hold AMR accountable, and needs to comply with code.”

7: Clinically Significant Response Time

The 3300 lecture guides students through a 9-1-1 call, explaining how the Clawson Medical Priority Dispatch system operates. Also discuss the APCO model.

Introduce students to the Seattle/King County Medic One program. Describe the 1979 “Project Restart” study of cardiac arrest survival in King County – 604 cardiac arrests between April 1976 to August 1977. Show how the results of this peer-reviewed research is the source of the 7:59 minute response time goal for a paramedic ambulance.

Describe how Seattle/King County and Rochester, Minnesota, achieved significant cardiac arrest patient survival. Share more recent peer-reviewed analysis of patient outcomes after out-of-hospital paramedic intervention. Show how Detroit went from a cardiac arrest survival rate of zero (1 survivor a year) to an Utstein survival rate of 25% in 2024, including a 39.5% rate when the patient received bystander CPR or AED use.

Review the June 2024 American Ambulance Association presentation “EMS Transformed: Delivering High-Performance, High-Value EMS in Mecklenburg.”

Small Group Activity to report out at next LIVE session: What Should Be An Appropriate Ambulance Response Time for BengalCare Mobile Health? 

Required readings/viewings

Pitt County NC (2018) reenactment of 9-1-1 cardiac arrest call (4:37 minutes)

Eisenberg, M., et al. (1979) Paramedic Programs and Out-of-Hospital Cardiac Arrest. American Journal of Public Health 69(1) 30-38

First hour of the American Ambulance Association June 2024 presentation “EMS Transformed: Delivering High-Performance, High-Value EMS in Mecklenburg.”

Featured picture: Figure 3 from Eisenberg, M., et al. (1979) Paramedic Programs and Out-of-Hospital Cardiac Arrest. American Journal of Public Health 69(1) 30-38

This week’s asks:

1. Is there a breakdown by percentage, number of ambulances, or employees of EMS Service by agency (fire department, private for profit, municipal, community owned, hospital, or public utility model) newer than 2017?
2. Is there a post-pandemic report on the workload of interfacility and authorized medical transports?
3. Should there be more emphasis on the risk/reward when using air ambulances?
4. Follow-up: Still looking for a short (5-minute) video describing a private/commercial EMS service that does both 9-1-1 and interfacility transports

You can answer by emailing michaelward@isu.edu or posting a reply below.

Why no textbook?

I contacted the publishers of the textbooks used for EMS Systems, and EMS Management/Operations courses. The existing books have copyright dates between 2015 and 2017. Much of their content is aging out. The publishers and editors said that they have no plans to update their books. The market for EMS systems, management, and operations books is tiny, with few sales.

2: Structuring EMS Operations

Skip Kirkwood, Rob Luckritz, Art Groux, Robert Waddell, and Mike Touchstone provided a great “Corporate Models for Ambulance Service Delivery” and Matt Zavadsky clearly described “Levels of Ambulance Service” in the Management of Ambulance Services (2015) textbook.

The lecture describes the different clinical levels of EMS care, and reviews the National Association of EMT’s “What is EMS?” description. We provide a more in-depth description of the five versions of the Emergency Ambulance Service with examples:

• Fire-Based (single role provider: FDNY – dual role provider: Fairfax County)
• Private for profit (AMR, Falck, and Acadian)
• Municipal (non-fire) (Wake County, Boston, and Indianapolis)
• Community-owned non-profit (New Jersey, and Virginia Beach)
• Hospital operated (New Jersey, and Atlanta)
• Public Utility Model (Richmond)

Mention of the impact of rural hospital closings on EMS.

The Small Group Activity is to prepare a presentation at the start of next LIVE session that advocates for one of the following versions of ambulance service for River County:

• Contracting with a commercial ambulance service. (Green team)
• River County government establishes and runs the ambulance service. (Yellow Team) 
• Columbia City Fire Department establishes and runs a countywide emergency ambulance service. (Red Team)

Required reading/watching:

NAEMT (2024) What is EMS?

VB Rescue Foundation (2022) We are VB rescue [3:26] – Announcing the rebranding of the ten independent rescue squads and Virginia Beach EMS agency.

3: Scheduled Transport and Air Operations

Explain the workload of scheduled medical transportation. Describe the CMS description of medical and non-medical transportation for insurance reimbursement.

Review the Emergency Triage and Transport (ET3) initiative and why it was prematurely closed.

Provide detailed information on River County interfacility transports. As an Individual Assignment, have the student decide whether our RFP response should include providing the interfacility transports currently performed by the hospital-based ambulance service that is closing. The assignment requires an evaluation of data and revenue.

Describe air ambulance operations and the different agencies that provide the service. Review the 2021 Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA in Prehospital Emergency Care.

Using the 2021 ASPE Issue Brief, discuss the cost, billing, and reimbursement of air ambulance services, including the “out-of-network” issue.

Mid Term exam question preview: Provided detailed information on recent history of medevac transports, including agency and geographic information, develop a Bengal Mobile Health Best Practice Operating Guide.

Required reading:

Blutinger, E., Ulintz, A. J., Chason, K. Gavin. N.(2025) 𝐋𝐞𝐚𝐫𝐧𝐢𝐧𝐠 𝐅𝐫𝐨𝐦 𝐓𝐡𝐞 𝐅𝐚𝐢𝐥𝐮𝐫𝐞 𝐎𝐟 𝐀 𝐂𝐌𝐒 𝐄𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲 𝐌𝐞𝐝𝐢𝐜𝐚𝐥 𝐒𝐞𝐫𝐯𝐢𝐜𝐞𝐬 𝐌𝐨𝐝𝐞𝐥 Health Affairs. https://www.healthaffairs.org/content/forefront/learning-failure-cms-emergency-medical-services-model

Viitanen, A., Richardson, A., et. al. (2024) Breaking Point: Unraveling the Strain on EMS in Colorado and the Rising Role of Interfacility Transports

Lyng, J. W., Braithwaite, S., Abraham, H., Brent, C. M., Meurer, D. A., Torres, A., … Larrimore, A. (2021). Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA. Prehospital Emergency Care, 25(6), 854–873. https://doi.org/10.1080/10903127.2021.1967534

Turrini, G., Ruhter, J., Chappel, A. R., & De Lew. N. (2021 Sept 10) Issue Brief: Air Ambulance Use and Surprise Billing. Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

Reference: CMS (2025 January 14) EMERGENCY TRIAGE, TREAT, AND TRANSPORT (ET3) MODEL: Final Evaluation Report.

Feature picture: Ambulance bay of a Baltimore hospital with AMR, Baltimore County Fire, Baltimore City Fire, and Hatzalah community ambulances. https://www.maryland-traumanet.com/

ISU is using a different learning management system starting in Fall 2025. Concurrently, the university approved new course descriptions for EMS 3300: Foundations of EMS Systems and FSA/EMS 3335: Management of Emergency Medical Systems. I plan to include many NFPA Standard 1020 (2025) EMS Officer I and II Job Performance Requirements (JPRs) and meet the spirit of the National Fire Academy FESHE “Foundations of EMS Systems” (2019) model course outline.

Who Are The Students?

The ISU students are 60% traditional undergraduates, full-time students in their late teens and early 20s, completing their initial paramedic training. The rest of the students are early to mid-career West Coast practitioners finishing their online bachelor’s degree. Both 3300 and 3335 are upper-division undergraduate courses.

EMS 3300 Course Description

This course provides an overview of high-performance Emergency Medical Services systems by analyzing organizational structures, EMS staffing, and ambulance deployment practices. Topics include medical regulation, financing, fleet management, and workforce retention.

Course objectives:

• Describe the structure of Emergency Medical Services (EMS) in the United States.
• Apply the benchmarking elements of a High-Performance EMS system.
• Examine clinically significant ambulance response time.
• Allocate ambulance resources based on dynamic deployment principles.
• Describe EMS funding sources.
• Analyze an existing ambulance fleet to develop a replacement schedule.
• Characterize the expanding role of paramedics in out-of-hospital care.

Lectures

Course Structure

ISU requires a LIVE online face-to-face Zoom session each week. Each course includes a simulation that allows the application of the learning objective through Small Group Activities that report out in a LIVE session, and individual graded Assignments. For EMS 3300, it is a response to a River County request for proposal, followed by establishing BengalCare Mobile Health services.

Each LIVE session consists of a Small Group Report out, a lecture, and an introduction to that week’s readings and assignments. We are not using a textbook with this update, so I need to increase the weekly content. The four quizzes cover the material presented in the lectures.

The mid-term and final exam are open-book short-answer responses to simulation scenarios that cover the learning objectives. There is a research paper requirement.

BengalCare Mobile Health versus Wombat Fire Department simulations.

EMS 3300 provides the “big picture” of EMS using a request for proposal and creation of a commercial 9-1-1 and interfacility ambulance service to apply the concepts – including scheduling and fleet issues. The student role plays as the BengalCare Operations Manager.

Both EMS and Fire Service students take FSA/EMS 3335, it is focused on the day-to-day management of an overworked fire-based EMS service, including Just Culture and first-line supervisor development. The student role plays as a Captain assigned to the EMS Chief’s office.

1: Introduction to EMS Systems

Brief description of urban and suburban/rural ambulance services before 1966. Ask students to read “Three Bells and a Jingle” an August 16, 1930 The New Yorker magazine interview with a Manhattan hospital ambulance surgeon.

Modern EMS starts in 1966 from three activities:

• Federal funding to establish a system to reduce motor vehicle traumatic fatalities
• Medical research on out-of-hospital cardiac arrest survival
• President Lyndon Johnson’s “Great Society” funded a Black-owned ambulance service for the Hill and Oakland communities in Pittsburgh in 1967

Briefly describe all three activities. Point out that the Freedom House paramedics were the first caregivers to deliver ALS care on the streets without direct supervision by a physician or nurse (June 15, 1968). The initial EMT-Paramedic National Standard Curriculum came from the University of Pittsburgh/Dr. Nancy Caroline.

Have students read Edwards, M.L. (2019) Pittsburgh’s Freedom House Ambulance Service: The Origins of Emergency Medical Services and the Politics of Race and Health. Journal of the History of Medicine and Allied Sciences. (74)4, 440-466.

Finally, I had the students watch Hodgkins (2013) “Ambulance Service of Manchester – Episode 1 – Introduction” (2:29 minutes). This is a regional 9-1-1 and interfacility ambulance service that is similar to what BengalCare Mobile Health will be. It is no longer available. Is there a newer video that provides the same service overview?

You can post your responses in the comments section or email michaelward@isu.edu

Over half of the first lecture is spent discussing the mechanics of how to get an “A” in this course and walking them through the River County Request for Proposal. The first Small Group Exercise is for each group to read the RFP and generate three questions about the RFP before we submit a proposal.

Next week we will look at two later lectures.

Feature picture: Maury EMS at Maury County Regional Health Center. Columbia, TN. Devin Dickey picture.

Rodney Dyche noted that the EMS Media Log documented 26 ambulance thefts in 18 states in 2024. Six of those thefts resulted in significant crashes. Matt Zavadsky observed that: “For patient safety, community safety, this is something that is a zero-failure option, and if you fail to secure your vehicle, you can go work somewhere else. Period.” Rob Lawrence said: “We need to work hard to ensure that we don’t have that statistic in 2025, an ambulance stolen every 2 weeks.”

I reviewed the stolen ambulance articles posted on Company Commander.com and the Company Commander Facebook page since 2018.

Crimes of opportunity

The most frequent theft comes from an unattended ambulance parked at the emergency department or medical clinic. Some were idling, and all were unlocked. Nashville Fire had two idling ambulances stolen on the same day in October 2023.

Less frequent is the ambulance stolen from an incident scene, either by the patient or a third party. Sometimes, the caregivers and patient are still in the ambulance. That happened in Charlotte, NC, in April 2019, Phoenix in November 2023, New Orleans in October 2023, and in Atlanta in April 2024.

In a rare event, an ambulance is stolen from a station. In April 2022, Chicago Ambulance 66 was stolen from the Chinatown fire station and chased nearly 80 miles. In October 2022 Chicago Ambulance 71 was stolen from the fire station. In June 13, 2021, an ambulance was stolen from the Kunkel Ambulance garage in Utica, New York, and driven into Irondequoit Bay

Our featured image is the aftermath of a person entering the Detroit Fire Department’s Medic 8-HazMat 1-Chief 1/Fleet Maintenance facility in November 2019. The interloper drove Medic 8 through a bay door and later crashed exiting Interstate 75, during a police pursuit.

Here is a two-step approach to thwarting crimes of opportunity:

1. Establish and enforce a policy of taking the keys and locking up the ambulance when it is unattended. The Commission on Accreditation of Ambulance Services (CAAS) mandates a standard for accredited agencies to have a written policy/procedure to prevent vehicle theft. These agencies must provide copies of the policy/procedure detailing how vehicles are secured when unattended.

• Install an anti-theft device that auto-locks the transmission when the vehicle is placed in park. Tremco (https://tremcoemergencyproducts.com/ ) and Intermotive (https://intermotive.net/autogard/) offer CAAS-compliant anti-theft devices.

Violence Against Caregivers

EMS caregivers are attacked, and the assailant steals the ambulance. The most tragic example is the murder of FDNY EMT Yadira Arryo on March 16, 2017, when Jose Gonzalez drove over Arryo with the ambulance.

It happened in Prince George’s County, Maryland in January 2014 (killing a bystander when the ambulance crashed in a restaurant parking lot), Kanawha County, West Virginia, in November 2017, Detroit in April 2019, Washington County, Georgia, in January 2022; Houston, Texas in July 2021, Bronx, New York in August 2021, Montgomery County, Maryland in February 2022, Greer, South Carolina, in May 2022, Macon, Georgia in January, 2024, and Schenectady, New York in September 2024.

Since the pandemic, the number of reported attacks on EMS caregivers has increased. This will require a more comprehensive and expensive effort to prevent, react, and obtain justice when our caregivers are attacked and vehicles stolen.

Preventing the attack involves caregiver training and practice in:

• Situation Awareness
• De-escalation
• Operational and tactical protocols when encountering high-hazard situations

React to an attack using:

• Self-defense training
• Wearing appropriate personal protective gear
• Effective emergency communication (panic button)
• Use an automatic vehicle locator or global positioning service to track ambulances
• Robust public safety response when an attack is announced

Provide consequences for attacks to obtain justice

• Complete reporting of incidents
• Caregiver body cameras
• Effective legal prosecution of assailants
• Employee assistance services for attacked caregivers

Since 2016 the Seattle Fire Department has experienced increased attacks on caregivers when responding to medical calls, especially in the homeless encampments. Because of the high frequency of these calls, police are not always available. In June 2018 the department added a fire company to respond with an aid car (EMT ambulance) to every EMS call in Pioneer Square (1,200 EMS runs a year) and homeless encampments. The frequency of attacks against fire department members continued to increase. Between January and April 2023, there were more than 50 attacks.

There was a need to close a legal loophole to protect Seattle firefighters from interference the same way police officers are covered when performing their work activities. Under the legislation passed in May 2023, people can be arrested and charged if they intentionally physically interfere with firefighters, EMTs, and other fire responders who are actively responding to an emergency. It would also prevent people from intentionally refusing to leave the scene of an investigation of a crime while an investigation is in progress after being requested to do so.  

What is a “Wicked Problem”?

The term “Wicked Problem” was introduced in 1973 by Horst Ritter and Melvin Webber in describing the challenge of addressing planning and social policy problems. Wicked problems of planning lack clarity in both their aims and solutions. Unlike the “clean sheet of paper” approach, wicked problems are subject to real-world constraints that prevent multiple risk-free attempts at solving them.

Rittel, H. W., & Webber, M. M. (1973). “Dilemmas in a General Theory of Planning.” Policy Sciences, 4(2), 155-169.

A Tale of Two Fire Department Ambulance Services

While an Assistant Professor of Emergency Medicine, I did a deep dive into Baltimore and Los Angeles City as they took different approaches to resolve the problems of staffing, ambulance workload and response time in 1999. Both departments use the same time-on-task measurements, and I had access to their data.

Baltimore: Underutilized Fire Companies and Overworked Ambulances

In 1999 Baltimore Mayor O’Malley asked the Greater Baltimore Committee and The President’s Roundtable to examine fire department operations. Using time-on-task analysis:

Baltimore engine companies averaged 1 hour 47 minutes in 24 hours working on incidents, while paramedic ambulances averaged 14 hours and 25 minutes in 24 hours on incidents. Over the past five years, structural fires declined 58% to 2,367 working fires in 1999. Half of the engine company responses (49,000) were to EMS calls. (1)

Baltimore staffed 40 engine companies, 21 truck companies, one rescue company, and 18 paramedic ambulances. Engine company average response time was 4:16 minutes, and paramedic ambulance response time was 8:44 minutes.

On May 10, 2000, the city started the process to close seven fire companies. Of the 140 firefighter positions affected, 100 will be moved to other fire companies to save $4 to $5 million in overtime, and 40 will staff 4 to 6 additional ambulances. After lengthy labor and legal negotiations – interrupted by a July 2001 chemical train fire in a tunnel that closed downtown for three days – the 2005 Baltimore Fire Department was comprised of:

• 32 Engine Companies – closed 4 companies and upgraded 4 companies
• 4 Squad Companies – engine companies upgraded to “rescue engines”
• 19 Truck Companies – closed 2 companies
• 22 Paramedic Ambulances – added 4 ambulances
• 1 Rescue Company
• 6 Battalion Chiefs – lost 1 battalion

The average time-on-task for all 22 Baltimore paramedic ambulances in 2005 was 14:40 hours:minutes in 24 hours, a system-wide Unit Hour Utilization of 0.61.

2021: Operational & Management Assessment by FACETS Consulting

Baltimore City engaged FACETS Consulting to perform a detailed fire department operations and management analysis. Their assessment showed an average ambulance response time of 8 minutes 31 seconds, with a 90th percentile of 13 minutes 56 seconds using 21 paramedic ambulances staffed 24/7. Paramedic ambulances are spending 14 hours and 54 minutes every 24 hours responding to, on-scene, transporting, and awaiting patient transfer to the emergency department. Engine company workload has increased to 3 hours and 36 minutes every 24 hours. Truck company workload has slightly decreased.

The workload among BCFD unit types is highest for the ALS and BLS ambulances (ranging from 39.27 percent to 71.07 percent). These numbers are exceptionally high, especially for caregivers working a 24-hour shift. 

Even the least busy ambulance exceeds the workload percentage recognized by many agencies for 24-hour shift durations by almost 10 percent. 

This level of workload can result in substantial employee wellness issues, does not provide on-duty time for essential training, and also leads to extended response times at the current level of resource deployment. Moreover, fatigue can negatively affect patient care and decision-making at incidents. (2)

Time-on-task for individual Baltimore paramedic and EMT ambulances in 2018-2019 ranged from 9:26 hours: a UHU of 0.39 to 17:03 hours:minutes – a UHU of 0.71. The caregiver on Ambulance 24 provided an over-the-radio perspective last September.

Los Angeles: Losing Paramedics Faster Than They Could Train New Ones

There needed to be more single-role Los Angeles Fire Department paramedics in 1999. Fourteen percent of the 435 authorized positions were vacant. A single-role paramedic made significantly more money than the fire chief, working five or more consecutive 24-hour shifts weekly. At that time, Los Angeles City lost paramedics quicker than they could hire replacements. (3)

One reason was the “force hire” that ordered paramedics back to work during their scheduled time off. In 1999 there were 60 unfilled LAFD single-role paramedic positions. If you wanted to make sure that you could get off to take a vacation, celebrate a holiday, or attend a family event, you needed to work 96 hours of voluntary “assigned hire” overtime in the previous month. (4)

Bad-outcome EMS calls highlighted in San Fernando Valley Secession Effort

LAFD established six rescue ambulances in the San Fernando Valley in 1957 to replace a private ambulance service in the 210-square-mile district. By 1968 eight LAFD rescue ambulances were handling 14,000 responses a year. (5 and 5a)

One of the 1957 GMC Suburban rescue ambulances assigned by LAFD to the San Fernando Valley. Restored by Lou Farah.

San Fernando Valley homeowners and businesses tried to secede from Los Angeles in the late 1990s. This effort by Valley VOTE was driven, in part, by a perception that San Fernando Valley tax payments were not used to provide city services in the valley. (6) Rescue ambulance average response time had increased to ten minutes, with over one-third of the rescue ambulances exceeding the department guideline of 350 responses a month. (7)  

The Valley VOTE campaign used high-profile, bad-outcome EMS incidents as examples of inadequate city services. While the secession vote was defeated, it was a driver of a significant five-year expansion of the Los Angeles Fire Department rescue ambulance and paramedic services.

EMS Resource Deployment Plan 2001-2006

By 2005 LAFD added 210 single-role paramedic positions, placed a paramedic in every fire station (on a rescue ambulance or a suppression company), and put a rescue ambulance in every fire station. The rescue ambulance fleet increased by 39% – 88 paramedic and 40 EMT ambulances.

Rescue ambulance workload is under 6 hours (responding to, at the scene, transporting, and delivering a patient to the hospital) in 24 hours. Paramedic Rescue Ambulance average response time is reduced to 6.5 minutes. The average Unit Hour Utilization for all 128 LAFD rescue ambulances in 2006 was 0.25.

2023: 15-Minute Wait for LAFD Rescue Ambulance to Arrive at a Cardiac Arrest

Michael Davis’s wife called 9-1-1 after he collapsed. It took about 15 minutes for an LAFD rescue ambulance to arrive. It is unclear in the Fox 11 news article if there was a fire company first responder. The three-month Fox 11 investigation uses anonymous paramedic sources that paint a picture of 10 to 20-minute rescue ambulance response times. (9)

The Ten Characteristics of a Wicked Problem

Rittel and Webber describe 10 important characteristics of a wicked problem:

1. They do not have a definitive formulation
2. They do not have a “stopping rule.” In other words, these problems lack an inherent logic that signals when they are solved.
3. Their solutions are not true or false, only good or bad
4. There is no way to test the solution to a wicked problem
5. The cannot be studied through trial and error. The solutions are irreversible so, “every trial counts.”
6. There is no end to the number of solutions or approaches to a wicked problem
7. All wicked problems are essentially unique
8. Wicked problems can always be described as a symptom of other problems
9. The way a wicked problem is described determines its possible solutions
10. Planners, that is those who present solutions to these problems, have no right to be wrong. Unlike mathematicians, “planners are liable for the consequences of the solutions they generate; the effects can matter a great deal to the people who are touched by those actions.”(10)

Fire-based EMS issues are challenging to solve because they involve complex, interconnected situations involving healthcare organizations and community populations. The environment of out-of-hospital unscheduled emergency medicine is constantly changing:

• New clinical best practices – including transport of 9-1-1 patients to specialty care centers (trauma, stroke, STEMI)
• Revenue or compensation opportunities
• Documentation requirements
• Emerging health issues
• Deteriorating hospital capabilities – increased “wall time” at emergency departments when delivering a patient
• Shrinking healthcare staff at nursing homes and assisted living facilities that generate more 9-1-1 calls
• Community population demographics

These problems often require creative solutions involving multiple stakeholders. Identifying the root causes and developing effective strategies to address them is difficult. Local government often lacks the resources or capacity to address these issues quickly or adequately.

Baltimore and Los Angeles invested financial and political capital in resolving the 1999 EMS crisis based on their resources, history, communities, and traditions. By 2005, they felt they had resolved the problems identified in 1999. Eighteen years later both cities are back in the news with staffing, workload, and response time issues.

Baltimore: Four Decades of Incremental Fire Suppression Reductions

Baltimore mayors have incrementally reduced fire suppression resources since 1984. Five quints were established in 1986 by combining an engine company crew and truck company crew of eight firefighters into a six-firefighter Aerial Tower company. Quint staffing was reduced until the unit was a 4-person truck company or eliminated. Fire stations have closed, and fire companies disbanded. (11)

Mayor Schmoke’s 1991 closing of three fire stations is a Harvard case study at the Kennedy School of Government. Case #1130.0 How to Bite the Bullet: Baltimore Mayor Kurt L. Schmoke and Fire Station Closings.

The 2005 final product from the Greater Baltimore Committee/The President’s Roundtable recommendations reduced fire suppression overtime costs. The four additional paramedic ambulances did not reduce the systemwide transport workload or improve ambulance response times as the EMS workload continued to increase yearly.

In 2012 Truck 15, Squad 11, and Truck 10 were shut down. In 2020 an effort was made to close Engine 4 (northeast Baltimore) and Engine 55 (Pigtown) to reduce the fire department Fiscal Year 2021 budget by $3.6M. Organized community effort delayed the closures pending the result of the FACETS report.

Los Angeles: Well-Funded EMS Expansion until the 2008 Recession

Los Angeles enjoyed political support and budget resources to expand the city’s emergency ambulance and paramedic services. A second five-year plan was issued covering activities through 2012. (12) The 2008 Recession halted the second five-year plan.

After three years of rotating closures of 15 engine companies and six ambulances, the 2012 Fiscal Year budget permanently closed 11 engine companies, seven light forces (a truck company with a pumper), and four EMT ambulances. Thirty command staff positions were eliminated. The 17 variably-staffed ambulances were closed.

Between Fiscal Year 2006 and Fiscal Year 2012, there was a net reduction of 228 firefighters and paramedics on duty each day. This is about a 17% reduction in the LAFD workforce.

A $15.4M Staffing for Adequate Fire and Emergency Response (SAFER) grant in 2018 allowed the reopening of four engine companies.

March 9, 2023: Los Angeles Fire Chief asks for 300 additional positions (13)

On April 21, 2023, Engine 8, with a paramedic/firefighter, responded to a drowning call where they encountered twin 4-year olds in cardiac arrest. They arrived within four minutes of the 9-1-1 call. Fire Station 8 is one of the eight LAFD fire stations without a staffed ambulance. Rescue Ambulance 107 is the closest ambulance with a six minute response time, but it was handling another emergency. The firefighters were doing CPR for 14-15 minutes before the nearest available ambulances arrived. (13a)

Evaluating Issues Impacting the Wicked Problem of Fire-Based EMS Staffing, Ambulance Workload and Response Times

Dover Professional Firefighters Local 1312 (2023 Feb 12) “Ambulances 1, 2, and 3 stacked up at Wentworth-Douglass Hospital. Just another Sunday evening.” New Hampshire. Ambulance 3 was added on September 18, 2022.

In considering this wicked problem, lets look at three areas impacting any solution today: best clinical outcome for patient, best situation for the EMS caregivers, and best result for the fire department.

What Provides the Best Clinical Outcome for the Patient?

This question is more focused and nuanced than the old-school “What is Best For the Patient?” In the first 18 months of the Seattle Medic One program (March 1970 – August 1971) firefighter/paramedics resuscitated 111 clinically dead patients. (14) Today, success is measured by the number of resuscitated out-of-hospital cardiac arrests (OOHCA) discharged from the hospital without neurological deficiencies.

Establishing an 7 minute, 59 second response time for paramedic ambulances

Preliminary results from “Project Restart,” a three-year Robert Wood Johnson funded study looking at community cardiac mortality identified two OOHCA survival metrics and established the 7:59 minute paramedic response time.

Mickey Eisenberg’s group analyzed 604 CPR incidents in Seattle and King County from April 1976 to August 1977. At that time, there were four paramedic ambulances in the community. Two Seattle Fire Department ambulances at Harborview Medical Center, one at Bellview Fire Headquarters, and one at Evergreen Fire Department. In 1976 only paramedics could use defibrillators, administer IV medications, record a heart rhythm, and use an advanced airway.

Eisenberg’s group identified two OOHCA survival metrics: If CPR was initiated within four minutes and if definitive care was provided within ten minutes, 43% of patients survived. If either time was exceeded, the changes of survival fell dramatically. (15)

Refining the Clinical Outcome Question

As research continued into out-of-hospital cardiac arrest survival, a subset of patients were identified as most impacted by these efforts. Focus was on patients who suffered a cardiac arrest that was witnessed by someone else and showed ventricular fibrillation as the cardiac rhythm. Adoption of the 1991 Utstein Style guidelines on uniform reporting of cardiac arrest, updated in 2004, 2015, and 2019 are an effort to provide “apples to apples” comparison for out-of-hospital and in-hospital cardiac arrest final outcomes.

The Resuscitation Outcomes Consortium is a massive research effort started in 2004 that conducted experimental and observational studies of out-of-hospital cardiac arrest and trauma treatments at eleven regional centers. (16) The most significant clinical change is the impact of two minutes of continuous closed chest compression (CCCC) applied at 100-120 compressions a minute to a witnessed cardiac arrest patient in ventricular fibrillation. The number of patients experiencing a restoration of spontaneous circulation (ROSC) almost doubled when first responders provided CCCC as the first treatment, followed by defibrillation as the second treatment. (17 & 18)

In 2007 the U.S. Metropolitan Municipalities EMS Medical Directors, known as the “Eagles,” developed evidence-based performance measures to benchmark urban EMS systems. They used the Number Needed to Treat (NNT) metric. NNT is the number of patients you must treat to prevent another bad outcome (death, stroke, etc.).

The clinical situations benchmarked included:

• ST-elevation myocardial infarction (STEMI)
• Pulmonary edema
• Asthma
• Seizure
• Trauma
• Cardiac arrest

Four of the situations required out-of-hospital paramedic-level medical intervention. Trauma situations focused on minimal on-scene time with transport to a trauma center. Cardiac arrest focused on the arrival of CPR-trained providers and a defibrillator within five minutes. (19)

For cardiac arrest the Eagles proposed that EMS systems not focus response time measurement on ALS ambulances, but rather pay greater attention to first response/BLS response time to measure what it called the “… most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.”

At the same time, I analyzed the out-of-hospital clinical tasks delivered by firefighter/paramedics in a large urban county. Using a year of patient care reports, I counted the number of times caregivers documented:

• Inserting an advanced airway, like an endotracheal tube or King LT
• Performing a chest decompression
• Administering a medication though an intravenous line, intermuscular injection, nebulized breathing treatment, or by mouth
• Infusing 500 or more milliliters of Lactated Ringer’s (the protocol for fluid resuscitation)
• Delivering a defibrillation or cardioversion

Six percent of the patients transported to an emergency department received one of those treatments. Within this group, one-fourth of the patients received two to more treatments, representing 1.5 percent of the patients transported. (20)

The majority of the patients transported did not receive paramedic-level care to improve clinical outcomes of serious medical conditions.

An updated survey of delivered out-of-hospital tasks will probably show a higher percentage of patients receiving paramedic-level care due to COVID complications, opioid overdoses, an aging population, and increased focus on stroke/ST-segment elevation myocardial infarction (STEMI) care. Using the percentage of transported patients getting paramedic-level care is a difficult metric to use when considering paramedic staffing, dispatch, and deployment.

Many fire departments identify critical EMS calls based on how the telecommunicator coded the incoming 9-1-1 call. Critical EMS calls are the “Echo” and “Delta” responses under the Medical Priority Dispatch System (MPDS). (21) This Pitt County video provides a reenactment of a “Delta” call,

The number of EMS calls coded as Echo or Delta is significantly higher than that of transported patients receiving paramedic-level care. The MPDS dispatches documents the fire department resource commitment to the incident before the first patient contact.

What care does the other 94% of transported patients receive?

Within the reports I reviewed, almost all patients had documented vital signs; some were splinted, some received wound care, some received a 12-lead EKG, and others had an intravenous line started without medication or fluid resuscitation. Many of the 94% transported needed to go to an emergency department, clinic, or physician’s office for further treatment.

What is the Best Situation for the EMS Caregivers?

Let’s look at three factors impacting EMS caregivers.

Excessive and exhausting work hours

Just before 5:20 a.m. Sunday, April 2, as BLS 16 responded to a call, it slammed into a power pole, a crosswalk sign, and a wall. The crew suffered minor injuries.

“Right now, we still have employees who are still dealing with sleep deprivation and knowing that this has been going on for over a year and didn’t come up with concrete solutions to solve it,” said Pritchard.

President Rex Pritchard, Long Beach Firefighters Association Local 372, said he and leaders of the International Association of Machinists Local 1930 have been urging the department to address what they say are extreme call volume and fatigue issues for over a year but haven’t seen any changes.

“What is very common in this department is to work 72-hour shifts,” said Pritchard. “You’re lucky if you get, in that 72 hours, four to six hours of rest. (22)

Phoenix firefighters interviewed by AZ Family discussed working “Stand Up 24’s” – a 24 hour shift with no rest periods. An increase in mandatory overtime means many firefighters and firefighter/paramedics are working “Stand Up 48’s”. (23)

Single-role paramedics treated like second-class fire department members

There is not much peer-review research on how fire service leaders influence the attitudes of firefighters as motivational predeterminate of performance and organizational outcomes. Perceived Organizational Support (POS) is a social exchange variable in which justice perceptions affect organizational commitment and job satisfaction. Huntsman’s group surveyed two metro-sized Western fire departments. The fire department members perceive justice in both procedures – such as promotions – and outcomes – such as pay rates. (24) I often hear EMS single-role caregivers complain that they are treated as second-class members within their fire department.

The pandemic identified unequal pay and working conditions for the single role EMS providers employed by the Fire Department of New York when compared to firefighters. Mayor De Blasio’s response “… EMS work is different.” was not well received.

Twenty five single role EMS caregivers filed a federal class-action lawsuit against the city and FDNY. The Equal Employment Opportunity Commission determined that:

… any difference in duties between the EMS first responders and firefighters fails to explain the pronounced gap in wages and benefits, and [the city has] failed to adjust the pay scales of EMS first responders to keep pace with the changes to their duties since the City merged EMS with the Fire Department in 1996. (25) We may learn a lot about “occupational separation.”

Moral injury and compassion fatigue

Moral injury was first used in 2009 to describe soldiers’ response to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (26) Physicians adopted the concept when describing the frustration of being unable to provide high-quality care and healing in the context of front-line health care. (27)

Moral injury occurs for paramedics and firefighters when there is a gap between what they want to do and the conditions they are confronting. An example is the opioid epidemic, where caregivers resuscitate the same person a couple of times a year with no change in addictive behavior. Or the person with a behavioral health situation who will not benefit from transport to an emergency department but that is your only option.

In some communities, the number of on-duty firefighters has shrunk while the workload has increased. There are incidents where paramedics and firefighters face devastating human conditions that they cannot reverse or mitigate, creating a situation described by Litz as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

Compassion fatigue (CF) is a secondary traumatic stress syndrome defined as a sudden or gradual loss of compassion from exposure to stress or stressful events. Colloquially, CF is referred to as the “cost of caring,” which describes the process by which compassion and empathy felt by a caregiver for their patient can devolve into a lack of compassion by the continuous exposure to traumatic situations that is both unhealthy for the caregiver and distorts reality, despite its protective notion. (28)

Examples of compassion fatigue include:

• Lack of compassion
• Frustration with the patient
• Rage response
• Gallows humor
• Somatization: “suppression of emotions and distancing strategies after exposure to intense emotional material, which can ultimately lower empathy and result in additional traumatization”

These are some factors that contribute to the suicide rate of caregivers (29) and the 26% voluntary turnover of active paramedics in 2022. (30)

What is Best Result For the Fire Department?

Fire departments have significant economies of scale when establishing a new emergency ambulance service. Existing fire stations, a two-way communication system that includes dispatch/deployment, vehicle maintenance capability, tiered command structure, and logistics. With all of those advantages, adding an emergency ambulance service is not revenue neutral. The insurance reimbursement system does not cover the actual cost of services. (31)

Changing community needs

Modern United States Emergency Medical Services started in 1966 with a combination of federal funding that was focused on reducing highway accident deaths and disabilities, medical research to improve the survival rate of out-of-hospital cardiac arrest, and President Johnson’s “Great Society” initiative that included the creation of the Freedom House Ambulance paramedics in Pittsburgh. (32 & 33)

Up to 80% of fire company responses are for EMS incidents. The opioid overdose crisis was overshadowed by the pandemic, but continues to outpace other accident-related morbidity and mortality situations, with more than 107,000 deaths in calendar year 2021. (34)

There has been a continuing increase in lift-assist calls from individuals and assisted living/nursing homes. It appears that some healthcare facilities are cost-shifting lift assistance from facility staff to EMS caregivers. They are calling 9-1-1 because the labor organizations representing security and maintenance workers removed patient handling as one of their job-related responsibilities. This was due to worker compensation claim denials and liability concerns. (35 & 36)

Advanced Practice Provider (APP)

The COVID 19 pandemic accelerated the expansion of emergency ambulance into other services. Los Angeles has added Advanced Provider Response Units (ARPU), staffed with a nurse practitioner or physician assistant teamed with a firefighter paramedic. The ARPU is capable of treating patients in place or navigating them to select alternate destinations, such as a mental health urgent care or a sobering center.

The initial APRU was deployed in South Los Angeles in 2016. It was able to safely treat or navigate 50% of patients away from the ED by performing on-scene, simple procedures that lie just beyond the traditional paramedic’s scope of practice, including applying clinical decision rules, performing uncomplicated laceration repair, providing culturally sensitive health teaching and promotion, connecting patients with social workers, and helping patients and their families navigate to ongoing in-network care. (37)

Street Crisis Response Team

An alternative to police or EMS response to behavioral health issues is the San Francisco Street Crisis Response Team (SCRT). SCRT is staffed with a fire department community paramedic, a behavioral health clinician from HealthRIGHT360, and a peer specialist with lived experience from RAMS, Inc. (Richmond Area Multi-Services) who have a range of specialist skills to engage on the scene with a person in crisis.

The first six months of the program showed that 9% of the SCRT encounters have ended in a 5150, an involuntary mental health hold for those who are a danger to themselves or others. 18% were transported to a hospital and 18% to a program such as residential care or drug treatment. (38)

With six teams launched, SCRT is now diverting over half (58%) of calls monthly for “mentally disturbed persons” from law enforcement. In the first year the SCRT responded to over 5,000 calls related to people suffering mental health and substance abuse issues on city streets. (39)

Los Angeles Skid Row – a Challenging Community of Addiction and Unsheltered Homeless

The out-of-hospital emergency medical services environment in 2023 is tremendously more complex than Baltimore and Los Angeles handled in 1999. A dramatic example is what LAFD encounters in the Skid Row community. Public Broadcasting Service (PBS) spent a day with the firefighters at Los Angeles Fire Station 9 in 2019. This 27-minute documentary was shown on SoCal Connected on February 18, 2020. https://www.pbs.org/video/fire-station-9-9syxup/

Footnotes

(1) staff (2000 May 24) The debate: city fire coverage. The Baltimore Sun. Accessed March 5, 2023 https://www.baltimoresun.com/news/bs-xpm-2000-05-24-0005240127-story.html

(2) Operational & Management Assessment: Baltimore City Fire Department – Final Report. (2021 November). FACETS Consulting LLP. https://fire.baltimorecity.gov/baltimore-city-fire-department-facets-report

(3) Fox, S. (1999 Dec 26). Proposal Targets Paramedic Shortage. Los Angeles Times. Los Angeles, CA. Accessed March 5, 2023 https://www.latimes.com/archives/la-xpm-1999-dec-26-me-47674-story.html

(4) Williams, E. (2007 Aug 29) Paramedic Coded Assign Hire to End Sept 9. Battalion 14 News & Information (dormant rss feed).

(5) Ditzel, P. (1965) Dial 0 for Rescue. The Firemen’s Grapevine.

(5a) Hisserich, J. C. (2020 July 1) How the Los Angeles Fire Department Became the City’s Ambulance Provider. Los Angeles Fire Department Historical Society

(6) Faught, J. (2006). “Breaking Up is Hard to Do: Explaining the 2002 San Fernando Secession Vote.” Journal of Urban Affairs 28(4): 375 – 398.

(7) Wells, W (2004 February 1) “Los Angeles Fire Department Implements EMS Resource Plan.” Firehouse.com Accessed Mar 5, 2023 https://www.firehouse.com/home/news/10526932/los-angeles-fire-department-implements-ems-resource-plan

(8) Bamattre, W. R. (2006 June 12). EMS Resource Deployment Plan Update, Los Angeles Fire Department.

(9) Silva, G. (2023 February 12) ” ‘It happens every day’: LAFD paramedics say 911 response times continue to rise. Fox 11 News, Accessed March 5, 2023 https://www.foxla.com/news/lafd-paramedics-say-911-response-times-continue-to-rise.

(10) “What’s a Wicked Problem?” Stony Brook University. accessed February 25, 2023 https://www.stonybrook.edu/commcms/wicked-problem/about/What-is-a-wicked-problem

(11) Baltimore Fire Officers IAFF Local 964 (2023 April 19) “On this date in 1986, Aerial Tower 111 was placed in service. Engine Co No 1 and Truck Co No 11 were disbanded and combined to place the tower in service, at their station at 401 W. North Avenue. The unit ran as both an engine and a truck company on fire boxes, and was staffed with 6 personnel. The tower lasted a little over 10 years, being disbanded on 4/9/1997, and the firehouse closed.” FaceBook https://www.facebook.com/BFO964/posts/693953376068826

(12) LAFD (2008). Five-Year Emergency Medical Services (EMS) Plan 2007-2012, Los Angeles Fire Department.

(13) ABC 7 (2023 March 7) Fire Chief Crowley and Mayor Bass Discuss State of the LAFD. https://youtu.be/NOvvSgigols

(13a) Silva, G. (2023 May 1) LA’s ambulance shortage impacting city’s public safety, paramedic says. Fox 11 News. Accessed May 6, 2023 https://www.foxla.com/news/las-ambulance-shortage-impacting-citys-public-safety-paramedic-says

(14) “50th Anniversary” in Seattle Fire Department 2020 Annual Report. City of Seattle. p. 26.

(15) Eisenberg, M., Bergner, L., & Hallstrom, A. (1979). Paramedic Programs and Out-of-Hospital Cardiac Arrest: I. Factors Associated with Successful Resuscitation. American Journal of Public Health, 69(1), 30 – 38. 

(16) Zive, D.M.; Schmicker, R.; et al. (2018) Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium, Resuscitation. 131:74-82

(17) Brown SP, Wang H, et al. (2015) A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. Am Heart J;169:334-341.e5

(18) Nichol, G., Leroux, B., et al. (2015) Trial of continuous or interrupted chest compressions during CPR N Engl J Med, 373 (23), pp. 2203-2214

(19) Myers, J. B., Eckstein, M. et al. (2008). “Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking.” Prehospital Emergency Care 12(2): 141-151.

(20) Unpublished 2006 data from an internal study.

(21) Pennino, J. A., III. (2021). The expanded implementation of the medical priority dispatch system (MPDS) in Pinellas County: A public value perspective [Doctoral dissertation, Valdosta State University]. In Dissertation Abstracts International: Section B: The Sciences and Engineering (Vol. 82, Issue 1–B).

(22) staff (4 April 2023) Long Beach unions say ambulance crash highlights staffing shortage. KCAL CBS. Accessed April 6, 2023 https://www.cbsnews.com/losangeles/news/long-beach-unions-say-ambulance-crash-highlights-staffing-shortage/

(23) staff (31 January 2023) Phoenix Fire Department in Staffing Crisis. AZ Family. Accessed 8 April 2023 https://youtu.be/qulxrnOtNO8

(24) Huntsman, D., Greer, A., & Murphy, H. (2020) Leveraging Justice: How Leaders Influence Performance Determinants in the Fire Service. Risk, Hazards & Crisis in Public Policy. 11(3) 270 – 295. doi: 10.1002/rhc3.12188

(25) Freeman, D. (2023 January 10) EMS unions sue city, FDNY alleging pay discrimination: Suit concerns effects of ‘occupational separation’. The Chief Leader. Accessed January 22, 2023 https://www.thechiefleader.com/stories/ems-unions-sue-city-fdny-alleging-pay-discrimination,49591

(26) Litz, B. T., Stein, N. et. al (2009). “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review 29(8): 695-706.

(27) Talbot, S. G. and Dean,W. (2018) “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.” STAT.

(28) Renkiewicz, G. K., & Hubble, M. W. (2021). Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying and Predicting Compassion Fatigue in Emergency Medical Services Personnel. Prehospital Emergency Care. https://doi.org/10.1080/10903127.2021.1943578 

(29) Vigil, N. H., Grant, A. R., et. al (2018). Death by Suicide—The EMS Profession Compared to the General Public. PreHospital Emergency Care, 23(3), 340-345. https://doi.org/10.1080/10903127.2018.1514090 

(30) Doverspike, D. (2023) 2022 EMS Employee Turnover Study. American Ambulance Association and OnShift Inc-Avesta Systems Inc.

(31) Finance Committee. (2016 ). EMS Funding and Reimbursement: FINAL. National EMS Advisory Council. Washington, DC: U.S. Department of Transportation 

(32) Shah M. N. (2006). The formation of the emergency medical services system. American Journal of Public Health, 96(3), 414-23

(33) Edwards, M.L. (2019) Pittsburgh’s Freedom House Ambulance Service: The Origins of Emergency Medical Services and the Politics of Race and Health. Journal of the History of Medicine and Allied Sciences 74 (4) 440-466. dot: 10.1093/jhas/jrz041

(34) Advocacy Resource Center (2022 December 22) Issue Brief: Nation’s drug-related overdose and death epidemic continues to worsen. American Medical Association

(35) Thomas, L. & Biantoro, C. (2021 March) A Review of Fire First Responder Responses to Lift Assist and Traumatic Fall Incidents: Analysis on City of Surrey Medical Incident Response. Surrey, British Columbia: City of Surrey Fire Services

(36) Ward, M. (2020 January 20) Looking at Fire-EMS Lift-Assists: Aging Community, Troubling Health Trends and Healthcare Cost Shifting. Reston, VA: CompanyCommander.com Accessed April 11, 2023 https://companycommander.com/2020/01/20/looking-at-fire-ems-lift-assists-aging-community-troubling-health-trends-and-healthcare-cost-shifting/

(37) Sanko, S., & Eckstein, M. (2021). Mobile Integrated Health Care in Los Angeles: Upstream Solutions to Mitigate the Covid-19Pandemic. NEJM Catalyst: Innovations in Care Delivery 2021, 2(2). https://doi.org/https://doi.org/10.1056/CAT.20.0383 

(38) Thadani, T., & Cassidy, M (21 May 2022) S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping? San Francisco Chronicle. Accessed 10 April 2023 https://www.sfchronicle.com/local/article/s-f-s-new-street-crisis-team-is-helping-people-16180437.php

(39) Office of the Mayor (2021 November 30) San Francisco Celebrates One-Year Anniversary of Street Crisis Response Team. Accessed April 10, 2023 https://sfmayor.org/article/san-francisco-celebrates-one-year-anniversary-street-crisis-response-team

These situations provide opportunities and challenges for the front-line emergency service officer.

FIRE DEPARTMENT AS A SOCIAL SERVICES PARTNER

The San Francisco Fire Department Street Crisis Response Team (SCRT) is staffed with a community paramedic from SFFD, a behavioral health clinician from HealthRIGHT360, and a peer specialist with lived experience from RAMS, Inc. (Richmond Area Multi-Services) who together have a range of specialty skills to engage on the scene with a person in crisis.

In the first year of operation, November 2020 – November 2021, SCRT took more than 5,000 calls and engaged with nearly 3,000 people in crisis. In early 2022, the seventh team with six additional staff will launch.

The first six months of the program showed that 9% of the SCRT encounters have ended in a 5150, an involuntary mental health hold for those who are a danger to themselves or others. 18% were transported to a hospital and 18% to a program such as residential care or drug treatment. (source)

Demonstrating the program’s success as an alternative to law enforcement, SCRT diverted more than one-third of all 911 calls (38%) for “mentally disturbed persons” from law enforcement cumulatively during its first year of operation. With six teams launched, SCRT is now diverting over half (58%) of calls monthly for “mentally disturbed persons” from law enforcement. Once fully operational, SCRT seeks to divert 100% of calls.

City of San Francisco (2021 November 30) San Francisco Celebrates One-Year Anniversary of Street Crisis Response Team Press Release

RISING PROBLEM OF HOMELESS ENCAMPMENTS: FIRES, INFECTIOUS DISEASE, VIOLENCE AGAINST CAREGIVERS, AND EMS WORKLOAD

Lexipol provided a 2019 webinar on “Crisis in the Streets: Fire Department Response to Homeless Individuals” that was eye-opening. Click on this link to see the on-demand webinar.

Homeless encampments experienced a 1,000% increase from 2007 to 2017 and are occurring throughout the United States. Half of the encampments have 11-50 residents, 17% of the encampments have more than 100 residences. (NLCHP 2017) Fire departments are responding to calls for violence, fires and infectious diseases like typhus and tuberculosis (Gorman 2018)

Due to violence against first responders, some fire departments are sending two crews to any EMS event at an encampment, to have one company commander function as the scene safety officer while the others work at the task-level. (Goldfeder, Long & Schaeffer 2019)

Seattle Fire Chief Harold Scoggins reports that from Jan. 1 to April 10 of 2022 the department responded to 478 encampment fires – three to five encampment fires a day. In 2021 during the same time period, it was 327. The year before that, they responded to 168 encampment fires. They are also responding to 30 to 35 medical calls to homeless encampments every day. (source)

Los Angeles Fire Department, a city 6 times larger than Seattle, responded to 24 encampment fires a day in May 2021, many spreading to adjacent businesses and residences creating millions of dollars of property damage. (source) In downtown Los Angeles, fires from homeless encampments account for 80% of the blazes in the summer of 2021. (source)

WE ARE NOT TELLING OUR STORY: FIREFIGHTERS RESCUE A LOT OF CIVILIANS

Stunning results from the Firefighter Rescue Survey. They have been collecting information on rescues made by firefighters as reported in the media or by fire departments. In 2021 they found that 2,173 civilians were rescued by firefighters. They received 757 completed rescue surveys. 

As of April 5, 2022, Firefighter Rescue Survey has received reports of 300 incidents where civilians have been rescued by firefighters in 2022. Statistically, that equates to nearly 3.3 incidents per day where firefighters are making grabs. (source) You can get Chief Brian Brush’s “2021 Rescue Survey & The Culture Shift for 2022: People Before Water“ through this (source).

The goal of the Firefighter Rescue Survey initiative is to reduce civilian home fire deaths to under 2,000 per year. U.S. news media reported 2,264 civilian home fire fatalities for the calendar year 2021. Please visit their website http://www.firefighterrescuesurvey.com/

REFERENCES

Thadani, T. & Cassidy, M. (2021 May 17) S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping. San Francisco Chronicle. accessed April 14, 2022. https://www.sfchronicle.com/local/article/S-F-s-new-street-crisis-team-is-helping-people-16180437.php

NLCHP (2017). Tent City, USA: The Growth of America’s Homeless Encampments and How Communities are Responding. Washington, DC, National Law Center on Homelessness and Poverty. http://nlchp.org/wp-content/uploads/2018/10/Tent_City_USA_2017.pdf

Gorman, A. and Kaiser Health News (2019 March 8). Medieval Diseases Are Infecting California’s Homeless: Typhus, tuberculosis, and other illnesses are spreading quickly through camps and shelters. The Atlantic. New York, Atlantic Media, Inc.  https://www.theatlantic.com/health/archive/2019/03/typhus-tuberculosis-medieval-diseases-spreading-homeless/584380/

Goldfeder, B., A. Long and B. Schaeffer (2019 July 9). Crisis In The Streets: Fire Department Response to Homeless Individuals. Webinar. Irvine, CA, Lexipol.  https://info.lexipol.com/webinar-fire-department-response-to-homeless

Markovich, M. (2020 April 15) Seattle Fire Chief: Responses to daily encampment fires taxing already short staffed fire dept. Fox 13 Seattle. Accessed April 15, 2022. https://www.q13fox.com/news/seattle-fire-chief-reponses-to-daily-encampment-fires-taxing-already-short-staffed-fire-dept

Smith, D., Queally, J., & Molina, G. (2021 May 12) 24 fires a day: Surge in flames at L.A. homeless encampments a growing crisis. Los Angeles Times Accessed April 17, 2022. https://www.latimes.com/california/story/2021-05-12/surge-in-fires-at-la-homeless-encampments-growing-crisis

(2021 June 14) Homeless Encampment Fires Account For 80% Of Blazes Plaguing DTLA In Recent Weeks: ‘It’s So Sad.’ CBS Los Angeles. Accessed April 17, 2022. https://www.cbsnews.com/losangeles/news/rash-of-homeless-encampment-fires-continues-across-southland/

Feature image: Winthrop, C. (05 March 2021) One Dead Following Palms Homeless Encampment Fire in Possible Homicide. westsidetoday.com Accessed April 17, 2022 https://westsidetoday.com/2021/03/05/one-dead-after-palms-homeless-encampment-fire/

(2022 April 6) Year of the Rescue, FIREFIGHTER GRAB VIDEO, Reducing Civilian Fatalities Below 2000. County Fire Tactics. Accessed April 17, 2022. https://countyfiretactics.com/2022/04/06/year-of-the-rescue-firefighter-grab-video-reducing-civilian-fatalities-below-2000/

Brush, B. (2022 February) “2021 Rescue Survey & The Cultural Shift for 2022: People Before Water.” CountyFireTactics.com. Accessed April 17, 2022. https://countyfiretactics.com/2022/02/06/2021-rescue-survey-chief-brush-the-cultural-shift-for-2022-chief-isakson/

Out-of-Hospital Cardiac Arrest Research

Dr. Peter Safar conducted a number of experiments at John Hopkins University using expired-air ventilation with closed chest massage on human volunteers in the late 1950’s. “Closed-chest massage should be preceded and accompanied by pulmonary ventilation,” noting that the Baltimore City Hospital’s technique involved one operator inflating the lungs every five seconds, followed by a second operator providing four sternal compressions at one second intervals.

Closed chest massage was endorsed as in the United States as a:

• medical procedure in 1962
• reclassified as an emergency procedure in 1965
• Committee of Cardiopulmonary Resuscitation emphasized the A-B-C-D formula for resuscitation in 1966.

Baltimore City Fire Department Battalion Chief Martin McMahon encouraged his “ambulance men” to volunteer to be sedated so lung air exchange volumes could be determined when looking at different artificial ventilation techniques at John Hopkins University – including expired-air ventilation.

Out-of-hospital cardiac arrest research + The Great Society + federal response to traffic trauma = United States Emergency Medical Services

City “emergency” hospitals often included ambulance service at the start of the 20th century. (Burgess) Public safety organizations – police/fire/ambulance – got more involved in ambulance service after World War II. There was uneven coverage and levels of service.

Vince Robbins writes in Management of Ambulance Services that Miami was the first “nonphysician, mobile, advanced medical treatment service in America.” This determination is based, in part, on articles published in medical scientific journals describing out-of-hospital cardiac arrest research results.

Doctor Eugene Nagel developed a 54-pound defibrillator in Miami that was as effective as John Hopkin’s original 1959, 200-pound, portable defibrillator. The first out-of-hospital resuscitation from ventricular fibrillation occurred in Miami in June 1969.

United States EMS is a child of the Great Society

The Great Society was an ambitious series of policy initiatives, legislation and programs spearheaded by President Lyndon B. Johnson (D) with the main goals of ending poverty, reducing crime, abolishing inequality and improving the environment.

The first federal funding for EMS was $16M from the newly formed Division of Emergency Medical Services within the Department of Health Education and Welfare (DHEW) in 1972 to create demonstration projects in five states.

Congress passes the 1973 EMS Systems Act that provided a 5-year $454M Great Society grant program that funded the creation of more than 300 regional EMS systems. Funding was also provided for EMS feasibility studies, planning, operations, expansion and improvement, and research. In 1974 there was also a $15M Robert Wood Johnson Foundation grant that supported development of 44 EMS systems. (Shah)

Traffic Trauma

The 1966 National Academy of Sciences report on “Accidental Death and Disability” results in federal funding to establish Emergency Medical Services (EMS) as a component of the National Highway Safety Act of 1966.

A component of the National Highway Safety Act of 1966 was the improvement of emergency ambulance and rescue service to traffic collisions. This was assigned to the mission of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation. This component included the development of a national EMS education curriculum. (Institute of Medicine)

Pittsburgh’s Hill District

The Hill District is a Pittsburgh neighborhood that often would not get the police ambulance to respond to emergency calls.

• Freedom House Enterprises was a community non-profit using grants to create African-American owned businesses
• Reached out to create a commercial ambulance service to cover the Hill and Oakland Districts
• Partnered with Presbyterian-University Hospital

Dr. Peter Safar, now working at Presbyterian-University Hospital in Pittsburgh, accepted 44 residents of the Hill district through Freedom House Enterprises in 1967. They took a 9-month training program at Presbyterian-University Hospital that included classroom and clinical rotations.

Twenty six students completed the paramedic-level training (EMT II). Paramedic ambulance service started June 16, 1968. Miami and Los Angeles County Fire Department paramedics started responding to emergencies one year later. Seattle two years later

There is a different focus between the Freedom House paramedics and the Seattle, Miami and Los Angeles programs. As a grant-funded community development project, the Freedom House paramedics started running calls as the primary caregiver from the very first day. The paramedics in Seattle, Miami and Los Angeles, because they were in a clinical research project, responded to emergencies with a nurse or physician on the unit during the first year or so. All of the paramedic programs included physician review of calls, with feedback on their clinical performance and case management.

Freedom House is the source of the National Standard Curriculum for Paramedics

The National Highway Transportation Safety Administration (NHTSA) developed the National Standard Curricula outline using University of Pittsburgh/Freedom House 300 hour “EMT II” training program as template. I recall pages of concept and practice bullet-point lists for each of the 15 modules.

University of Pittsburgh Presbyterian-University Hospital contracted with the National Highway Traffic Safety Administration in 1975 to write a paramedic textbook based on the outline. Nancy Caroline, M.D., was the primary author and Walt Stoy, Ph.D./paramedic, was the principal investigator.

NHTSA projected that a textbook to be available by late August 1977. Something happened. Instead of getting 25 textbooks I was buying a “blue line” pre-publication manuscript from the Government Printing Office. I needed the manuscript to develop study guides for a paramedic course. Emergency Care In The Streets was eventually published in 1979 by Little Brown.

Freedom House Ambulance 1967-1975

Freedom House Ambulance staffed five ambulances to serve the Hill and Oakland Districts, averaging 6,000 responses a year. A 1971 University Hospital study compared “inappropriate care” delivered by the two ambulance services. The police ambulances, staffed with Advanced First Aid credentialed caregivers, delivered inappropriate care 62% of the time, Freedom House ambulances, staffed with University Hospital trained EMT and EMT II’s, delivered inappropriate care 11% of the time. (Edwards)

Matthew Edwards is a physician who researches the intersection of medical history, ethics and public policy. His look into the history of Freedom House includes identifying the situations that lead to its demise:

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In 1975 the Freedom House caregivers were paid at a much lower rate than the police, firefighters and “superambulance” personnel. Few of the Freedom House caregivers were able to thrive as employees in the city-operated EMS system. They were required to be “retrained” as city ambulance attendants.

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Safar P, Brown TC, Holtey WJ, Wilder RJ. (1961) Ventilation and circulation with closed-chest cardiac massage in man. Journal of the American Medical Association. 176:574-576.

Safar P, Escarraga LA, Elam JO. (1958) A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest pressure arm-lift methods. New England Journal of Medicine. 258:671–7

Rasmussen, FN. (2005 February 13) Chief Martin McMahon, 94, first-aid pioneer. The Baltimore Sun. Accessed September 8, 2020: https://www.baltimoresun.com/news/bs-xpm-2005-02-13-0502130054-story.html

Burgess, G. (2018, April 30) Early Days of the San Francisco Emergency Service: From the Police Infirmary to Mission Emergency. Brought to Light, UCSF Archives and Special Collections. Accessed January 30, 2021: https://blogs.library.ucsf.edu/broughttolight/2018/04/30/early-days-of-the-san-francisco-emergency-service/

Robbins, V. (2015) “The History of Ambulance Services and Medical Transportation Systems in the United States” in Kirkwood, S., ed. Management of Ambulance Services. Boston: Pearson/Brady. ISBN 978-0-13-503829-2

Zeitz, J. (2018) Building the Great Society: Inside Lyndon Johnson’s White House. New York: Penguin Books. ISBN 9780698191594

Committee on Trauma and Committee on Shock (1966) Accidental Death and Disability: The Neglected Disease of Modern Society. Washington DC: National Academy of Sciences/National Research Council.

Shah M. N. (2006). The formation of the emergency medical services system. American Journal of Public Health, 96(3), 414-23.

Committee of the Future of Emergency Care in the United States Health System, Board on Health Care Services (2007) Emergency Medical Services at the Crossroads. Washington DC: Institute of Medicine of the National Academies Press. ISBN 978-0-309-10174-5

Staresinic, C. (2004 February) Send Freedom House! Nobody has seen ambulance attendants like these before. PITTMED Vol 6, No 1. pp 32-34 Accessed September 14, 2020: https://www.pittmed.health.pitt.edu/Feb_2004/PittMed.pdf

Edwards, M. L. (2019) Pittsburgh’s Freedom House Ambulance Service: The Origins of Emergency Medical Services and the Politics of Race and Health. Journal of the History of Medicine and Allied Sciences 74(4) pp. 440-466. doe: 10.1093jhmas/jrz041

I have posed a similar question to hundreds of emergency service providers attending a university course, a fire officer credential program or Just Culture presentation. Very few of them elected to continue to wait for the ambulance. Neither did Major Corey Britt, the Senior Company Officer at Oklahoma City Fire Station 34, when they responded to this Christmas Eve burn incident. (Meyer)

The students are shocked when the correct response from the formal organization’s perspective is to continue to wait for the ambulance. Major Britt was in a disciplinary hearing last Friday for his decision to transport the child and mother to the hospital on fire apparatus. (Yager)

The Just Culture Approach

The “Just Culture” approach can assist high consequence organizations (airlines, healthcare, and 24/7 industries) in holding its system and staff accountable within a supportive environment that provides a non-punitive means of reporting errors, while demonstrating zero tolerance for risky behavior. (Woods and Dekker)

It is a system of justice – using investigatory and disciplinary actions – that reflects what we know of socio-technical system design, human free will, and our inescapable human fallibility. (Nance)

After A Bad Outcome Event Occurs

Professor Sidney Dekker, founder of the Safety Science Innovation Lab, describes two approaches to just culture. Retribution imposes a deserved and proportional punishment while Restoration repairs the trust and relationships that were damaged.

The investigation of the bad outcome event looks at:

• What happened?
• What normally happens?
• What does the procedure require?
• Why did it happen?
• How are we managing it?

During this inquiry, we check to see if there is alignment of the department’s mission and value. Is there a clear understanding of the duty, what is defined as a breach of that duty and what are the consequences of breaching that duty.

The inquiry conducts an analysis to identify failed or absent defenses that takes a hazard or risk and makes it a loss, using the human error concepts developed by Professor James Reason.

Designing A Better System

Analysis of earlier bad outcome events result in four areas where we can design a better system. Emergency services have made such changes based on experience.

Controlling Contributing Factors

Changing the pre-cursors to human error at at-risk behavior. Two examples are requiring responders stop at every red light intersection and wear seat belts.

Adding Barriers

Preventing individual errors. Requiring a spotter when backing up vehicles.

Adding Recovery

Catching errors downstream. An example is checking your colleagues personal protective clothing before entering a hazardous environment.

Adding Redundancy

Establishing parallel elements to ensure safe activity. Using more than one method to confirm proper endotracheal intubation.

Just culture is set up to learn from incidents and identify changes in design, procedure and reward systems to promote better behavioral choices.

Understanding Risk

After understanding “what happened?” and comparing it to “What does the procedure require?” we look at the behavorial choice made and the individual’s understanding of the risk involved. Just culture focuses on three behaviors:

• Human Error is an inadvertent action, slip, lapse or mistake.
• At-Risk Behavior is a choice where the individual did not recognize the risk or believed the choice is justified
• Reckless Behavior is a conscious disregard of a substantial and unjustifiable risk

Evaluating the behavior includes the impact of Imposers. Imposers are persons or organizations who set the standards and rules, determines the risk threshold and renders judgement. EMS operations are regulated by a state agency, usually the Health Department. They issue a permit to jurisdictions to provide out-of-hospital care. They issue a license to individual caregivers.

Failure to follow state EMS regulations could endanger the jurisdictional permit to perform out-of-hospital care. In jurisdictions that charge for transport services, losing the jurisdictional permit could result in losing the ability to bill for services. Transporting patients on fire trucks endangers the jurisdictional EMS permit. From the organization’s viewpoint, losing the state EMS permit is a high risk.

Meanwhile, In Oklahoma City

The Emergency Medical Services Authority (EMSA) is struggling with increased call volume, a workforce thinned by the pandemic, long waits to unload patients at the hospital and more time to disinfect ambulances after transport. This results in fewer ambulances on the road and more late arrivals to Priority 1 and 2 calls.

EMSA Chief of Operations John Graham states that with fewer ambulances on the street, more of the responses are coming from the hospitals instead of community posts. This may place the ambulance 15 to 20 miles further away from the incident scene. In December 2020 there were 40 ambulance responses that took longer than one hour for the ambulance to arrive. (Meyer)

An Area With No Pre-planned Guidance

It is not clear if Engine 34 received an accurate estimated time of arrival for the ambulance assigned to the burn incident. (Yager) They had been on the scene for 16 minutes and were told the ambulance was at least 10 minutes away. The Oklahoma City Fire Department regulations may not include guidance on this type of situation.

Dana Libby, a former firefighter/paramedic, police officer and executive with a faith-based international charity organization, observed that the Doctrine of Necessity, along with necessary safeguards, has long been recognized in civil and criminal law. (Christie)

Libby further states:

Every Standard Operating Procedure should start with a statement of policy, principle, or purpose. The enumerated procedures should provide guidance on fulfilling the policy, principle or purpose, under a set of circumstances.

If the circumstances and conditions differ, there is at least guidance concerning what you are supposed to be accomplishing . . . good training, creativity, experience and wisdom will then get you as close as possible to the goal.

Take-Away for All

Many jurisdictions and state medical agencies have made changes in clinical and operational guidelines in response to the COVID-19 pandemic. The transport of critical patients when no ambulance is available is no longer an obscure “what-if” but now a “what-when” scenario. What is a just procedure for the patient, family, emergency responders, and healthcare staff?

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Christie, George C. (1999 March) The Defense of Necessity Considered From The Legal and Moral Points of View. Duke Law Journal 48 (5), Accessed January 25, 2021 https://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1052&context=dlj&fbclid=IwAR10x3HC831W5BqI2pNo1pFzsWz17e48gzjw2qYBBt5uGa2kpKY59mI1Zug

Dekker, Sidney (2017) Just Culture: Restoring Trust and Accountability in Your Organization. 3rd edition. Boca Raton, FL: CRC Press, Taylor & Francis Group. ISBN 978-1-4724-7578-7

Meyer, Ali (2021 Jan 19) EXCLUSIVE: ‘The system failed us’ – Family disappointed in EMSA ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/exclusive-the-system-failed-us-family-disappointed-in-emsa-ambulance-delay/

Nance, John J. (2008) Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare, ISBN 978-1-93640-604-3

Reason, James (1990) Human Error. New York: Cambridge University Press. ISBN 978-0-521-31419-0

Woods, David D., et al (2010) Behind Human Error, Second edition. Burlington, VT: Ashgate Publishing Company. ISBN 978-0-7546-7834-2

Yager, Peyton (2021 Jan 22) Oklahoma City Fire Major faces punishment within the department after driving burn patient to the hospital after ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/oklahoma-city-fire-major-faces-punishment-within-the-department-after-driving-burn-patient-to-the-hospital-due-to-ambulance-delay/