While working as an Assistant Professor at The George Washington University, I followed the efforts of Los Angeles and Baltimore fire departments as they addressed the challenge of adding ambulances to their overworked systems (2000 – 2007). One element was the impact of authorized but unfilled full-time positions.

In looking at other fire departments, we observed that when the percentage of authorized career positions that are unstaffed exceeds 12%, the number of firefighters or single-role paramedics willing to work the overtime to fill those vacancies plummets. Anecdotal evidence suggests that some fire departments are wrestling with this issue today.

The Impact of Excessive Overtime

John Hicks, writing in The Firemen’s Grapevine, articulated the reality for LAFD employees:

You’re working another 72-hour shift. It’s okay, you’re young. You have a girlfriend/boyfriend, but it is just the beginning of the relationship. You recently bought your first condo, but the payment is low, and your health is good. A little time passes. You are still doing those 72-hour shifts, with an occasional 96-hour now thrown in. Your significant other is now wearing a wedding ring, and your first born is asking you if he or she is going to have a brother or sister soon. The condo was traded for a three-bedroom home in suburbia USA along with the cheaper mortgage. Overtime is now more of a necessity than a luxury.

Due to the abundance of overtime, the days of having a “C” shift job have all but disappeared for LAFD members. Not only has this hurt the department by limiting the talents learned by the experience gained by working other types of job, such as construction, electrical, and plumbing related careers, it means that overtime seems to be the sole means for most to earn a little extra money. (2022)

The Challenge of Fire Department Position Management

There has been a long dance over what staffing a fire department needs to meet its operational requirements. Jurisdiction leadership is resistant to creating new full-time positions, as they require 137% funding to cover salary, workers’ compensation, annual/sick leave, training, personal protective gear, and other human resource expenditures.

The jurisdictional administrators and elected leaders struggle with the concept of having a workforce where there are more full-time equivalents (FTEs) on duty than the minimum required seats to fill. As Fitch and Associates LLC partner Steven Knight, Ph.D., points out:

Using my old department as an example, the staffing was determined on a legacy basis and that legacy pre-dated most, if not all, of the institutional knowledge. For example, the department staffed five personnel for every seat on an engine, four for every seat on a truck company, and two for every seat on a rescue. While the daily minimum staffing was consistently applied, it had to overcome the inconsistency in staffing for each position. In fairness, these legacy-staffing strategies may have been compromises over the years and budget cycles, but to clearly articulate the strategy at a future moment in time proves difficult. (2019)

Looking At LAFD

A 2015 Evergreen Data Library audit of overtime led the Los Angeles City Council to approve hiring 48 additional firefighters. At that time, “420 LAFD employees earned more than $100,000 in overtime, and 19 earned more than $200,000. One Fire Captain made $311,316 in overtime on top of a $120,829 salary, for a staggering total of $448,594 in overtime pay. … a Commander at the LAFD informed the Controller’s office that the employee with $311,316 in overtime did obey all policies and procedures regarding overtime.” Evergreen noted that “Los Angeles uses what is called a ‘constant staffing’ model, which intentionally keeps firefighter positions open and uses overtime to make up for the missing employees. … LAFD is understaffed to the brink of collapse.”

Those 48 additional firefighter positions in 2015 did not end the overtime issue.

An audit of the Fiscal Year 2019 expenditures (July 2018 – June 2019) showed that “Eighteen employees of the Los Angeles Fire Department earned more than $200,000 in overtime pay last fiscal year, with one firefighter making $360,010 in overtime.” The 2019 audit also observed that “More than 90% of sworn police and fire employees last fiscal year received overtime, earning an average of $27,737, while 40% of the city’s general employees, defined as other sworn and civilian workers, received such pay. That group earned an average of $7,528” (Smith, 2019)

In 2022, The Center Square reported, “A captain in the department made $434,394 in overtime in 2021, pushing their gross pay to $598,532 to become the highest-paid employee in the city that year. Another fire captain made $420,055 in overtime, pushing that person’s gross pay to $593,314 in 2021. That person was the second-highest paid employee in the city, according to city payroll records. A firefighter with a base salary of $129,638 made $411,606 in overtime, making that firefighter’s total compensation $554,056. There were 86 employees in the fire department who made $400,000 or more in 2021. However, the highest ranking employee was not among those. The fire chief made $338,624, or nearly $250,000 less than the fire captain.” (Gantert et al., 2022)

The 2021 overtime increases in Los Angeles are linked to multiple-day wildfire campaign operations and the interrupted hiring cycle during the COVID pandemic. Emergency workers are dealing with the lingering effects of a massive increase in disease exposure (opioid overdoses and COVID) and a physically challenging workload. The 2023 Standards of Cover Analysis performed by CityGate Associates LLC made this observation: “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”(Citygate, 2023, p. 6).

ICMA and Center for Public Safety Excellence: 21st Century Fire & Emergency Services

The ICMA and Center for Public Safety Excellence white paper on 21st Century Fire and Emergency Services identified two themes:

• The past strategies of deferring conclusive action on critical issues with short-term solutions and leaving them for the next set of leadership are not a sustainable strategy for the future. To continue to do so will worsen the eventual correction(s) that will have to be made.
• We must begin recruiting talent with the mindset, skill sets, and resolve to help build a core organizational culture that can adapt and respond to rapid changes and that is not vested in a 20th-century fire service paradigm or antiquated local government bureaucracy. (2020)

This white paper may serve as a starting point to change the conversation with jurisdictional leaders and elected officials. We need to develop a new narrative that promotes appropriate organizational staffing to meet the expanded and complex roles that a fire department performs today.

The Impact of Overcommitting Existing Staff

Robert Peterson’s Executive Fire Officer capstone research paper examined employee perceptions of hours worked within the Corona (California) Fire Department (CFD). A ten-year retrospective analysis found overtime was only slightly cheaper than hiring, while daily vacancy levels were high enough to justify additional positions outright and identified fatigue-driven injury risk as the hidden cost. Corona Fire Department documented a 93% increase in injury-related time off alongside a 119% increase in forced hire/mandatory overtime over ten years (2024, p. 6). The vacancy is not eliminated; it is converted into overtime liability, workers’ compensation exposure, and attrition.

The National Highway Traffic Safety Administration (NHTSA) awarded a five-year contract to the National Association of State EMS Officials (NASEMSO) to understand the science of sleep health and apply these principles to develop fatigue risk management guidelines. One of the products is the Implementation Guidebook: 2018 Fatigue Management Guidelines for Emergency Medical Services that recommends EMS personnel work shifts shorter than 24 hours (Patterson & Robinson, 2018, p. 7).

Just before 5:20 a.m. Sunday, April 2, 2023, as BLS 16 responded to a call, it slammed into a power pole, a crosswalk sign, and a wall.  The crew, in the 69th hour of a 72 hour shift, 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.” (CBS LA Staff, 2023)

Changing The Conversation

The fire service has argued about staffing in the same terms for decades: seats, minimums, and the price of one more position. Los Angeles added 48 firefighters in 2015 and, by 2021, had 86 fire department employees earning more than $400,000, with a captain out-earning the fire chief by nearly $250,000. Incremental hiring against a structurally under-authorized workforce does not close the gap; it only changes who is exhausted.

The ICMA and Center for Public Safety Excellence white paper offers a more useful frame, calling for recruitment of talent with “the mindset, skill sets, and resolve to help build a core organizational culture that can adapt and respond to rapid changes” rather than one “vested in a 20th-century fire service paradigm or antiquated local government bureaucracy.” That reframing matters because the fire department is no longer staffed for the mission it actually performs. It is an all-hazards, high-acuity, medically dominant enterprise being resourced by a formula built for structural firefighting.

The new narrative should describe risk exposure, service reliability, and total labor cost rather than in seats and minimums. It should treat fatigue management as a standard of care. And it should be honest that the choice was never between spending and not spending. The choice was between spending deliberately on positions and spending involuntarily on the consequences of leaving them empty. The departments that make that case successfully will be the ones able to staff without force hires in the future.

References

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

CityGate. (2023). Los Angeles Fire Department Standards of Cover Analysis. Volume 1 of 3: Technical Report. CityGate Associates LLC.

Evergreen Data Library (2015) Los Angeles – Payroll & Overtime Analysis. https://evergreen.data.socrata.com/stories/s/Los-Angeles-Payroll-Overtime-Analysis/ijhv-thke/

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

Gantert, T., Apel, E., & Rowland, B. (2022, July 18). Los Angeles’ $600,000 fire captain and 86 firefighters made more than $400,000 in 2021. The Center Square. https://www.thecentersquare.com/california/los-angeles-600-000-fire-captain-and-86-firefighters-made-more-than-400-000-in/article_ca6b4cbc-06a8-11ed-9919-679807fe6e61.html

Hicks, J. (2022, April 1) Overtime – Too much of a good thing? The Fireman’s Grapevine. Los Angeles Firemen’s Relief Association. https://www.lafra.org/overtime-too-much-of-a-good-thing/

ICMA & CPSA (2020) 21st Century Fire and Emergency Services. https://www.cpse.org/wp-content/uploads/2020/07/21st-Century-Fire-and-Emergency-Services-White-Paper-Final-07.15.20.pdf

Knight, S. (2019, March 12). Full time, part time, overtime: How to fill fire department vacancies. FireRescue1.com. https://www.firerescue1.com/fire-chief/articles/full-time-part-time-overtime-how-to-fill-fire-department-vacancies-uRC8dscpvRkfgRhN/

Patterson, P. D., & Robinson, K. (2018, October). Implementation Guidebook: 2018 Fatigue Management Guidelines for Emergency Medical Services. National Association of State EMS Officials. https://s3.amazonaws.com/ClubExpressClubFiles/157064/documents/Fatigue_in_EMS_Implementation_Guidebook_1551393887.pdf

Peterson, R. (2024, April). Employee Perceptions of Hours Worked in the Corona Fire Department. [Capstone research project, National Fire Academy]. U.S. Fire Administration. https://apps.usfa.fema.gov/pdf/efop/Robert-Peterson-Employee-Perceptions-of-Hours-Worked-in-the-Corona.pdf

Smith, D. (2019, Nov 6) L.A. firefighter banked $360,010 in overtime pay in one year, city audit finds. Los Angeles Times. https://www.latimes.com/california/story/2019-11-06/lapd-lafd-audit-overtime-city-controller

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

The EMS Systems course has been taught at three universities. I have been through four textbooks, five learning management systems, and many initiatives to better engage students. The Fall 2026 version of the course for Idaho State University barely resembles the original course I developed for The George Washington University.

No Textbook

When the National Fire Academy issued the Fire and Emergency Services Higher Education (FESHE) EMS Model curriculum, textbook publishers responded as they did with the earlier Fire Science curricula, providing one or two textbooks for every course. There were 16 textbooks covering the FESHE EMS curriculum. Unfortunately, the market for EMS textbooks is tiny. By Spring 2023, there were three FESHE EMS textbooks with 2015 to 2017 copyright dates. About 50% of their content was obsolete. The publishers said that they were not planning to update or replace these textbooks. EMS 3300 went textbook-free in Fall 2024.

Working Backward To Develop Content

Rewriting the course without a textbook required looking backward. What content would satisfy the course objectives (measurable outcomes of the student competency) and stay within the course description and the curriculum goals? Peer-reviewed research, industry or special interest group white papers, trade journal articles, and webinars provide current information in place of the textbook. Linking them together for an online course meant that the lectures became longer and many of the slides became wordier. Last summer, I crowdsourced EMS 3300 on LinkedIn to update course content.

Using Simulation To Demonstrate Student Competencies

EMS 3300 provides the “big picture” of EMS by creating a commercial 9-1-1 and interfacility ambulance service to demonstrate course competencies, including staff scheduling and fleet replacement. We start by evaluating a Request for Proposal to replace a hospital-based ambulance service supplemented by community volunteer ambulances with a single ambulance service system serving a two-county suburban-rural jurisdiction. Each week, the students apply the concepts or processes covered in the lecture to the fictional River County EMS through an individual assignment, small group exercise, or a graded problem-solving assessment.

The Only Constant is Change

I thought that last summer’s crowdsourcing provided a nice bolus of updated content for the textbook-free course. This summer I planned to coast with a few course tweaks, like finding a new state contract showing the cost of purchasing or remounting an ambulance.

Yikes, I was wrong. Five of the 14 lectures needed major rewrites. The introduction to the 2026 AIMHI High Performance / High Value EMS Benchmark Survey describes the current EMS industry environment:

Emergency Medical Services is undergoing one of the most significant periods of transformation in its history. Workforce shortages, rising operating costs, reimbursement challenges, increasing clinical complexity, and growing expectations for patient-centered care are fundamentally changing how EMS systems are designed, managed, and evaluated. At the same time, EMS has expanded well beyond its traditional role as a transportation service, becoming an essential component of the healthcare continuum, public health infrastructure, and community resilience. (AIMHI, 2026, p. 1)

AIMHI’s benchmark report release inspired this post. On July 10th, I completed my course update for EMS 3300 and loaded the lectures, PowerPoints, and the peer-reviewed journal articles, industry white papers, trade journal articles, and links to webinars onto the ISU learning management system. The AIMHI benchmark was issued July 30th. Had to update two lectures, one assignment, one mid-term exam problem, and add the AIMHI 2026 benchmark survey document as required reading.

Oh, and while doing the final edit of this article, I watched a great interview of Hilary Gates and Bob Davis, 6 Minutes to Live: Why Your ZIP Code Can Determine Cardiac Arrest Survival on Derek Hanley’s The DOHP Signal. https://youtu.be/C4e4edSN5t0

We are living in interesting times.

AIMHI (2026) 2026 AIMHI High Performance / High Value EMS Benchmark Survey: Organizational, Operational, Clinical and Financial Benchmarks from North America’s Leading EMS Systems. Academy of International Mobile Healthcare Integration. https://aimhi.mobi/benchmarking-resources/

What Do Retired Firefighters Dream About?

A recently retired firefighter posted that question on a private social media account comprised of other retired members from the same department. Those who responded mentioned dreaming of being back in the fire station, interacting with the crew, and recalling the mundane non-emergency aspects of the job.

In my back-on-the-job dreams, a feeling returned that I was an integral part of something bigger, something important in a group that makes a difference in the community. I felt calm, competent, and connected. A feeling that has not shown up in any of my endeavors after retiring from the fire department.

Robert McCarl spent 18 months embedded with the Washington, District of Columbia, Fire Department (1978-1979) to conduct an ethnographic study of urban firefighters. An ethnographic study is an immersive, qualitative research method where a researcher embeds themselves into a specific community or social group to understand their culture, behaviors, and everyday practices from the participants’ own perspectives. McCarl explained his presence to firefighters this way, “I was hired by the union to document how information is passed from one guy to the next, say from an experienced man to a rookie” (McCarl, 1985, p. 21).

McCarl’s interviews with firefighters reinforce the concept of the fire department as a second family:

It’s hard to describe the closeness you felt with the guys in the fire house. I don’t think my wife has ever really understood it. I just used to love coming to work – especially on those long Saturdays when we’d have a big roast or ham or something and sit around and talk or play cards. … It’s a group of men with unique brotherhood feeling – they’ll never let you down (McCarl, 1985, p. 97)

A theme that will be repeated in the EMS section, “After the first few months in the house and on the fireground, however, this formal education (recruit school) has been shaped by the informal culture of the company and the officer, and the rookie has begun to reflect the attitude and techniques of those he has chosen as a model” (McCarl, 1985, p. 39).

Where’s My Gear?

I was surprised to find I was not the only retiree searching for my gear (fire coat, bunker pants/boots, helmet, portable radio) while dreaming of firehouse life. Probably something hard-wired from the recruit school/rookie year.

Emergency Medical Services (EMS) Is Different

Ethnographic studies of U.S. 9-1-1 ambulance service focused on private providers (Prener, 2022; Seim, 2020; Mannon, 1992; Metz, 1982). In these organizations, EMS caregivers arrive already credentialed as EMTs or paramedics. New employees receive orientation and, usually, a skills checkoff. Then they are sent out to work as part of a two-caregiver team.

Supervision may be remote and infrequent. They may spend a lot of their time between responses parked at an intersection or parking lot. This is a very different team environment from that of a fire station, with a larger fire suppression crew that includes a supervisor and a home base with a kitchen, bathrooms, bunkrooms, and dayroom to relax and recover. Caregiver annual turnover for United States EMS staff in 2022 is 25-30% (Zarei et al., 2026).

In The Ordinary Hours, James Weber uses the business fable storytelling technique to illustrate the EMS caregiver retention problem at a fictional four-station EMS 9-1-1 agency. The descriptions are vivid and valid. Following the retention improvement journey from Station 4 to the challenging Station 7 – with a 71% turnover in one year – is engaging.

Weber shows that EMS has 90 days to develop a new hire. It is a three-phase process.

• Month 1 is stabilization: provide psychological safety and agency orientation, using one consistent person as a mentor.
• Month 2 is to deepen agency integration and skill building,
• Month 3 is caregiver autonomy and organizational commitment, where the new hire’s mentor evolves into one of many resources the new hire has within the agency.

If the new hire is not anchored to the EMS agency by the 90th day, they will decide to leave.

References

Country Callbacks. (2026, June) Country Roads Went Viral at the FIFA World Cup – Here’s Why Soccer Fans are Obsessed! [YouTube] https://youtu.be/1-vSER43-GY

Mannon, J. M. (1992). Emergency encounters: EMTs and their work. Jones and Bartlett Publishers.

Metz, D. L. (1982). Running Hot: Structure and Stress in Ambulance Work. Cambridge, MA: Abt Books. https://doi.org/10.1525/maq.1983.14.3.02a00210

McCarl, R. (1985) The District of Columbia Fire Fighters’ Project: A Case Study in Occupational Folklife: Smithsonian Folklife Studies, Number 4. Smithsonian Institution Press. https://repository.si.edu/server/api/core/bitstreams/10e84cae-cc7f-4b6b-aea8-f02c2ad9208a/content

Prener, C. (2022). Medicine at the margins: EMS workers in urban America. Fordham University Press. https://doi.org/10.5422/fordham/9781531501075.001.0001

Reliable Source (2013, October 4) Bill Danoff on how ‘Country Roads’ became a German Oktoberfest hit. The Washington Post. https://www.washingtonpost.com/news/reliable-source/wp/2013/10/04/bill-danoff-on-how-country-roads-became-a-german-oktoberfest-hit/

Seim, J. (2020). Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Human Suffering. Oakland, CA: University of California Press.

Weber, J. (2026) The Ordinary Hours: Why Your Best People Leave – And The Small Things That Make Them Stay. Oak Street Press. https://www.amazon.com/Ordinary-Hours-People-Leave-Things-ebook/dp/B0FQTNKY2Y/ref=sr_1_2

Zarei, E., Safari, M., Zamani, Z., & Kakemam, E. (2026). Turnover intention and its predictors among Emergency Medical Services (EMS) professionals: a systematic review and meta-analysis. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 34. https://doi.org/10.1186/s13049-026-01567-8

Since the COVID-19 pandemic, more fire departments have added 9-1-1 emergency ambulance services. Some have been successful bidders on ambulance service contracts, replacing commercial ambulance providers like AMR and Falck. Others have resulted from a political decision by the authority having jurisdiction. Finally, some are functioning as the municipal safety net after a private or community volunteer ambulance service ceases to provide service.

Many of these transitions promise lower costs to the municipality. Once the ambulance service starts, the reality is that the fire department or municipality used unrealistic or naive financial analysis. This article provides a background and recommendations for chief fire executives.

A $3.65B Bolus of Federal and Robert Wood Johnson Funding to Start EMS

The current United States EMS system started in 1966, with Congress reacting to the National Academy of Sciences white paper on Accidental Death and Disability: The Neglected Disease of Modern Society. Congress included Emergency Medical Services (EMS) as a component of the National Highway Safety Act of 1966. The Federal Department of Health Education and Welfare’s (DHEW) five demonstration projects, the 1973 EMS Systems Act, and the Robert Wood Johnson Foundation poured $3.65 billion (in 2026 dollars) into 349 EMS systems (Shah, 2006; Bass, 2015; Sadler & Sadler, 2022).

DHEW funded demonstration projects in Arkansas, California, Florida, Illinois, and Ohio. The University of Oklahoma’s Center for Economic and Management Research (CEMR – economists and behavioral scientists) got the assignment in 1975 to study the performance of the DHEW EMS demonstration projects. 

The Jacksonville (Florida) Fire Department got the highest assessment. They took over the emergency ambulance service from funeral homes in 1967 and used DHEW money to train and equip firefighters to better handle cardiac-related calls. Jack Stout, director for the Arkansas EMS demonstration project, recalled:

AIl five of the demonstration project directors were to speak, and I was scheduled (set up) to follow Jacksonville, Florida’s Captain John Waters. When Captain Waters finished, the audience of about 800 folks was rolling in the aisles from his truly professional comic delivery. Waters’ famous dual slide show presentation had convinced even me that death was a thing of the past in ]acksonville. Watching Captain Waters, I felt sorry for other department heads who had to compete with him for a share of the ]acksonville city budget (Stout, 1985, p. 55).

Birth of High-Performance EMS and the Public Utility Model

Jack Stout moved from the Arkansas EMS project to be a researcher at CEMR. An economist, Stout believed that under the right conditions private sector ambulance services could provide better services than the Jacksonville Fire Department’s “socialized medicine” (Stout, 1985, p. 55).  This evolved into the High-Performance EMS (HPEMS) concept where the ambulance service was self-sustaining based on revenues and effective use of resources. There were nine “Public Utility Model” (PUM) high-performance EMS agencies in the 1980s. Many of the metrics we use today, like Unit Hour Utilization, came from HPEMS.

A key aspect of HPEMS is that every ambulance transport – 9-1-1, critical care, interfacility, and facility-to-home is provided by the HPEMS ambulance service (Overton & Stout, 2002). When I attended meetings of the Virginia State EMS Advisory Board, I heard complaints from volunteer rescue squads outside the City of Richmond that were not allowed to transport patients from city hospitals to their homes. The ordinance that established the Richmond Ambulance Authority (RAA), a public utility model, required that all patients transported on an ambulance stretcher in the city be moved by RAA.

When the Kansas City Fire Department took over ambulance duties from the Municipal Ambulance Services Trust (MAST) in 2010 (Mansur et al., 2009), and the Fort Worth, Texas, Fire Department replaced MedStar Mobile Health in 2025 (Wolf, 2024), the fire departments did not continue to provide interfacility transports. This dismantling of the Public Utility Model range of services affects the fire department EMS budget, as revenues from interfacility transports subsidized the cost of 9-1-1 responses in the PUM system.

A Look At Billing Revenues

The FY 2027 EMSA Strategy & Budget Book from the Emergency Medical Services Authority – a public utility model serving Tulsa and Oklahoma City – includes an EMSA Reimbursement Reality section. “The chart below underscores the vast difference between projected FY2027 billed charges and net revenue expected to be collected from the federal government Centers for Medicare & Medicaid Services (CMS) – two payors that account for nearly 70% of EMSA’s payor mix.” (EMSA, 2026, p. 4)

Breaking The Reimbursement Information Silo

While working as an assistant professor at The George Washington University, I did a deep dive into non-fire EMS. I remained active as an IAFC EMS Section member and engaged in committee work. Our tribal roots were clear, as it seemed that if the American Ambulance Association (AAA) advocated for a federal policy change, the fire service organizations would oppose it. I felt a bit like a stranger in a strange land when attending the AAA conference as an academic. Information was rarely shared between these tribes.

The first Fitch & Associates Pinnacle Conference in 2005 was an eye-opener. Dr. Jay Fitch exclaimed, “It reminds me of the Fourth Party!” The Fourth Party was an organization created by Jack Stout to provide training and advocacy for HPEMS. As with the AAA conference, some of the keynote speakers and many of the topics found at Pinnacle were not covered in fire conferences, including IAFC’s Fire-Rescue Med (FRM).

A lot has happened since 2005 …

Inadequate Ambulance Service Reimbursement

Until the Bipartisan Budget Act of 2018 directed CMS to build the Ground Ambulance Data Collection System (GADCS), the 2002 Medicare national ambulance fee schedule was established without actual cost data. Since 2004, Congress has added temporary add-ons to the fee schedule that have to be repeatedly reauthorized.

The Finance Committee of the National EMS Advisory Council, a nationally recognized council of EMS representatives and consumers to provide advice and recommendations regarding EMS to the federal government, issued a report on EMS Funding and Reimbursement in 2016. Their first conclusion:

The systematic cost of providing emergency ambulance services in the US exceeds currently available revenue. This mismatch can be resolved with one of two actions: 1) increase reimbursement or subsidies or 2) decrease costs. With fixed costs required to provide a clinically acceptable level of service, decreasing dollars spent on will result in a direct negative impact on the quality of care provided. The NEMSAC has previously recommended to FICEMS that it increase reimbursement for ambulance services utilizing the existing payment structure (NEMSAC Finance Committee Final Report, 2009). In the current economic climate, that recommendation is unlikely to be realized. (NEMSAC, 2016, p. 15)

Analyzing the Ground Ambulance Data Collection System (GADCS) Results

The first results of the GADCS surveys were published last year. Matt Zavadsky and the team from Page Wolfberg & Wirth LLC Advisory Group (PWW|AG) have been analyzing the data and interacting with the RAND Health Care’s lead author. The 2025 article Quantifying the gap between expenses and revenue for EMS services, posted on ems1.com, is the start of a continuing series analyzing the data, how the RAND author interprets it, and the implications for EMS operations. In PWW|AG’s January 21, 2025 webinar, “What We Learned From the First CMS Ambulance Cost Report,” they used CMS data to create Table X, which shows the stunning average revenue shortfall for all ambulance suppliers.

You can view this webinar and additional information on EMS reimbursement by enrolling in the PWW|AG Resource Hub, which includes a monthly EMS Financial Index. For policy issues, they have PWW|AG Industry Updates.

The post-pandemic 21% Solution that Unraveled Public Utility Models

Private-sector ambulance services poorly paid EMS caregivers before the pandemic. California is the only state to create an industry profile of the EMS caregiver workforce. The UCLA Labor Center identified “Private-sector EMTs and paramedics earned 39 percent less than their public-sector counterparts. Even when controlling for age, gender, geography, education, and race and ethnicity, public-sector wages were still much higher than private-sector wages” (Jacobs et al., 2017, p. 4). California public sector EMS employers are fire departments.

Non-fire municipal and commercial 9-1-1 paramedic ambulance services significantly raised salaries to fill EMS caregiver positions left vacant after the COVID-19 pandemic. Wake County EMS in North Carolina, a non-fire municipality, increased caregiver pay by 21% for existing and future caregivers to fill open paramedic positions and slow attrition. The 70-some open paramedic positions represent an 18% vacancy rate (Melmed, 2022). The Richmond Ambulance Authority increased caregiver salaries by 23%, raising the hourly rate by $4. Its employee turnover rate decreased from 43% to 17% (RAA, 2025, p. 13).

Similar pay raises were implemented at MedStar Mobile Health in Fort Worth, Texas; the Emergency Medical Services Authority in Tulsa and Oklahoma City; and the Three Rivers Ambulance Authority in Fort Wayne, Indiana. The increased salaries and the post-pandemic exponential jump in ambulance, medical equipment, and supplies costs placed all of these systems into financial peril. Stout’s High-Performance EMS process is financially unsustainable in the current healthcare environment.

Recommendations for the Chief Fire Executive

1) Identify and utilize a EMS reimbursement expert on your state’s regulations and practice

Medicine is a state-regulated activity. CMS regulations for reimbursement are complex. Especially now, with the dramatic DOGE initiatives and a chaotic federal government change process, you could benefit from having access to an insurance reimbursement expert in ambulance billing for your state.

2) Establish an effective audit process for submitting reimbursement claims

Some metro-sized fire departments have encountered significant potential federal fraud penalties for inaccurate or improper claim submissions. The municipal liability does not go away if you employ a vendor or subcontractor to process the claims.

3) Clearly show the expenses in adding an ambulance service

Some fire departments lump all of the operational expenses into a single budget category – if it has a siren and emergency lights, it goes in this bucket. Either internally or publicly, the municipality should be able to identify the direct expenses and the increase in existing services (911 center, apparatus shop, warehouse, training, etc.) associated with implementing a new ambulance service.

4) Consider EMS Services Going Beyond a Lights-and-Siren Rush to a Critical Patient

We will explore this in a later article, but only about six to seven percent of the patients treated and transported are clinically improved through paramedic street medicine. For those in cardiac arrest, stroke, sepsis, cardiovascular failure, allergic reaction, multi-system trauma, asthma attack, or acute metabolic crisis, we are lifesavers.

A recent study using 9.5 million EMS encounters in the 2024 ESO data revealed that:

Three percent of patients accounted for 16% of all encounters. Patients with very-high utilization were disproportionately covered by Medicaid, resided in socioeconomically vulnerable communities, and more commonly presented with chronic conditions. Despite higher transport rates, they were 40% less likely to be admitted than single encounter patients. The median time between encounters was 10 days for very-high utilizers (Fernandez et al., 2026).

Many of our 9-1-1 EMS calls are for situations never imagined in 1966. An ESO Solutions review of a little over ten million fire company responses (pumpers, ladder trucks, and heavy rescues) in 2025 shows that 66% are to EMS calls. Is this the best use of this resource?

References

Bass, R. (2015). History of EMS. In D. C. Cone (Ed.), Emergency Medical Services: Clinical Practice and System Oversight (2nd ed., Vol. 1, pp. 1-16). John Wiley and Sons, Ltd. 

Crowe, R. P., Fernandez, A. R., Treichel, A., Gardner, B., & Myers, B. (2026). Fire Service Index: Insights and Best Practices for Fire Departments (8^th edition) [White Paper]. ESO Solutions. https://www.eso.com/fire-service-index/

EMSA (2026) FY 2027 EMSA Strategy & Budget Book. Emergency Medical Services Authority. https://emsaok.gov/fiscal-strategy-and-budget/

Espinoza, M. (2026, July 26). Sonoma County Fire District, the regions largest ambulance service provider, seeks 16.36% rate increase. The Press Democrat. https://www.pressdemocrat.com/2026/07/18/sonoma-county-fire-district-regions-largest-ambulance-service-provider-seeks-16-36-rate-increase/

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

Fernandez, A. R., Myers, J., Bourn, S. S., Crowe, R. P., Preusser, E. C., Muisyo, J., Treichel, A., Green, A. M., Onaeko, K., & Beck, E. (2026). A national description of emergency medical services patient utilization patterns. Health Affairs Scholar, 4. https://doi.org/10.1093/haschl/qxag144

Jacobs, K., Heller, N., Waheed, S., & Appel, S. (2017, February 7). Emergency Medical Services in California: Wages, Working Conditions, and Industry Profile. UC Berkeley Labor Center. http://laborcenter.berkeley.edu/emergency-medical-services-in-california-wages-working-conditions-and-industry-profile/

Mansur, M., Horsley, L., & Ochsner, C. (2009 Sep 28). MAST Takeover Won’t Change Service, Officials Say. The Kansas City Star.

Melmed, G. (2022, Mar 23). Wake County increases pay for EMS employees in effort to fill jobs and retain workers. CBS 17 https://www.cbs17.com/news/local-news/wake-county-news/wake-county-increases-pay-for-ems-employees-in-effort-to-fill-jobs-and-retain-workers/

Overton, J., & Stout, J. (2002). System Design. In Kuehi, A. E. (Ed.) Prehospital Systems and Medical Oversight. (3rd ed. pp. 114-131) Kendall Hunt Publishing.

Richmond Ambulance Authority (RAA). (2025). Presentation to City Council’s Public Safety Standing Committee. https://www.rva.gov/sites/default/files/2025-02/Richmond%20Ambulance%20Authority.pdf

Sadler, A. & Sadler, B. (2022). (P)LUCK: Lessons We Learned for Improving Healthcare and the World. Silicon Valley Press. ISBN 9781735873183

Shah M. N. (2006). The formation of the emergency medical services system. American Journal of Public Health, 96(3), 414–423. https://doi.org/10.2105/AJPH.2004.048793

Stout, J. (1985). 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

Wolf, E. (2024 May 21). Fort Worth council approves switch from MedStar to fire-based EMS system. Fort Worth Report. https://fortworthreport.org/2024/05/21/fort-worth-council-approves-switch-from-medstar-to-fire-based-ems-system/

Zavadsky, M., & Wolfberg, D. (2025, February 17). Quantifying the gap between expenses and revenue for EMS services, ems1.com. https://www.ems1.com/ems-trend-report/quantifying-the-gap-between-expenses-and-revenue-for-ems-services

I collect items that may show up in the sixth edition of Fire Officer: Principles and Practice, which comes out after NFPA Standard 1020 is updated around 2030. The St. Lucie County Fire District in Florida has provided a climate survey example. The fire district employs 523 firefighters operating out of 19 fire stations. Three Battalion Chiefs and a Deputy Chief on duty for each shift. 2025 Annual Report.

Fire Station 1 at Fort Pierce is the busiest station, with the 8 employees responding to 11,044 incidents in 2025 while staffing an engine and two rescue (ALS ambulance) trucks. The department responded to 71,203 incidents.

Severe Hazing Results in 3 Terminated and 2 Suspended

Senior firefighters, including acting supervisors, severely hazed rookie firefighter/paramedics at Station 1A, including using a modified bug zapper to administer shocks in 2024. The fire district obtained the videos in March 2026. The 17-page media advisory released by the fire district on July 18th provides extensive details and can be accessed through this link.

In-Station Behavior

The law firm that conducted the investigation included the July 2025 Susan Gainey Workplace Culture Analysis. Those findings include:

• Overly aggressive banter, mockery, sarcasm, and personal questioning unrelated to job performance, including 1A firefighters asking recruits in front of a group about drug usage.
• Mocking or public correction of apprentices, which some described as humiliating or going “overboard.”
• “Light hazing,” “playing jokes,” or “horseplay” that blurs the line between camaraderie and misconduct. One employee noted that such behavior would not be accepted at other stations.
• A sentiment among multiple firefighters that certain individuals were “not welcome” unless conforming to unspoken social norms.
• An environment that is “cliquish” such that new employees or employees on short-term assignments do not feel part of the team and may feel isolated.
• More than one employee stated that 1A is composed of “cowboys” who “do their own thing.” One employee stated that he was told by someone from 1A that they “did things their way, not the department way,” suggesting that they do not follow District policies and procedures.
• Multiple employees stated that the workplace culture at 1A was not inclusive.
• Firefighters had requested transfers or expressed discomfort due to the 1A environment.
• One firefighter stated that the environment at 1A “made it tough to come to work.”
• Loyalty among existing crew members can result in the informal exclusion of newcomers.
• One firefighter reported there appeared to be favoritism or bias in advancement at 1A.

My experience on the job and as a consultant is that while the formal fire department may have a specific way or philosophy of doing things, each fire station creates its own version of “the fire department way.” Station 1A behaving like cowboys is an observation I have heard in earlier bad-outcome investigations at other jurisdictions.

The decentralized nature of fire departments makes effective emergency response, but diffuses fire headquarters directives. I spent a year as a relief Fire Lieutenant, filling C-shift vacancies in all six battalions in a department with 36 fire stations. Every station was different. The fire company commander and the battalion chief have a profound impact on crew behaviors and task competencies.

If you are a supervisor, manager, or administrator, you should read the St. Lucie County Fire District media advisory. The culture described in this report is troubling, but not unique. How would you handle it in your department?

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.