Thanks for the continuing conversations. This week, we examine two key components of EMS Systems: Deployment and Staffing. Like earlier lectures, I strive to find original source documents to lay the groundwork for our discussions. Surprised to find an opportunity to provide a 25-year perspective from two systems I performed deep dives on when I started as a full-time academic.
This week’s asks:
- Has ambulance staffing gotten easier in 2025 than it was in 2020?
- What is driving caregiver turnover today: workload (hours), work conditions, or pay?
- 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/