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.

Replaceable Semi-Skilled Carbon Based Productivity Components

A speaker at the Fitch and Associates Pinnacle EMS leadership conference was the chief executive officer of a commercial ambulance company that could be found in many regions of the United States. His presentation acknowledged that many of his younger caregivers were waiting to get a fire department job. He used the fast-food industry approach, expecting a high turnover of caregivers that perform services using standardized tasks and responsibilities in a regimented format. I thought Skip Kirkwood’s head would explode.

That CEO, as well as the corporation, is no longer in the medical transportation industry. But his approach may be based on workforce reality. We have two distinct ems caregiver workforces: private/jurisdictional and fire department. As well as two generations. Let’s look at the available data.

The 2019 AAA/Avesta Ambulance Industry Employee Turnover Study provides details concerning the private/jurisdictional/community EMS services. This is the second year this survey has been conducted. The overall annual turnover shows:

• Full-Time Paramedic: 19%
• Part-Time Paramedic: 37%
• Full-Time EMT: 28%
• Part-Time EMT: 47%

Part-timers, or per-diem caregivers, are the hardest to retain. Per-diems represent up to 50% of the ambulance service workforce in commercial and jurisdictional services. Only full-time paramedic positions have a slightly better annual turnover than the national rate of 20% for all occupations.

EMS Is A Professional Afterthought 

Michael Corman points out in his 2017 industrial ethnography of Alberta, Canada, paramedics that there has been little sociological attention paid to EMS providers. Donald Metz was a professor of sociology who produced a 1981 ethnography of ambulance work while he was a part-time Emergency Medical Technician (EMT) for a private ambulance service providing urban 911 services.

Metz pointed out the incongruity of an ems caregiver police-style uniform as found in the early 1980s – collared shirt, badge, shoulder patch, name tag and metal jewelry showing authority – and the requirement to use a clip-on tie. The clip-on tie is to protect the caregiver if the patient or a bystander grabs the tie. Metz also pointed out that EMTs in the private ambulance service as well as EMTs and paramedics in the fire department face no future advancement – “EMS work is at best a detour, and perhaps even a barrier, on the road to advancement” (page 185).

Sociologist Eddie Palmer (1989) looked at paramedic performances and “trauma junkies” indicating that the street performance of paramedics was similar to police officers. “Within an occupational milieu of excitement, danger, and public attention, paramedics perform a variety of roles constituting street work similar to that documented for police officers. Playing the roles of authority figure, lifesaver, information specialist, partner, grief manager, and counselor, paramedics are immersed in a work world replete with teamwork demands, conflicts with medical and nonmedical personnel, vaguely defined legal standards, and occupational uncertainty due to the newness of their medical niche.”

In a small qualitative study looking at recruitment and retention of ems caregivers in 2005, P. Daniel Patterson’s team identified three themes:

1. EMS Is a Professional Afterthought
2. EMS is an Emotional Paradox
3. EMS is an Educational Black Box

In Theme 1, many of those interviewed by Patterson did not originally plan to be an EMS caregiver. This job was chosen after completing their first career, often military or nursing. Or they chose this job after failing to complete training for another, more attractive job.

When I ran an online bachelor degree completion program at a private university many of the students were going back to school after suffering an academic or career crash 4 to 10 years earlier. Now, often with a spouse and children, they want to go back to their original plan. About 12% of the bachelor degree graduates went on to get a master’s or professional degree with 6 of them becoming physicians. All of them were credentialed as a paramedic before 2014.

University of New Mexico EMS Physician Scene Response Program – Albuquerque

Pay, Unionization and Education

The paramedic recredentialling exam as administered by the National Registry of EMTs (NREMT) includes industry research questions. Paramedics must take the recertification exam every two years. In 2013 NREMT asked those who identified that they worked for Zero EMS agencies the reasons they were not working as a caregiver and their intention to return to practice (Cash) . The most frequent reason they were not working as a paramedic was a desire for better pay and benefits.

Paramedics, especially the majority who do not have union labor representation, fall into the lower-middle class level of pay. The California 2017 study of ems caregivers identified that there was a 39% difference in pay from those working for commercial ambulances and those working for fire-department based ambulances. (Jacobs) The single-role, non-firefighter, paramedics working in California fire departments are members of IAFF, the local labor organization.

The second most frequent reason paramedics were not working was the desire for further education. It appears this further education is to move beyond the role of a paramedic and to become a nurse (18% of the respondents) or go to medical school (5%). This reinforces Patterson’s Theme 1 that “EMS is a Professional Afterthought.”

Despite the vigorous pushback by old school paramedic leaders at the proposal to require an Associate Degree before credentialling as a paramedic, a 2020 study of the demographics of National Registry credentialed caregivers show that 28.5% of paramedics possess an associate degree (Rivard).

This is due, in part, to the caregivers that received their initial training since 2014, when the new Educational Standard went into effect. A snapshot from the Committee on Accreditation of Allied Health Education Programs shows that there are 375 paramedic programs run by a two-year technical or community college where the student is required to complete the degree requirements before they are eligible to sit for the NREMT paramedic credential exam.

In addition, there are 171 accredited paramedic certification programs not directly affiliated with an academic institution or teaching medical center. An example would be a paramedic training program run by a fire department. To meet the new Educational Standard, they were required to have a consortium agreement to allow academic transfer credit for successful credentialed paramedics. For many of these students, they will need to complete about 15 semester hours of general education courses to get an associate or technical degree from the consortium educational partner.

The Next Generation of Caregivers, 2014 and onward

It appears we may be seeing a change in the demographics of paramedic caregivers with the 2014 implementation of the 2008 Educational Standard for initial paramedic training. With many paramedics having a “clinical caregiver career” of just 3-7 years, many single-role paramedics initially trained before 2014 will be aging out. On the other hand, fire department paramedics, both single role and firefighter/paramedic, tend to work an entire 20-to-30-year municipal career (Byron).

If You Were Credentialed as a Paramedic AFTER 2013 What Do You Need to Become an EMS Professional?

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ACEP (2020 May 16) “EMS Week” Irving, TX: American College of Emergency Physicians. Accessed May 16, 2020:  https://www.acep.org/administration/ems-resources/emsweek/

AAA/Avesta (2019 July) AAA/Avesta 2019 Ambulance Industry Employee Turnover Study. McLean, VA: American Ambulance Association.

Ethnography is a set of qualitative methods that are used in social sciences that focus on the observation of social practices and interactions. Its aim is to observe a situation without imposing any deductive structure or framework upon it and to view everything as strange or unique.

Corman, M (2017) Paramedics On and Off The Streets: Emergency Medical Services in the Age of Technological Governance  Toronto: University of Toronto Press

Metz, D. L. (1981) Running Hot: Structure and Stress in Ambulance Work. Cambridge, MA: Abt Books.

Palmer, C. E. (1989). Paramedic performances. Sociological Spectrum, 9 (2), 211-25. http://dx.doi.org/10.1080/02732173.1989.9981884.

Palmer, E. (1983) “Trauma junkies” and street work: Occupational behavior of paramedics and emergency medical technicians. Urban Life, 12 (2), 162-83. http://dx.doi.org/10.1177/0098303983012002003

Patterson, P.D., Probst, J. C., Leith, K. H., Corwin, S. J., Powell, M. Paige. (2005) Recruitment and Retention of Emergency Medical Technicians: A Qualitative Study. Journal of Allied Health 34 (1) 153-162.

https://emed.unm.edu/clinical/emergency-medical-service-consortium/physician-ems-field-response.html

Rebecca E. Cash, Remle P. Crowe, Riddhima Agarwal, Severo A. Rodriguez & Ashish R. Panchal (2018) Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice, Prehospital Emergency Care, 22:1,28-33, DOI: 10.1080/10903127.2017.133974

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

Rivard, M.K., Cash, R.E., Mercer, C. B., Chrzan, K. & Panchal, A. R. (2020): Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting. Prehospital Emergency Care. DOI: 10.1080/10903127.2020.1737282

CAAHEP (2019) Emergency Medical Services – Paramedic. Clearwater, FL: Commission on Accreditation of Allied Health Education Programs https://www.caahep.org/Students/Program-Info/Emergency-Medical-Technician-Paramedic.aspx Accessed November 15, 2019.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, EMTs and Paramedics. Accessed April 22, 2020: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm.

Byron, J. (2018) Career Paramedic-Firefighter Staffing Problems: Is Recruiting Women Part of the solution? (master’s thesis) Naval Postgraduate School, Monterey, California. Retrieved from https://www.hsdl.org/?view&did=821413

The creation of knowledge is the core of the activity of a research scientist or professor. The peer-review publishing process was started during a smallpox outbreak in the 1820s when the powerful Académie de Médecine medical institute in Paris published a weekly account of their discussions as they evaluated a new vaccine. (Tingley) This process of moving from private conversations to public papers was the foundation of peer-reviewed scientific journals.

Getting published in a peer-reviewed journal takes time, this graphic from Voight and Hoogenboom provides the details:

Once published, this new information becomes part of the on-going conversation in this field of study. Eventually, someone will build upon this new information to further expand the understanding of this field of study.

The Crisis of a Novel and Unknown Virus

In an earlier post, we described the situation facing medical staff and first responders:

At the start of this pandemic, medical, public health, and first responders were like a test pilot in an out-of-control experimental airplane. Transmitting a non-stop detailed radio commentary of what the pilot is observing, what the pilot is doing, and what are the results. Often factoids will pop-up out of context or be incompletely reported.  5 Tips When Commanding During A Time of Great Hazard and Uncertainty

The traditional peer-reviewed process would mean that what is being learned on the front lines of the coronavirus fight would not be shared in a peer-review journal for 6 to 12 months. 

Kim Tingley, writing for The New York Times Magazine, describes two actions taken by peer-reviewed publishers to make potentially life-or-death research available as quickly as possible:

1. Dropping the paywalls of Science, The Lancet, Journal of the American Medical Association (JAMA) and The New England Journal of Medicine to make coronavirus content free online.
2. Encouraging researchers to post their submissions on pre-print servers, where anyone can access them before they undergo a peer-review process.

This means that a finding submitted to Science was publically available in days instead of months. Posting initial research findings on pre-print servers allows researchers to quickly share preliminary work and may help the scientific community to collaborate more effectively and efficiently.

This also means that many more people are following scientific journals. That means many factoids, cautions, or concepts are getting significant media attention without noting that this is a preliminary finding that has not been verified.

Awash in Stories

There are heartbreaking and amazing stories of loss and survival. From Dallas, a patient who was on a ventilator for 30 days:

The Texas Health Dallas team had already tried at least a half-dozen therapies.  … Then they turned to a treatment from the history books. Convalescent plasma, antibody-rich blood donated by survivors of infectious disease, was developed in the late 1800s to fight diphtheria. It was the subject of the 1901 Nobel Prize in Physiology or Medicine and has been deployed against measles, mumps, and the 1918 Spanish flu.

Texas Health Dallas obtained emergency permission from the federal government to administer convalescent plasma on a compassionate-use basis because Michael remained critically ill. (Kuchment)

That does not mean that every patient who is on a ventilator should immediately receive convalescent plasma. But it does add to the knowledge of COVID-19 treatment outcomes and needs further study.

Getting a Handle On The Work In Progress

There are efforts to keep track of clinical developments. Over 600 clinical trials have been registered at various clinical sites. A global coronavirus COVID-19 clinical trial tracker has been developed. https://www.covid-trials.org/

This remains a bumpy ride over unfamiliar terrain for fire and ems commanders. We are seeing some signs of a framework, not unlike the imposing of order on the chaos of a multiple alarm/multiple hazards incident. The situation remains deadly and fluid.

Stay safe, be smart, mask up.

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Tingley, K. (2020 April 21) Coronavirus Is Forcing Medical Research to Speed Up. The New Your Times Magazine. Accessed April 24, 2020: https://www.nytimes.com/2020/04/21/magazine/coronavirus-scientific-journals-research.html 

Voight, M. L., & Hoogenboom, B. J. (2012). Publishing your work in a journal: understanding the peer review process. International journal of sports physical therapy, 7(5), 452–460.

Ward, M.  (2020 March 30) 5 Tips When Commanding During A Time of Great Hazard and Uncertainty CompanyCommander.com Reston, VA: Gold Badge Enterprises.

Kuchment, A. (2020 April 25) Dallas medical team rescues coronavirus patient after 30 days on life support: Doctors at Texas Health Dallas relied on their experience with Ebola — and a treatment from the history books — to help a Dallas man recover. Dallas Morning News. Accessed April 26, 2020: https://www.dallasnews.com/news/public-health/2020/04/25/dallas-medical-team-rescues-coronavirus-patient-after-30-days-on-life-support/

Thorlund, K., Dron, L. Park, J., et al (2020 April 24) A real-time dashboard of clinical trials for COVIC-19. The Lancet. DOI: https://doi.org/10.1016/S2589-7500(20)30086-8 Accessed April 26, 2020: https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30086-8/fulltext#articleInformation 

Featured image:

Professor Neil Postman’s book Amusing Ourselves to Death: Public Discourse In The Age of Show Business pointed out that visual communications, inspired by television, has made our world more like Aldous Huxley’s Brave New World – a population too amused by distractions like entertainment, leisure, and laughter to realize they have been made powerless – rather than George Orwell’s 1984 – a tyrannical state that bans information to keep the public powerless.

The larger point that Postman made was that societies are molded by technologies atop which they communicate. :

• Oral cultures teach us to be conversational.
• Typographic cultures teach us to be logical. Fire departments operate as a typographical culture – paper empires of logic and procedures.
• Televised cultures teach us that everything is entertainment and emotional.

I wonder how Postman would evaluate FaceBook memes, YouTube, and social media algorithms that are built to maximize the time users spend within the application. (Derakhshan 2016)

Nicholas Carr, the author of The Shallows: What the Internet is Doing to Our Brains, argues that the rise of the Intenet intensifies the move away from print culture. This move away from print even affected Carr as he confesses his own inability to concentrate after switching from physical books to online reading:

I’d sit down with a book, or a long article, and after a couple of pages my brain wanted to do what it does when I’m online: check e-mail, click on links, do some Googling, hop from page to page…the more time we spending surging, and skimming, and scanning…the more adept we become at that mode of thinking.  (NPR interview of Carr on 2010 June 2)

Conflict Drives Eyeballs

When I am “curating” items to post on the Company Commander Facebook feed in the early morning I am looking for items that evoke the type of reaction Chicago columnist Mike Royko went for – his daily columns took about two sips of coffee to read, sometimes ending with the reader exclaiming “!#%$!! Chicago.”

I was late getting on-board about Atlanta Captain Danny Dwyer. On Thursday I linked a post to the Wednesday editorial from the Atlanta Journal-Constitution.

The post quickly reached 1,309 people, getting 405 Facebook “engagements,” 117 emoticons, 16 comments, and 15 shares.

This is a “!#%$!! Fire Service” article.  High outrage, anger at the fire chief and some over-the-top responses. The Fire Atlanta Fire Chief Slaughter Facebook page was already up and this issue is “viral.”

Headline Readers

Most readers will not click to read the article attached to a Facebook post. They react to the headline and the picture. I try to put enough information in the FaceBook comment to describe the story, but that is not always done.

For example, it is clear that many of the 107 commenters responding to “Catastrophic Fires in Mid-Rise Multifamily Dwellings Under Construction – 5 Considerations” that was posted last Monday were only reacting to the dramatic picture and headline without the benefit of reading the article.

That commenter behavior may be a function of boosting the Catastrophic Fires item as a week-long Facebook Ad to a group of Facebook members that identify as fire or ems. Reached 14,000 additional people beyond the usual group of Company Commander readers, so …  eyeballs.

Monetizing Content

Controversy, over-the-top activities, and conflict increase online views. I like YouTube videos from automotive-themed personalities and wonder how much money they are making. (… and if Company Commander can do the same.)

In 2015 Garrett Mitchell was working for 1320Video. He created a character “Cleetus McFarland” in a motel parking lot late one night. He got over 100,000 views.

Cleetus McFarland became its own youtube site, with 1.87 Million subscribers as of this week. Revenue must be great, as the 24-year-old Garrett just purchased an abandoned racing track on 63 acres in Manatee County, Florida. The “Freedom Factory” will be used to create additional content and sponsored events.

Tyler Hoover, with 904K subscribers, pointed out that his routine of buying “the cheapest version of a luxury or exotic car” for Hoovie’s Garage and then trying to fix them get many more views than the videos of fixing up a car without much drama or problems. In fact, the videos without drama do not bring in enough revenue to justify Hoover making any more of them.

What to do when you get outraged?

Being in a constant state of outrage over real or imagined issues that are well beyond your sphere of responsibility is as unhealthy on your emotional condition as a steady diet of caffeinated drinks have on your cardiac physiology (Bodin FDSOA).

When we add energy drinks on board we have increased our risk of a cardiovascular event to happen even sooner. Over 38 countries around the world have either banned these drinks due to the detrimental side effects or placed age limitations on them according to Quartz Media. Studies world-wide have proven the dangers of regular intake of these drinks. (IAFC Cardiac Awareness Toolkit)

I like what Bill Carey posted in “I Don’t Think It’s What You Think It Is” on Backstep Firefighter.

So instead of memes and live Facebook rants, review your department’s disciplinary procedures, appeals, grievances and the like.

Be prepared for when a bit of bullying – which is what is happening in Atlanta – happens to you. Be better than a chief with nothing more than an ax to grind.

A fire in June 2019 suddenly gets a disciplinary review? No, it’s not about the fire.

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Parts of this column were originally published in the August 5, 2019, Company Commander column: “Fire Officer Supervising In The Age of Show Business – 3 activities to stay on top”

Neil Postman (1931–2003) was chairman of the Department of Communication Arts at New York University and founder of its Media Ecology program. He wrote more than twenty books.

Postman, Neil (1985/2005) Amusing Ourselves to Death: Public Discourse In The Age of Show Business. 20th-anniversary edition. New York, NY: Penguin Books.

Silvestre, Dan (2018 Sept 11) Lessons from Amusing Ourselves to Death by Neil Postman. Medium.com.  Accessed August 3, 2019.  https://medium.com/@dsilvestre/lessons-from-amusing-ourselves-to-death-by-neil-postman-962221ee622tk 

Derakhshan, Hossein (2016 Nov 29) Social Media is Killing Discourse Because It’s Too Much Like TV: We need more text and fewer videos and memes in the age of Trump. MIT Technology Review.

Carr, Nicholas (2011) The Shallows: What The Internet is Doing to Our Brains. New York, NY: W. W. Norton & Company.

Athitakis, Mark (2015 February 26) Reading the Midwest: Mike Royko. Belt Magazine. Cleveland, OH: Belt Publishing. Accessed February 15, 2020. https://beltmag.com/reading-the-midwest-mike-royko/

Adams, Rick (2020 January 31) YouTube star Cleetus McFarland buys Desoto Speedway in Manatee County. WWSB. Sarasota, FL: Gray Television. Accessed February 15, 2020. https://www.mysuncoast.com/2020/02/01/youtube-star-cleetus-mcfarland-buys-desoto-speedway-manatee-county/

Riedl, Matt (2018 July 05) Wichitan becoming an online celebrity thanks to his crazy car collection. The Wichita Eagle. Wichita, KS: Kansas.com Accessed February 15, 2020. https://www-1.kansas.com/entertainment/ent-columns-blogs/keeper-of-the-plans/article213617609.html#

Bodin, Dan (2018 August) The Effects of Energy Drinks in the Fire Service. Ann Arbor, MI: Fire Department Safety Officers Association.  Accessed February 16, 2020. https://www.fdsoa.org/wp-content/uploads/2018/08/The-Effects-of-Energy-Drinks-1.pdf

Carey, Bill (2020 February 14) I Don’t Think It’s What You Think It Is. Backstep Firefighter. Trumbull, CT: Clarion UX. Accessed February 15, 2020.  http://www.backstepfirefighter.com/2020/02/14/i-dont-think-its-what-you-think-it-is/

Feature photo: Page from a 1962 Fire Education book that has appeared on threads discussing Captain Dwyer’s discipline.

They proposed that EMS systems focus attention to first response/BLS response time to measure

… the most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.

That change did not happen, but we need to reconsider what the Eagles advocated.

8:59 minute response criteria started in Seattle

The 1979 “Cardiac Arrest in the Community” paper in the Journal of the American Medical Association made this observation; If CPR was initiated within four minutes and if definitive care was provided within eight minutes, 43% of the patients survived. If either time was exceeded, the chances of survival fell dramatically. This document appears to be the foundation of the requirement that an ambulance (paramedic) arrive within 8:59 minutes 90% of the time.

In 1979 definitive care was a paramedic on an ambulance with a defibrillator and medications. Only physicians, nurses, and paramedics could use a defibrillator outside of a hospital. The ambulance was the only street-level provider of care above Red Cross Advanced First Aid.

Doctor Eisenberg reflected on the evolution of prehospital care when he gave the C. J. Shanaberger Lecture in 2006. He observed that a study from King County, Washington, demonstrated no improvement in survival rates over a 25-year span. Eisenberg’s response was to establish the Resuscitation Academy to go beyond a speeding ambulance to develop and deliver a community-based 10 step program that improves cardiac arrest survival.

4:00 minutes from recognition to clinical intervention

What would happen if we focused on community response to get a chest compressor and AED to a patient’s side within 4 minutes of a cardiac arrest alarm? What would that system look like?

Many of the advanced skills that were restricted to highly qualified medical caregivers in 1979 are available to a large part of the caregiver and general public population.

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Myers J.B, C. M. Slovis, et al. (2008) Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking. A Statement Developed by the 2007 Consortium U.S. Metropolitan Municipalities’ EMS Medical Directors. Prehospital Emergency Care 12(2) 141-151

Eisenberg, M.S.; L. Bergner and A. Hallstrom. (1979) Cardiac Resuscitation in the Community: Importance of Rapid Provision and Implications for Program Planning. JAMA (241(18) 1905-1907

Eisenberg, M.S. The C. J. Shanaberger Lecture: The Evolution of Prehospital Cardiac Care: 1966-2006 and Beyond. Prehospital Emergency Care October-December 2006 10(4) 411-417.

Featured image, two women provide CPR in street.

He persisted, “… you know the incident where the second search team found a bigger safety hazard.” More silence. “How many have heard about (the full formal name of the incident)?” A few hands went up.

Wow. This multiple-firefighter fatality incident occurred three-and-a-half years earlier and made national news for a couple of days. Departments made operational changes based on the lessons learned from this tragedy. Most of the attendees at the FDIC presentation did not remember the incident.

Memory

Memory is our ability to encode, store, retain and subsequently recall information and past experiences in the human brain. It is the sum total of what we remember. Memory gives us the capability to learn and adapt from previous experiences as well as to build relationships.

It is how Recognized Prime Decision Making works when making emergency scene decision-making, using the ability to remember past experiences, and the power or process of recalling to mind previously learned facts, experiences, impressions, skills, and habits.

History

Every society has its collective and individual memories, history is a more self-selective and conscious enterprise. Historian Pierre Nora defines history as a means with which modern societies organize their past that they will otherwise forget because they are driven by change.

For that FDIC instructor, the XYZ City event remains a vivid memory. For the attendees, it represents a historic LODD incident. The key to preserving those hard-earned emergency service lessons is to provide context, connection, and emotion.

Context

Provide the “why” this lesson learned is important. For example, the six greater alarm structure fires at multifamily Type IV buildings under construction in 2017 featured explosive fire development that overwhelmed the first alarm crews. Significant resources were needed, the equivalent of a big-city 5th alarm assignment. Each incident generated a loss of $20 million or more.

Another “why” is found in the NIOSH line-of-duty investigations where they note that a thermal imaging camera was present but not used, on-scene but broken or the firefighter was not competent using the tool.

Connection

Link the lesson learned to your department’s environment. California departments in the wildland/urban interface have been reviewing best practices for air tanker operations after Battalion Chief Matthew Burchett was killed August 13, 2018, under a retardant drop at the Mendocino Complex fire north of San Francisco.

The footage shows what happens when a CAL FIRE Grumman S2-T air tanker carrying 9,000 pounds or 4.5 tons of flame retardant releases its load on an SUV during a low-drop flyover. The vehicle buckles, teeters and rocks back and forth on its wheels from the force of the retardant crashing to the ground during the flyby. An accompanying message poses a question: What would the SUV look like if the plane needed to drop 85 tons of flame retardant on a wildfire?

Emotion

Link the lesson learned to an emotional hook with the student. This varies by individual, but Steve Crothers finds value in telling What, How and When stories.

Stories are intended to educate, entertain, engage, and inspire your students into action. The power of a story is profound and can dramatically change your ability to share your message. Students are much more likely to remember a certain idea if they can relate to it by understanding how it played out in a story.

American poet Maya Angelou best summed it up by saying, “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

A new book provides an oral history of 9/11 as these events “… are shifting from memory to history.”

In Garrett Graff’s book, “The Only Plane in the Sky,” he has compiled a comprehensive oral history of the day. The book is a timeline of Sept. 11, 2001, told via brief diary-like accounts, many intensely personal, from a broad range of Americans — flight attendants, high-ranking government officials, first responders and also people in New York and Washington going to work that day.

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The Human Memory

Nora Pierre. 1989 Between Memory and History: Les Lieux de Mémoire. Representations (26) 7-24.

Fox, Justin (2019 February 13) Why America’s New Apartment Buildings All Look the Same: Cheap stick framing has led to a proliferation of blocky, forgettable mid-rises—and more than a few construction fires. Bloomburg Businessweek

Picture of Avalon at Edgewater NJ apartment fire.

Starnes, Andrew (2018 April 3) Thermal Imaging Cameras in the Fire Service: Asset or Detriment? You Decide. Fire Apparatus Journal (3) 21

Thompson, Don (2018 September 14) Utah firefighter’s death caused by retardant drop from 747. The Salt Lake Tribune.

Crothers, Steve (2019 February 02) The Power of Using Stories When Instructing. FireRescue Magazine (2)15.

Political cartoon by Dave Granlund.com (2018 September 10)

The World staff (2019 September 11) Remembering how America experienced 9/11. Public Radio International.

Graff, Garrett (2019) The Only Plane In the Sky: An Oral History of 9/11. New York: Simon & Schuster.

Featured Image from 2014 FDIC