JOURNAL OF EMERGENCY MEDICAL SERVICES ®
I JEMS 2012 Salary & Workplace Survey I
The future looks bright—but how bright?
By Michael Greene, MBA/MSHA
OctoBER 2012 Vol. 37 No. 10
42 I Healthcare Reform I
Changes present an unparalleled opportunity for EMS
By Teresa McCallion, EMT-B
46 I Mobile Warming I
Lessons learned in hypothermia prevention under difficult
By 2LT Collin Hu, EMT-E, James Spotila, PhD, EMT-B
52 I A Study on Safety I
Highlights from workshop on ambulance patient compartments
By Jennifer Marshall Y. Tina Lee
60 I Innovative Design I
7 I Load go I Now on JEMS.com
12 I EMS in Action I Scene of the Month
14 I From the Editor I Patches, Pride Patients
Pumper/ambulance model takes service to a new level
By Bob Vaccaro
64 I Vital Pathways I
Detect treat symptoms related to hemorrhagic shock
By Peter Taillac, MD, FACEP, Chad Brocato, DHSC, CFO, JD
y A.J. Heightman, MPA, EMT-P
16 I Letters I In Your Words
18 I Priority Traffic I News You Can Use
24 I lEADERSHIP sECTOR I Closed Door Policy
y Gary Ludwig, MS, EMT-P
26 I Tricks OF the TRADE I Warm Enough for Ya?
y Thom Dick
28 I case of the month I Naked Unconscious
y Kimberly Doran
I employment Classified Ads
I Ad Index
I Hands On I Product Reviews from Street Crews
I Lighter Side I Clenched Teeth Verbiage
y Steve Berry
82 I LAST WORD I The Ups Downs of EMS
About Salary Survey, we revisit Flowing Springs EMS from this past year’s survey in an effort to anathe Cover
In this year’s JEMS
lyze how the economy and the overall structure of U.S. healthcare is affecting typical EMS agencies across
the country. And as the subtitle “The future is bright—but how bright?,” hints, we found the data to be (cautiously) optimistic. pp. 30–41. Photo Chris Swabb
Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med
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Unlike an operations position, which manages the dayto-day workings of an organization, the board of directors is all about leadership and governance. In “View from
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OCTOBER 2012 JEMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
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JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES ®
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Department
Associate Medical Director, North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Professor EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Ill.) Community Hospital
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals
Emergency Services Institute
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager,
Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue
EMS IN ACTION
Scene of the month
Photos Roland Webb
iders collide during the start of day six of the seven-day BC
Bikerace, a rugged mountain bike course stretching from
Vancouver to Whistler, British Columbia, Canada. According to
Roland Webb, course medical manager, the EMS team of approximately 20 paid and volunteer paramedics and nurses treat nearly
all of the approximately 520 participants at some point during the
seven days, whether for minor or complex injuries. (Top right) A
basecamp nurse cleans foreign bodies from a man’s eye after a
day racing in heavy rainfall and mud. Performing effective care at
the race presents many challenges for EMS, including re-locating
daily and dealing with remote locations and potentially challenging
extrications, Webb says. “In some places, access is a nightmare, and
in others it’s easy, so you have to be flexible and get a clinic staff
together for one week a year that can handle it.”
from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
Patches, Pride Patients
Consistent cooperation should be the goal
ave you noticed how well personnel from different agencies—and
those wearing different uniforms
and shoulder patches—get along and work
together during a cardiac arrest or mass casualty incident?
Know why that is? It’s because they’re all
focused on a common goal: the mitigation
of a complex incident or resuscitation of a
person whose life will slip away if they don’t
focus on the most appropriate
care, set aside personal biases
about who’s in charge and follow the command system
regardless of who’s “in charge.”
I’ve found this to be the case during most
“big” calls. But when you get public, private,
third service and hospital-based EMS system
administrators together for a planning meeting or at a city council hearing on the best
way to offer EMS in a region, their protective attitudes, operational and staffing biases,
and agency loyalties, will often surface like
the teeth on a shark that smells blood in the
It shouldn’t be that way. We should check
our egos and biases at the door whenever
we leave home to head to work. We should
simply focus on the patient and delivering
optimal service to the community.
Wars have taught us invaluable lessons
about strategy development, command and
control, and the use of innovative tactics.
They have also taught us many hidden lessons
about group interaction, the use of limited
resources and, most importantly, “blind” faith
and cooperation between forces from different service branches without bias or prejudice—particularly when it comes to combat
The importance of this unbiased attitude
and approach to patient care was never more
evident to me than in the sad, but powerful, story of the life and tragic death of Sgt.
Eric E. Williams, an Army flight medic from
Southern California who was killed on July 23
At Williams’ funeral, Army Staff Sgt.
Michael Constantine told of being on the
receiving end of Williams’ care in 2008, and
vividly recalled the battle that almost took his
life. A bullet tore through Constantine’s ribs
and collapsed his lung during a fierce battle in
Sgt. Williams was the flight medic who
rapidly arrived on an Army helicopter to
attend to him as he gasped for breath, watch
High School and later became an EMT for
American Medical Response.
He did his job then based on what was in
the best interest of his community and his
patients. Later, while serving as a medic in
the Army, he provided care indiscriminately
to those in need whether they wore a patch
from the Army, Marines, Air Force, Navy or
Afghanistan military—or no patch at all.
During his memorial service, the last entry
in Williams’ Internet blog entry titled
“Coming Home” was read. In his
short blog message, the dedicated,
humble Army medic noted having
witnessed “the atrocities of war” and
wrote words that sum up why we all work in
the field of EMS:
“We have thrust ourselves into the midst of
chaos in order to do something so important,
so visceral, that few will ever understand what
it means. We collectively have risked it all and
put everything on the line to save our fellow
man, regardless of nationality, race, religion
Remember Sgt. Eric Williams’ ultimate
sacrifice and never let personal bias or your
agency affiliation stand in the way of patient
care or decisions that are the best interest of
your patient or the community you serve.
We all have to accept and embrace the fact
that we will always wear different shoulder
patches and have different employer-driven
philosophies and service objectives. But we
must work cooperatively together, particularly in the years ahead as new approaches to
healthcare delivery require a more comprehensive, integrated EMS delivery model. JEMS
He never made it home, but the
stories of his heroic acts did.
his vision begin to fade and “tunnel,” and
had a significant amount of blood filling his
Constantine says, “I had started to give up
and let the inevitable rush over me until, in
a calm voice, I heard Williams’ voice say ‘Just
breathe out.’ So I did.”1 He then felt Williams’
hands repairing his massive, open wound.
Constantine says he looked up and
searched the medic’s face for some indication
of how bad the wound was. He told those in
attendance at his funeral that he was met with
a reassuring smile and words of promise from
Williams, who told him he would do all that
he could to save him.
Williams and his flight crew members did,
in fact, save Constantine, and he never saw
In July, four years after Williams saved
Constantine’s life, he learned that Williams
was killed as his second deployment ended.
Williams was in transit from his duty station
in Ghazni Province, Afghanistan back to the
U.S., and his forward operating base came
under enemy fire.
He never made it home, but the stories of
his heroic acts did.
The most important part of this story is
that Williams grew up in civilian life serving
with public and private emergency response
agencies. He had served as president of the
fire explorers while at Murrieta (Calif.) Valley
1. Kabbany J. (Aug. 4, 2012). WILDOMAR: Region remembers slain Murrieta soldier. In North County Times.
Retrieved Aug. 4, 2012, from www.nctimes.com/
Read Sgt. Eric E. Williams’ last blog entry,
“Coming Home,” at http://myfriendthemedic.
Perhaps it’s not surprising
that JEMS readers had a lot to
say about the August feature
article by Rollin J. Fairbanks,
MD, MS, that discussed how
to combat the longstanding
issue EMS providers have
with being referred to as
“ambulance drivers” in the
media and elsewhere (“More
than Words: how we can influence the ‘ambulance driver’ media epidemic.”) Is
there a solution, or will this continue to be a problem for the profession?
If you want to advance and improve our profession
(and help make it a profession) then you will understand that a single, simple collective term of identity
is necessary for the media to describe us and what we
do. We have to make it easy for THEM to get it right.
When I’ve had this conversation with media representatives (and I have), they say, “Oh, OK.”
The Canadians and Australians have figured this
out. Those who work on ambulances are all paramedics, just like those who work on fire trucks are firefighters, and those who work in police cars are police
officers. It has worked well enough that they have a
public identity in those countries that is substantial.
How about we “real” paramedics get over it and share
our “elite” (cough, cough) title with the others who
work with us. We should all be paramedics. I don’t
care; we can be called “BLS paramedic,” “ILS paramedic,” “ALS paramedic,” “critical care paramedic,”
“tactical paramedic” or “flight paramedic,” etc., etc.,
ad nauseam infinitum amen. The bottom line: They’re
New Zealand still uses the generic term “ambulance
officer” to describe those at all clinical levels, be they
a technician, a paramedic or an intensive care paramedic. Technician level officers are overwhelmingly
volunteers; they complete a six-month block course,
perform a limited number of procedures and dispense
a limited number of drugs (about 10). It’s not appropriate to call them a “paramedic,” and it’s certainly not
appropriate to call an American EMT who, under the
EMS Agenda for the Future, completes a course of less
than 200 hours and has oxygen, aspirin and glucose,
a “paramedic.” Elsewhere in the world, a paramedic
must go to college for three years to earn the right to
use the title. As much as I applaud Canada for its use
of the titles, primary and advanced care paramedic,
I’m going to have to play devil’s advocate a little here.
We are ambulance drivers. We work with fire truck drivers
and police car drivers to provide first aid and a ride to the
hospital. Once we arrive there, the vital sign takers, bed
makers and report takers help the prescription writers and
test orderers take care of the medical services consumer.
After all, it’s all about the words, isn’t it?
I am an ambulance driver. I’m probably a decent EMT
as well. I teach the Emergency Vehicle Operator Course
(EVOC) after spending years of white knuckle driving.
My primary focus when teaching a class is to impart the
enormous responsibility involved in driving an emer-
gency vehicle. In addition to being an emergency room
on wheels, that truck is a billboard for your service, and
potentially an instrument of destruction. If I haven’t scared
the crap (spark) out of my students before the road test,
I haven’t done my job. When I stand in front of or behind
the ambulance during the road practical, I make it clear
that my life and that of those in the truck as well as on the
road is in their hands. They are proud of that accomplishment when they receive their EVOC certificate. Yet some
consider being called “ambulance driver” the equivalent of
a racial slur? Get over yourself.
Thank you for a great article. The term also leads to a misconception about what the ambulance is used for. I can’t
tell you how many times nurses or unit secretaries have
asked us as we’re leaving to take someone home because
we happen to be going “his way.” When I politely decline,
they usually become irritated and say things to the effect
of “what good is driving an ambulance if you don’t drive
people places?” We in EMS have a long way to go, but I
think we all collectively appreciate your effort and your
article. Thanks again.
Nice article. After almost 30 years at this, I still don’t like
being called an “ambulance driver.” However, I also wish
the media would use a thesaurus: The only verb they have
for us is “rush.” It doesn’t matter what we do, the standard
line is, “And EMS rushed the victim to the hospital.” As
long as all we do is “rush,” then I guess our primary job
is driving. JEMS
illustration steve berry
in your words
NEWS YOU CAN
Hurricane Isaac HITS
Crews Activate Response Plans
Photo Associated Press/Gerald Herbert
s Hurricane Isaac headed toward
the Gulf Coast region in the end
of August, residents were figuring
out to ways evacuate, and EMS operations
were swinging into full gear in their efforts
to receive for back-up assistance. With the
potential of a major storm hitting a wide
swath of land, officials initiated emergency
plans and waited out the weather early on.
An uprooted tree lies across Poydras St. in New Orleans as Hurricane Isaac made landfall with 80 mph
winds, making it a Category 1 storm.
Photo Associated Press/Eric Gay
On Aug. 26, with the storm just two days
away, Acadian Ambulance in Lafayette,
La., activated its Evacuation Response
Operations Center (EROC), a system borne
out of responses to previous storms, to
specifically handle the evacuations of
“Compared to other storms of the past
10 to 15 years, it was not one of the most
challenging we’ve had,” says Jerry Romero,
senior vice president of operations at Acadian. “But, we had to execute our disaster
plan.” Part of this plan included having 40
additional ambulances in service.
The EROC system was created after hurricanes Gustav, Katrina and Ike struck the
regions Acadian serves. Evacuating healthcare facilities and nursing homes is a major
part in the storm preparation process. To
meet that need, Acadian activates a separate
communications center to handle only those
types of evacuations, rather than have those
calls bog down the normal 9-1-1 system.
For instance, during Hurricane Katrina,
Acadian evacuated more than 2,000 patients.
During the first day of the EROC operation for Hurricane Isaac, the company transported 150 people.
Hurricanes are challenging for EMS organizations. Officials are faced with calling in
extra staff at a time where the staffers’ families
and homes may be in danger. This happens at
the same time that government officials are
asking residents to evacuate the area where
first responders are being sent to wait. The
result, however, can sometimes be a shortage
Trevelle Bivalacqua, 12, at right, helps firefighters and other volunteers evacuate residents from the
Riverbend Nursing Center as Hurricane Isaac makes landfall in Jesuit Bend, La.
of employees physically unable or unwilling
to return to work.
“Our employees are pretty hurricane
savvy,” says Romero. “At the beginning of
hurricane season, we put out our employee
update to remind them of the points to
have a family plan prepared, to know what
you’re going to do, and have a three-day
supply of clothes and food in case you don’t
get home. We get a lot of people who call in
Officials at SunStar EMS in Pinellas County,
Fla., like others, began altering their hurricane
response plans in 2004 and have upgraded
NIH creates Office of Emergency Care Research: www.jems.com/article/nih-creates-office-emergency-care-resear
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• Securing the Airway:
The expanding role of extraglottic devices
• Maximizing Your Revenue
• May the G-Force Be With You
• ‘Posting’ Is Not a Dirty Word
• When You Leave a Patient Behind: Refusals, Non-Transports Best
Practices for Documentation
• The Mobile Transformation
• EMS Strategies for Improving Cardiac Arrest Survival
• Are You Bagging the Life Out of Your Patients?
• Drug Shortage Action Plans for EMS
• Statewide Trauma System Enables Multi-Agency Coordination
with Trauma Centers to Improve Patient Outcomes
• CPAP in EMS: The Standard of Care Argument
• Top 5 Ways an In-Vehicle Router Improves EMS Operations
• CPR Quality Improves Survival
• Breathe Deeply: How CPAP and Ventilation Can Help Your Patients
• Simulating Work: How to Effectively Incorporate Simulation
into Prehospital Care
• CPAP: Filling The Sails to Respiratory Relief
Go to www.JEMS.com
continued from page 18
Photo courtesy Mark Postma
Two must be on duty at all
times, which gives the other providers a chance to check on their
families. Another 250 go to the
Bringing everyone in inevitably involves logistical challenges
for managers, such as the feeding
and housing of staff. And once
a storm begins, there will ultimately come a point where the
crews can’t go out.
SunStar EMS hurricane deployment units prepare and debrief
“We’ve kind of learned from
during the Republican National Convention at Tropicana Field
other hurricanes that have hapas they mobilize for Hurricane Isaac response.
pened,” says SunStar Vice President Mark Postma. “We’ve tried to be as
them after every storm since then.
SunStar’s current plan includes a man- flexible as we can.”
Early on, it appeared the region covered
datory callback for all employees, and
it also includes provisions to make sure by SunStar might get hit by Hurricane Isaac.
employees’ family concerns are taken into However, the storm track went further west.
consideration. For instance, six responders The plan has been tested several times, though
and an ambulance are placed in 20 hotels it’s been activated only once since its implethroughout SunStar’s response area—and mentation, Postma says.
SunStar was prepared, however, says
geographically near the responders’ homes
Richard Schomp, director of operations.
to assist families if needed.
The company had already activated special
EMS coverage for an event staged for the
A Word of Encouragement
Republican National Convention on the SunEditor’s note: Jullette M. Saussy, MD, served
day before the storm. That coverage, says
with NOEMS during hurricanes Katrina and
Schomp, included 14 additional ambulances,
Gustav. She provided this message to EMS
extra management and a mass casualty supcrews responding to Hurricane Issac.
“I’d already staffed up the system to handle
It’s incredibly difficult to be so far away and yet
an extreme amount of volume,” Schomp says.
to still feel the deep longing to be right beside
“With the storm coming, we maintained that
each of you as this hurricane approaches. Katrina
high amount. It had very little impact, but we
in 2005, Gustav in 2008, and now Isaac in 2012—all
on or about the same day seems more than just
Typically, EMS operations experience a
large influx of 9-1-1 calls after a storm when
For those of you who have been through this
residents have no power. Romero says there’s
drill, I know it brings up all kinds of emotions. It
often a jump in heat-related calls, chainsaw
has for me, and I’m not even there. For the newcuts and falls from roofs as homeowners
est members of the team, take a few lessons
work to rebuild.
from the seasoned men and women of New
Getting crews time to rest, especially when
Orleans EMS (NOEMS.) If they seem on edge, it’s
they’re stationed over a wide geographical
for a reason. Be patient. If they seem emotional,
location, is one of the largest challenges,
it’s for a reason. Be patient. If they tell you to do
Romero says. However, each storm, Romero
something, it’s for a reason. Do it.
says, helps the company prepare for the next
You have capable leaders, and they need the
one. Hurricane Isaac was no different.
team to pull together and perform at their high“Katrina, Rita, Gustav and Ike taught us a
est capacity. We have one mission and that is to
lot,” says Romero. “We’ve gotten better every
stay safe and to keep our citizens and visitors
time. We can always improve and will consafe. Stay focused on that, and you will succeed.
tinue to improve after this one.”
Thank you for the work you do each day.
—Richard Huff, EMT-P
—Jullette M. Saussy, MD
Robert Forbuss was an
EMS advocate, speaker,
author, leader and pioneer known for promoting EMS, EMS careers
and high-quality private
and public ambulance services. He died in
August after a long battle with amyotrophic
lateral sclerosis (ALS), also known as Lou
Gehrig’s disease. He was 64.
Janet Smith, a former Mercy Ambulance
employee and colleague of Forbuss’ says,
“The Bob Forbuss story is about how a man
in an emerging new healthcare service in
the 1970s, leveraged his company’s position in a growing Nevada metropolis to
open political and strategic access to the
power structure of the city and county his
Co-founder and subsequent president
of the American Ambulance Association
(AAA), Forbuss presided over the National
Showcase for EMS in Washington, D.C. He
served on the AAA committee to institute
the process for ambulance accreditation
from which the Commission on Accreditation of Ambulance Services (CAAS) was
Jay Fitch, PhD, founding partner of Fitch
and Associates, LLC, reflects, “He was my
second private client, the best thing that
could happen to a young consultant. Energetic and passionate, I came to admire his
Forbuss served as the industry’s spokesperson during the national Ford ambulance
crisis and was named EMS administrator
of the year at the EMS Today Conference
Exposition in 1988 for his work during that
crisis. Forbuss coordinated the ambulance
and walking wounded components at the
1980 MGM Grand and 1981 Hilton high-rise
hotel fires, an effort JEMS founder James O.
Page described as a “command performance.”
Smith reflects, “Who knows how many
have lived to see another birthday, a graduation or a grandchild’s first steps because
of him, his influence, his care in countless cities and towns throughout America
and especially in those communities where
CAAS Accreditation is the benchmark. He
will be missed.” —Mike Ward, EMT-P
Halloween safety tips: www.jems.com/article/don-t-get-spooked
continued from page 20
When Patients Don’t Stay Put
e’ve seen some tragic headlines recently that should be a cause
Aug. 19, 2012: “Woman Dies After Jumping from Ambulance” (Calif.)
March 12, 2012: “Patient Jumps from Ambulance Only to be Struck by
Dec. 23, 2011: “Naked Man Jumps from Ambulance, Dies on Freeway”
Oct. 13, 2011: “Patient Jumps Out of Ambulance and Into River” (Okla.)
Is this a trend? How can these incidents happen in the first place? We don’t
know the statistics, but we do know that patients who unexpectedly leap from
your ambulance—while you’re with them in the patient compartment—not
only can get injured or killed, but can also present huge liability issues for you
and your EMS agency.
Dealing with patients with psychological issues is a big challenge. They may
appear “fine” and “calm” one moment and then they snap into another person
the next second. They often don’t have any outward physical injury, so they
almost appear “normal.” This is when we may let our guard down ever so slightly,
and bang: The next thing you see is the rear door flapping open and no patient in
your vehicle. Not a good scenario.
We need to always remember to strive to never let something bad happen to
a patient while they’re under our care. We don’t want them to be worse off than
when we first found them, because if they are, then the obvious question from
a “fact-finder” will be: “Did the EMS crew do enough to prevent this unfortunate
incident?” And if the answer is no, then you may be looking at a negligence or
wrongful death action against your agency.
Follow these tips for reducing your risk when transporting patients who have
a “questionable” mental state:
Always be attentive: Keep your eye on the patient at all times in a faceto-face position. The first sign that the patient is about to escape may be a
change in their facial expression. You can’t see that sitting in the captain’s chair
texting a friend, staring out the side window, or chatting with the driver. We
must be totally attentive to the patient every second they’re with us. Being complacent or distracted leads to dead patients in these situations.
Follow your protocols: Most systems have a protocol for dealing with a
patient who may have psychological issues or has exhibited signs they may hurt
PennWell Acquires Elsevier Public
Safety; JBL Acquires EMS Product Line
On Sept. 14, PennWell Corporation announced the acquisition of Elsevier Public Safety, the publisher of JEMS, from
Elsevier, Inc. The deal also includes JEMS.com, the EMS
Today Conference Exposition (the JEMS Conference),
EMS Insider, FireRescue magazine, FirefighterNation.com,
FireEMSblogs.com, Law Officer magazine, LawOfficer.com
and the publishing contract for APCO’s Public Safety Communications magazine.
Elsevier Public Safety, a division of Elsevier, Inc., was
founded in 1980 as JEMS Communications, with JEMS, one of
the most iconic brands in the EMS market. During the past
32 years, Elsevier Public Safety expanded to become the
themselves. Make sure you review that protocol and follow it. Your protocol will usually be
the patient care standard by which you will be
judged in a negligence lawsuit.
Get good Information at the scene:
Ask lots of questions of the facility staff or
family members concerning mental stability, suicidal ideations, and so forth.
Document exactly what the patient, nursing staff and bystanders tell you. Never
accept a patient who looks “fine” without a good explanation as to why you’re
Don’t hesitate to call law enforcement: True, police officers are not
always helpful, but it’s best to err on the side of calling them, and then keep
them there for the remainder of the transport or ask an officer to ride in the
back if possible. Always consider the option of an involuntary mental health
commitment in accordance with your state law, if you’re concerned.
Use two people in the back: If you question the mental stability of a
patient, it’s always best to have two providers in the patient compartment—
positioned strategically so that the patient can’t escape easily. Someone should
definitely be between the patient and the rear door of the ambulance. Don’t
make it easy for them to escape.
Use restraints when needed: We’re not talking about the cot straps,
which by the way, should always be in your complete view so that you can see
them if a patient is trying to get unbuckled; never cover buckles under a blanket.
Chemical restraints may be the safer way to go and can reduce patient anxiety.
Don’t hesitate to use them or ask your medical command physician.
Keep in mind from a risk management standpoint, it’s far better to get sued
for false imprisonment for excessively restraining a patient, than to get sued for
wrongful death if the patient jumps from your ambulance as you look up and it’s
too late. There are only a few lawsuits where EMS providers were sued for taking a patient involuntarily, but there have been hundreds of lawsuits against EMS
for negligence when the patient is left worse off than when you found them —
regardless of your defense.
The authors are all attorneys with Page, Wolfberg Wirth, a national EMS law
firm. Visit the firm’s website at www.pwwemslaw.com for more information on
a variety of EMS law issues.
only media company serving all four key public safety segments—EMS, fire/rescue, law enforcement and communications. The management and staff will join PennWell, a
diversified global media and information company, and will
remain based in San Diego. PennWell conducts more than
50 conferences and exhibitions, including the Fire Department Instructors Conference (FDIC), and has an extensive
line of trade publications, including Fire Engineering and Fire
PennWell will bring its trade show management knowhow to the EMS Today Conference Expo, held annually
each spring. EMS Today celebrated its 30th anniversary this
year and in 2013 will be held March 5–9 at the Washington
Convention Center in Washington, D.C.
For more information, visit www.jems.com/article/
For more of the latest EMS news, visit jems.com/news
Pro Bono is written by
attorneys Doug Wolfberg
and Steve Wirth of Page,
Wolfberg Wirth LLC, a
national EMS-industry law
firm. Visit the firm’s website
at www.pwwemslaw.com for
more EMS law information.
In other acquisition news, Jones Bartlett Learning (JBL),
a division of Ascend Learning, acquired the EMS product
line from Elsevier, Inc., closing the deal in July, according to
JBL Executive Publisher Kimberly Brophy. EMS education
resources previously published under the Elsevier brand are
now part of the JBL EMS product line, including those marketed under the Mosby, Saunders and Churchill Livingstone
imprint. The added value, Brophy notes, is that customers
can now order a large variety of titles from one publisher.
JBL is a provider of instructional, assessment and learning-performance management solutions for the secondary,
post-secondary and professional markets. JBL will continue
to support and enhance EMS products, domestically and
internationally. Customers should note that Elsevier will
be responsible for accepting returns on any products purchased directly from Elsevier through April 30, 2013.
presented by the iafc ems section
by gary ludwig, ms, emt-p
Closed Door Policy
Keeping lines of communication open can help you your staff
recently received an e-mail that told me of
an innovative new management principle
that most major business schools, such
as Wharton, Harvard and Yale, would soon
be scampering to teach. The e-mail added
that management books would need to be
rewritten and this new management practice
would set teaching of leadership and management back 200 years.
Intrigued, I couldn’t resist reading further
into the e-mail about this earth-shattering
management principle. I was curious about
what was so tremendous and incredible.
Could I possibly be on the brink of some
utterly fantastic discovery that maybe somehow I could share with fellow EMS managers?
Closing the Door
As I read further, I discovered that the writer
was being facetious. He was being tonguein-cheek and not really writing about an
earth-shaking innovative or unfounded
management application. What the author
wanted to share with me was what the management at his EMS service had distributed to
its employees; a memorandum appropriately
called the “Closed Door Policy.”
The memorandum basically said that managers were too busy to deal with employees
when they had an issue that needed addressing. Here is what the memo said (with the
To All Employees,
During business hours (9–17), [name deleted]
and [name deleted] are being bombarded with operational issues every five minutes. This makes it impossible to complete our tasks and work assignments.
We are tired of answering the locked door that
specifically says, “AUTHORIZED PERSONNEL
ONLY” to find out that you need to talk about
scheduling, supplies, etc.
Although we appreciate all your concerns, unless
it’s on fire, please e-mail us. We will get back to you
in a timely manner. You cooperation is much appreciated and no exceptions will be made nor tolerated.
Please take this seriously. We have a larger work load
and get seriously behind due to constant visitors.
Surprisingly, this wasn’t a large service
where 1,000-plus employees would keep the
head of an EMS organization from doing
their job because they were inundated with
employees knocking on the door. So when I
read the memo, I was baffled.
Leading with Your Feet
Management does need to prioritize tasks.
And, as I have always preached, management
shouldn’t be bogged down in minutia and
should focus on strategic issues. However,
I have also advocated they can’t sit in their
offices behind closed doors and not interact
with their employees. They need to find a
balance between staying focused on strategic
issues and getting out of the ivory tower to
find out what’s happening in the operation.
When you get out and talk with employees, you find out what’s working and what’s
not. As I’ve often said, you don’t want to
wake up in the morning and read in the paper
what’s happening in your operation.
A label for this practice is “Management by
Walking Around,” or MBWA. I have always
felt this concept was misnamed and
would be better termed “Leadership
by Walking Around.” After all, we
manage budgets and inventories; we
should be leading people.
Nonetheless, this spontaneous
practice in an unstructured manner allows
managers to randomly check with employees
or equipment to find out what is happening
in the operation.
My favorite method to do MBWA is to
stop by one of our busier hospitals in Memphis where I know I’m going to find three
or more Memphis Fire Department ambulances dropping off patients. It gives me the
opportunity to randomly and spontaneously
meet with personnel. It allows me to talk
with them, and it allows them to ask me
questions, let me know about any issues that
need addressing, and, my favorite—deny or
confirm rumors they’ve heard.
This is probably one of the best tools I
have to discover what’s wrong and needs to
be fixed, build rapport with employees and
receive feedback. I may hear things I don’t
want to hear, but that comes with the job and
I would prefer employees to be honest. Sometimes it seems like it’s a small problem. But
I’ve discovered if you don’t deal with the small
problems, they can become big problems.
A Balancing Act
It’s important to point out that, if you’re
going to use MBWA, you have to do it the
proper way. You can’t just walk around to
say “Good morning.” Don’t criticize. Don’t
create an atmosphere of fear that causes your
employees to get scared and “clam up” when
they see you coming.
And, most importantly, EMS managers
can’t just sit in locked offices and shelter
themselves from what’s happening outside
the confines of their office. Maintaining that
careful balance between becoming a recluse
and interacting with your employees can
allow you to truly find out what’s happening
within (and around) your operation. JEMS
Gary Ludwig, MS, EMT-P, has 35 years of
EMS, fire and rescue experience. He currently
serves as a deputy fire chief for the Memphis
Fire Department. He’s also Chair of the EMS
Section for the International Association of
Fire Chiefs. He can be reached through his website at
TRICKSour patients ourselves
OF THE TRADE
by Thom Dick, EMT-P
Warm Enough for Ya?
Preventing failures to start
Photo Thom Dick
’m melting, I’m melting!”
So said the Wicked Witch of
the West just before she magically
shriveled her way into history. I’m beginning to sympathize with that cranky lady.
At the time of this article’s writing, my
state has had a record-breaking summer of
wildfires after more than a month of temperatures in excess of 90° F and multiple
strings of 100-plus days in the mix. And
the calendar says our summer is still ahead.
We need rain.
One of my duties is to oversee the
maintenance of a small fleet of six Type
III Ford ambulances. They’re all 7.3-Liter
PowerStroke Diesel chassies with LifeLine
boxes. We’ve hung onto the 7.3s because
we don’t generate a lot of miles, and those
engines and their TorqShift transmissions
have been bulletproof. Just as importantly,
the quality of the boxes has supported our
continued investments in chassis maintenance. In fact, so far we’ve sent two units
back to the factory in Sumner, Iowa, to
refurbish and return them to service.
When I was originally assigned to take
care of this fleet, we were having two kinds
of starting failures. One was an easy fix:
We began replacing the batteries annually.
The other, which had plagued us for years,
was alternator failures—especially of the
upper alternators. Of course, the easiest
way to correct that would be to switch to
Type I ambulances.
One of the disadvantages of a cutawaybased Type III chassis is its teeny engine
compartment. There’s not enough room
in there for an alternator big enough to
supply the needs of an ambulance (or a
leprechaun to service it). So Ford resorted
to a pair of alternators: one mounted high
and the other one low. A Type I chassis
has a longer hood, like a pickup truck, that
offers much more space. But our garage
bays aren’t physicially deep enough to
accommodate Type I ambulances. And
Colorado’s range of temperatures can
Maintaining proper vehicle temperature isn’t
rocket science, but it does require proper training.
reach 110 degrees winter to summer. So
you pretty much have to keep an ambulance garaged.
Neither of those alternators is just a
spare; if one fails (usually the upper one
because of heat), the other will follow soon
enough. You can minimize the load on
them by switching your emergency lighting from incandescent to high-intensity
LEDs. LEDs produce a lot of light with a
little energy. Decreasing the load on an
alternator should lower its operating temperature, minimize the wear on its drive
belt and improve its reliability. But LEDs
require a lot of rewiring, and that’s pricey.
You can’t just replace bulbs.
You can idle a diesel all day long,
even on a hot summer day with a
heavy electrical load (including both
air conditionings on full-blast). But
when you turn the motor off, the
radiant heat of all that metal has
nowhere to go. So your underhood tem-
peratures will rise. If the cooling system is
in good shape and your coolant is mixed at
the proper concentration, it should be OK
up to a temperature of almost 300° F. But the
underhood temperature won’t be constant.
It’ll be hottest up high (like where the upper
alternator is) and not so hot down low.
We talked to our friend Cap Unrein at
Rocky Mountain Emergency Vehicles
(EVMARS) of Denver, who does our maintenance. Cap recommended the basis of the
following hot-weather procedure. We leave
an ambulance running when we park it outdoors for just a few minutes. Nobody wants
to climb into a 120° F ambulance, right?
EVMARS installed externally accessible security switches that either lock or unlock all of
our doors simultaneously. So we can leave
a locked vehicle idling, yet we can access it
quickly for a call. Then, when we return to
quarters, we turn off the engines and leave
the hoods open.
Looks funny. Makes sense. Obviously,
we try not to leave the hoods open in public. Our crews don’t post on street corners,
and they’re mindful of the temperaturesensitive contents of their compartments, so
they normally return to quarters between
calls. And we don’t know yet if this will even
work. But it makes sense for any vehicle,
whatever its design. And in this heat, we’ve
gotta do something.
I have to tell you, there’s one more component to this plan. The crews have to understand their instruments—and the mechanics
of their vehicles—well enough to make it
work. To my way of thinking, that requires
training and experience.
Neither of which happens by magic. JEMS
Thom Dick has been involved in EMS for
41 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at boxcar414@
CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Kimberly Doran
Crew’s misdiagnosis could have cost patient her life
Arrival at the ED
On arrival to the ED, the medic hands
over the loaded syringe containing 2mL of
unidentified solution, as well as the empty
vial of Solu-Cortef and the bottles of dexa-
call comes in to 9-1-1 dispatch.
“Help” is all that’s spoken before the
operator hears the phone hit the
floor. The 9-1-1 dispatcher calls back only
to get a busy signal. Police and EMS are dispatched for a well-being call.
On arrival, the front door is found to be
slightly ajar. The crew knocks, but there’s
no reply. Entering the home, the crew sees a
young woman lying on the floor in a pool of
vomit. A syringe with an unknown substance
is on the ground nearby. Suspecting a drug
overdose, the EMS crew begins treatment.
The patient is unconscious with emesis about
her head and face. Her vital signs are blood
pressure 60/45, heart rate of 130 bpm and
respiratory rate of 10.
The patient shows no signs of waking.
The crew clears the airway and administers
oxygen. An IV is established and the patient
is readied for transport. As the crew leaves
the scene, one of the medics turns to shut the
door and sees a vial under a chair. He retrieves
it and notes that the label says Solu-Cortef (a
glucocorticoid). He bags it for the emergency
department (ED). Following his instinct, he
looks around the area for medications and
finds two bottles. One is labeled dexamethosone and the other is labeled fludrocortisone.
He takes his findings and rushes out the door
into the awaiting ambulance.
During transport the patient continues
to deteriorate. The medic administers 0.5
mg of narcan and a 500mL bolus of normal
saline with no response. He radios ahead to
let the hospital know that they’re en route.
Now questioning the original diagnosis of
drug overdose, he reports the medications he
found on the scene in hopes it will help the
receiving physician determine the cause of
the patient’s condition.
Symptoms of adrenal insufficiency can mirror a
drug overdose, so providers need to be wary.
methosone and fludrocortisones.
As they arrive at the hospital, the ED physician meets the crew and informs them that
he’s familiar with the medications and they’re
all used for people who have various forms
of adrenal insufficiency (AI). The symptoms
seen in this patient coincide with life-threatening adrenal crisis. The physician administers 100mg of Solu-Cortef via IV and within
minutes, the patient rouses. In 30 minutes,
she can explain what happened in the desperate moments before her crisis.
The adrenal medulla (inside of the adrenal
gland) secretes epinephrine and norepinephrine. The adrenal cortex (outer layer of the
adrenal gland) secretes cortisol and aldosterone. Cortisol, a glucocorticoid, is often
called the “stress” hormone. One of the things
cortisol in the body is responsible for is elevating blood glucose levels in times of stress.
It also functions as a mediator for several
Absence of cortisol can result in hypotension, hypoglycemia and death. Aldosterone,
a mineralocorticoid, is responsible for the
regulation of sodium and water. Absence of
aldosterone can result in hypotension and
electrolyte imbalance. AI is a life-threatening
condition in which the body is unable to produce enough cortisol to sustain life. In other
words, their adrenal cortex is “asleep.” People
suffering from AI take daily cortisol/glucocorticoid steroid replacement because whatever adrenal function they have is depleted.
These patients are glucocorticoid dependent.
In times of injury, dehydration, illness or surgery, they require an injection of Solu-Cortef.
Solu-Cortef contains both glucocorticoid
and mineralocorticoid properties, helping
the body to compensate during a stress event.
AI in the prehospital setting may be difficult to recognize in the absence of a good
history, including medications, to point providers to the cause of the problem. Two
conditions associated with AI include hypotension and hypoglycemia. If not managed,
these two conditions are life threatening.
Prehospital treatment should include management of the patient’s airway, vascular
access and fluid resuscitation. If blood glucose levels are low, the patient should receive
dextrose per local protocol. It’s important
to complete a thorough physical assessment and obtain a complete patient history.
Providers may confuse patients having an
adrenal crisis with drug overdose patients
because of their similar symptoms. Although
the condition is rare, it should still be considered as a potential diagnosis.
Authors’ note: Parts of the above case are
taken from a true story. However, the difference is that there was no syringe on the floor,
no vial under the chair and no one found
the medications. The patient was diagnosed
as a drug-overdose patient and treated with
charcoal. She likely would have died, but her
mother charged into the ED and expressed
the need for Solu-Cortef. Security was called,
but luckily someone listened, researched and
called the patient’s treating physician. The
patient was treated and released. JEMS
Kimberly Doran is medical liaison for Adrenal Insufficiency
United. She is committed to bringing about awareness and
proper medical care and treatment for all who suffer
from various forms of adrenal insufficiency. She can be
contacted at firstname.lastname@example.org.
For more information about this condition,
go to www.AIUnited.org.
The future looks bright—but how bright?
photo vu bahn
About the Data
The Web-based survey consisted of approximately 150
questions. It allowed participants to voluntarily “skip”
sections they considered “not applicable.” Two hundred
twenty-one organizations (N=221) initiated the survey - a
return rate of 10% from a distribution of 2,411 invitations.
Survey participation was open for a five-week period
during May and June 2012. Figure 1, p. 32, shows the
breakdown of provider types and their call volumes.
The median of respondents serves populations of 50,000
and responds to 5,000 calls annually. Total respondents are
noted as “n =” for each dataset where possible. In some
instances, data was limited, not available or not applicable
for all respondents. For example, respondents may answer
call volume but not provider type, which means that “n” can
change from dataset to dataset.
A representative sample of participation from provider
organizations in each region of the U.S. and across all
system model designs (see Figure 2, p. 34) was achieved.
All 10 federal regions are represented in this year’s data
national salary rollup, however several job classes and
regions did not reach required participation for reporting.
Salary reporting follows Department of Justice and
Federal Trade Commission issued Statements of Antitrust
Enforcement Policy in Health Care.1 The text of the
guidelines as they relate to salary surveys can be accessed
online; the following are the most relevant extracts:
The agencies will not challenge, absent extraordinary
circumstances, provider participation in written surveys
of a) prices for health care services, or b) wages, salaries
or benefits of health care personnel, if the following
conditions are satisfied:
The survey is managed by a third party (e.g.,
a purchaser, government agency, health
care consultant, academic institution or
Information provided by survey participants is
based on data more than three months old.
There are at least five providers reporting
data on which each disseminated statistic
is based, no individual provider’s data
represents more than 25% on a weighted
basis of that statistic, and any information
disseminated is sufficiently aggregated such
that it would not allow recipients to identify
the prices charged or compensation paid by
any particular provider. 1
By Michael Greene, MBA/MSHA
n the JEMS 2011 Salary Workplace Survey, we followed a long day in the
life of fictional character Duke Gracie, a field training officer and veteran
paramedic at Flowing Springs EMS (FSEMS). For 28 years, running the
JEMS Salary and Workplace Survey, conducted in cooperation with
EMS consulting firm Fitch Associates, provides insight and
understanding on key human resource topics. Continuing
on the narrative from a year ago, we’ll check in not only
on the fictional Duke Gracie, but also his boss Margaret
Taylor and FSEMS.
This year, participating EMS organizations were given
the option to complete the survey anonymously.
Thirty-six respondents selected this option. With this
selection the author and research staff are “blinded” to
the e-mail or IP address of the respondents. Regardless
of how information is submitted, raw data is only
available to the research staff and author, and only
aggregate data is published.
Data accuracy is a primary objective. Survey results
may be limited by the accuracy of respondent submitted data, organizational selective participation
and an inconsistent pool of respondents year-toyear. Ambiguous, unclear or incomplete answers were
unilaterally excluded from the dataset, rather than
interpreted by the author, thus creating a potential
The survey represents
all federal regions. But
the individual states
not responding were
Delaware, District of
In total, 221 survey
participants resulted in a
10% response rate.
The median population of
respondents is 50,000.
Median annual call volume
Nearly one-third (27.5%) of
responses were from multirole fire services.
In a 2011–2012 comparison,
some salaries have declined.
However, wage growth
between 2006 and 2012,
including the recession years
of 2008–2009, ranks high
among U.S. jobs (8%).
Word of mouth and
electronic media were
the top tools used to find
potential job candidates.
New employees spend
less time in orientation, 160
hours vs. 240 in 2011 and less
time in field training, seven
weeks down from 10 in 2011.
One-third of employees
are cleared to work after
training without ever
meeting with a medical
director, with more than
20% “never” meeting with a
Fourteen of 19 job
wage gains in 2012.
Of 25 employee benefit
categories, 15 were reported
as being “reduced” and 14
The “JEMS Salary Workplace
Survey” is a joint research
project in collaboration with
Fitch Associates, LLC (www.
fitchassoc.com). For 28 years,
Fitch Associates is the leading
international emergency services
consulting firm and serves a
diverse range of clients.
Salary Workplace Survey
continued from page 31
This year, we find Duke as a newly minted Director Maggie Taylor leverages the same
community paramedic, looking like a new technology in her recruitment strategy as
man who is refreshed and self-assured. In a her industry colleagues. Recruitment via an
freshly pressed uniform, Duke steps out of a “agency website” (31%) takes a narrow secFlowing Springs EMS Community Paramedic ond to “employee referral” (32%) in this year’s
rig and pulls his sunglasses down over eyes in survey results. Other job websites, such as
the bright early morning sunlight. “Another Monster.com and CareerBuilder.com (10%),
day in paradise, saving lives and stomping as well as electronic mailing/list-servs (7%),
out disease,” he thinks as he smiles to himself. round out the technological approach to
In EMS, the human element—be it patient recruiting. Trade journal ads (4%) and conferor provider—is the driving force in the sys- ence booth recruiting (6%) are the least-used
tem. As Michael F. Staley wrote in Igniting tools to find new employees, while local EMS
the Leader Within, “Knowing how to motivate training programs (23%) continue to be fertile
a person in emergency medical services ground to fill job openings.
requires that you understand the
person, the passion and the pay- Figure 1: Participant Distribution
Survey Respondent Mix
check—in that order.”2
After his internal struggle in
this past year’s survey, Duke is
now passionate about his work.
See Regional Map (Figure 2), p. 34
“It’s not like building widgets
Provider Model Distribution
in some factory,” he tells fam%
ily and friends. “I save lives, and
City/county third-service governmental
get paid for doing it. I can’t imagPrivate, not-for-profit organization
ine doing anything else!” (Doing
something else was exactly what
Duke was pondering a year ago,
Private, for profit company
but more on that later.)
Fire department, single-role
“I haven’t been ‘texted’ about
open shifts in months now,”
Duke comments as he walks
into the FSEMS Communications Center. “Maggie must have
gotten my replacement hired.”
“Yup, you’ve been replaced,”
replies Lyndy Grayson, the communications supervisor. “We got
hundreds of hits on Monster and
our Facebook page, tens of qualified candidates from Maggie’s
Tweet and a huge response from
the buzz on the streets. Your job
was as hot as a software IPO [initial public offering].”
“Tweet, Monster, Facebook,
IPO … this sounds like ‘Maggie
speak’ to me,” Duke responds
with a snort. “Kids these days
don’t use the same language as
they used to.”
Although these terms might
sound unfamiliar to Duke, Flowing Springs EMS Executive
Fire department, multi-role
Seventy-six of 221 agencies reported
vacancies within their organizations. They
reported an average of three vacancies in
2012, down from five in 2011.3 Additionally,
agencies continue to use part-time EMS personnel (67%) with nearly 30% reporting an
increased interest from applicants in parttime employment.
Of key frontline EMS positions, organizations continue to report a shortage of paramedic staff (39% vs. 40% in 2011) with an
increase in a shortage of emergency medical dispatchers (28%), which is up 10%
from 2011. The EMT-Basic category continues to exhibit a low percentage of
reported shortages (18%).
When positions are available,
Flowing Springs EMS is able to
hire qualified candidates that they
recruit. Similarly, 83% of survey
respondents report “hiring as usual”
with a single-digit minority saying
“hiring is on hold or frozen” (greater
Public utility model
Total Population Served
Less than 5,000
More than 1,000,000
Call Requests vs. Transports
n=199 Transports n=199
Less than 1,000
50,001 - 70,000
Greater than 90,000
“Turn and burn,” quips Duke. “Those
newbies are in and out of orientation quickly; they’re in the field at
“It’s like a well-oiled machine,”
Lyndy comments. “We’ve got the
orientation process dialed in.”
Little has changed this year over
last in the subject matter covered in
new employee orientation (e.g., policies, patient care guidelines and customer service). What has changed
are the average hours the employee
spends in orientation. In 2011,
respondents indicated that 240
was the average number of hours
of orientation training required for
new EMS employees. The average
number of hours in orientation has
dropped to 160 hours for 2012. A
concurrent drop in the “average
length of time (weeks) an employee
new to your organization spends
in the clearance/probation process
before they are considered a fully
functional and independent member of field staff” is noted in 2012
data. This is down from 10 weeks in
2011 to seven in 2012.
Salary Workplace Survey
continued from page 32
illustration amane kaneko
Figure 2: Participant by Region
Note: The number in parentheses is the number of
respondents from that region. Standard Federal Regions
established in 1974 by the Office of Emergency Management
and Budget. The same regions are used by the federal
Emergency Management Agency and the Centers for
Medicare Medicaid Services.
organizations, more frequently
“What’s Dr. Mark’s stance on Figure 3: Participant Unit Hour Utilization
than monthly at 27%, quarterly
this ‘speed training’ process?”
Avg Unit Hours/ Avg Call Volume/ Avg Unit Hour
at 16% and on-demand at 13%.
Duke asks Lyndy.
“I guess I don’t know,” she
Less than 1,000 (999)
responds. “He’s been a bit overDoing More
committed to the new commuDuke’s former partner and field
nity paramedic (CP) training.
trainee Dave stops as he’s walk15,001–30,000 (29,999)
“Between that and trips to the
ing by. He leans in the door,
rural health clinic, he hasn’t been
“Hey old man, how’s it going
as hands-on as in the past,” she
with the new job?” Duke stands
adds, looking at a closed office
and they shake hands and
door marked with “Mark Manexchange backslaps.
Greater than 90,000 (99,999)
gus, MD—Medical Director.”
“Good,” Duke responds.
Duke thinks about how unusual that is, that it “believes that all aspects of the orga- “We’re always doing more; it’s job security,
remembering the days when he and Mangus nization and provision of basic (including you know.”
first responder) and advanced life support
ran calls together.
“It’s not enough to be a paramedic and field
“Maggie needs to talk to him,” Duke tells emergency medical services (EMS) require the training officer. No, Duke’s got to be a comLyndy. “Now that the CP program is up and active involvement and participation of phy- munity paramedic too,” mocks Dave. “Looksicians.”4 How much time does your medical ing to the future’s not a bad thing,” responds
running, he needs to get back in here.”
Only 30% of “new employees who have director spend one-on-one with field staff?
Duke, “Do more, or someone else gives you
completed their probationary credentialing
Few organizations report that continu- more to do. Besides, if I can make the system
process must complete an interview with a ing education (CE) content is developed and work even better, then I’ve made a difference.”
medical control physician as the final step delivered solely “in-house” (9%) or entirely
“It’s all about productivity,” Lyndy chimes
“outsourced” (15%); in fact, most use “both” in. “I’d rather be in Duke’s shoes than handing
Worse yet, following the probationary (76%). CE occurs in a “traditional classroom” out parking tickets.”
credentialing process, some field employees at 40% of the agencies responding. Less than
City managers in a Tennessee commu(22%) “never” meet one-on-one with the med- 2% use “distributive methods” (e.g., video and nity may have found a win/win on producical control physician. Furthermore, in 2012 the Internet) exclusively; most, or 58%, use tivity and budget. Firefighters in Oak Ridge
organizations reported field staff only met both methods. Monthly CE occurs at 49% of will be issuing parking tickets according to
with the medical director “when
one online publication.5 Whether it’s
to generate revenue or boost proFigure 4: Unit Hour Utilization Calculator
Although the American Colductivity, doing more with less is the
Total Unit Hours per Week = (A)
lege of Emergency Physicians
(Total number of staffed hours per week)
(ACEP) doesn’t specify how
As director of Flowing Springs EMS,
Average Call Volume per Week = (B)
much face-to-face time a mediMaggie knows it’s imperative that the
(Total number of responses per week including transports, refusals, no transports, etc.)
cal director needs to spend with
service operates in an economically
Unit Hour Utilization = (B/A)
EMS caregivers, ACEP has stated
sustainable and accountable model.
continued from page 34
Mention productivity to staff, and you can see a visible shudder. If she
mentions unit hour utilization (UHU), she can almost hear the chorus
of moans. As a visionary leader, she sees great potential for a win/win
in her new community paramedicine program.
As uncertainty over the financial impact of the Patient Protection
and Affordable Care Act (PPACA) leads the media headlines and political campaigns, some EMS systems are looking to expand their role
in healthcare. PPACA places increased priority on prevention, wellness and improved outcomes within a healthcare system. According to Wikipedia.com, “An accountable care organization [ACO] is a
for Salary Data
Choose 27 at www.jems.com/rs
Choose 28 at www.jems.com/rs
Emergency Medical Technician (EMT-B): This section inquires about
your full-time emergency medical technicians with basic EMS skill levels that may include additional skills, such as defibrillation, assisting
patients with medications, and first aid based on the current National
Emergency Medical Technician-Intermediate (EMT-I): A full-time
emergency medical technician–intermediate based on the current National
Emergency Medical Technician-Paramedic (EMT-P): A full-time emergency medical technician at the paramedic level based on the current
National Standard Curriculum.
Emergency Medical Dispatcher (EMD): A full-time emergency medical dispatcher that includes frontline communications positions. Duties
include call taking, dispatch, or both. This person may also be certified as
an EMT or paramedic.
Communications/Dispatch Supervisor: A first-line supervisor of emergency medical dispatcher(s). Duties may include shift supervision, scheduling, performance evaluation as well as call taking, dispatch or both. This
person may also be certified as an EMT or paramedic.
Communications Manager: A senior management position of the EMS
communication center. This position may oversee all operations, budgeting, hiring, quality and strategic planning.
Field Training Officer: A full-time field training officer whose duties
include field training of new employees or EMT students at all levels. This
may be a full-time position or performed as part of regular shift work.
Education Coordinator: An entry-level management position. This
position may be charged with providing or coordinating continuing medical education, overseeing field training and supporting recertification of
staff. In some organizations, duties may be blended with the quality
Quality Coordinator/Manager: Traditionally, an entry-level management
position that may be charged with coordinating and managing key clinical performance indicators (e.g., cardiac arrest survival) and quality assurance (e.g., run
form review and complaint investigation). In some organizations, duties may be
blended with the quality management functions.
healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population
Can EMS do more? For a UHU calculator, see Figure 3, p 34. Using
this year’s respondent data, participant UHU is presented in Figure
4, p. 34. Reported annual response volume and average unit hours
were distributed by 52 weeks per year to determine an average UHU.
Comparing that UHU to several published benchmarks the conclusion is clear.6–8 There’s capacity to do more within many EMS
Financial Officer/Manager: A full-time management position focused
on budget and finance that may also have blended duties related to the
oversight of billing operations.
Billing/Reimbursement Clerk: A frontline position responsible for processing patient care records, billing payers and collecting reimbursement
Billing/Reimbursement Manager: Traditionally a middle management
position responsible for supervising the processing of patient care records,
billing payers and collecting reimbursement for services.
Fleet Mechanic: A frontline mechanic in fleet services whose duties may
include preventative maintenance, scheduled/unscheduled maintenance,
vehicle remounting/replacement and purchase specifications.
Fleet Manager: A middle management position charged with leading fleet services. Duties may include supervising mechanics, coordinating preventative maintenance, vehicle remounting/replacement and
Information Technology/Systems Manager: This position may or
may not be a management position. Responsibilities may include maintaining technological infrastructure (e.g., e-mail, servers, networks, etc.) for
Logistics/Supply Manager: May be management position or not.
Responsibilities may include supply purchasing, storage, distribution and tracking.
This position may also manage restocking of stations or ambulances.
EMS Operations Manager/EMS Chief: A middle- to upper-management
position responsible for managing day-to-day operations. This position may
have field supervisors and other frontline leadership positions reporting
directly to them.
Administrative Director/EMS Administrative Chief: A senior-level
management position that traditionally includes oversight of all nonoperations functions and may include finance, billing/reimbursement and
Executive Director/Highest-Ranking EMS Chief: A senior leader of
all EMS functions whose duties include strategic planning, constituent
relations and leading senior management team.
Choose 29 at www.jems.com/rs
Salary Workplace Survey
continued from page 37
to healthcare, personal care and social
assistance … are projected to have
the fastest job growth between 2010
Listed as one of the “top five industries for salary growth,” health2006 Average (Max.)
care workers have gained the biggest
2012 Average (Max.)
changes in wages, 9.4%, since 2006.15
What does that mean to EMS workers? There’s reason for some optimism
Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing
manger, fleet mechanic, information technology manager, operations manager, administrative director, executive director.
in EMS wages. Twelve job categories
from the 2006 JEMS Salary and Workplace Survey were compared to 2012 data
organizations, whether it be writing parking of Labor Statistics (BLS) reported that the
tickets or becoming more accountable for unemployment rate ticked up a tenth of (See Figure 5, at left).16 Despite losses in two
the health of your community. If you had to percent to 8.2.13 Yet a February 2012 BLS individual categories, EMS salaries increased
choose between the two, it doesn’t seem to be report on employment projections opened 8% over that timeframe. This increase places
a difficult decision; EMS is at its best when it’s with, “Industries and occupations related EMS with general healthcare as one of the
caring for patients.
Can CP programs make a dif- Figure 6: Existing Employee Benefits
ference? According to the Agency
for Healthcare Research and QualPaid by
ity (AHRQ), they do.9 MedStar
Health’s Community Health ProNew Employee Relocation Expenses
gram in Fort Worth, Texas, has
saved millions in emergency room
charges and reduced 9-1-1 use.10
The Centers for Medicare and MedMajor Medical (Employee)
icaid Services (CMS) must think
Major Medical (Employee’s Family)
so as well. In July, the CMS Health
Care Innovations Grant program
awarded Prosser Memorial Hospital in Washington almost $1.5
Employee Assistance Program
million to develop and provide a
community paramedic program.11
Which model for community paramedicine should you
choose? It could be a “new niche
EMS Tuition Reimbursement
for EMS,” according to the August
College Tuition Reimbursement
JEMS article “It Takes a Village.”12
Scholarship Fund for Employee’s Children
The article identifies the key component of the multiple CP modRetirement or Pension Plan
els as the needs of and resources
Retirement or Pension Plan
in the community. “They all feaProfit Sharing
ture aspects of home assessment,
Stock Purchase Program
home care and patient followup. They all focus resources on
Shift Differential Pay
target population, follow-up care
and prevention,” the article states.
Health Club Membership Reimbursement
The take-home message: “Community need” should drive model
Paid Time Off (PTO) Combined Benefit
development and implementation, creating a partnership in the
healthcare of the community.
Dry-cleaning of Uniforms
Figure 5: Annual Salary Growth Index from 2006 to 2012
In May 2012, the U.S. Bureau
Show Me the Money
“Daylight is burning,” declares Duke
as he ends the conversation and heads
toward the Communications Center
for a schedule of today’s community
visits. During his workday Duke will
visit a number of “frequent flyers” that
have been identified within the healthcare community as needing screening
and help with chronic care.
One of Duke’s congestive heart failure patients wrote in recent thank-you
card to FSEMS that Duke saved him
from an ambulance trip to the hospital. “He listened to me breathe, took a
blood pressure and made a complete
assessment. Then he called my doctor,
who adjusted my pills. He did all of
this before I was really sick,” Mr. Write
wrote, adding that Duke even stopped
by later to check on him again that
day, concluding with a thank you to
both Duke and FSEMS for good community service.
National salaries for 2012 are broken down into several categories and
stratified by region (see Figure 7, at
right) and call volume (see Figure
8, p. 40). The job descriptions used
in the survey are also presented in
“Job Descriptions for Salary Data,” p.
36–37. Regional data is reported where
antitrust guidelines were achieved. All
wages are adjusted to reflect a 40-hour
workweek for comparison. See Figure
9, p. 40, for instructions on calculating wages for comparison to different
Author’s note: Comparing 2012 salary data to 2011 appears unreliable due
to a qualitative participation bias. Data
reported for 2011 national average salaries was significantly higher than data
Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing manger, fleet mechanic, information technology, operations manager, administrative director executive director.
Figure 7: Salaries by Region
best jobs for wage growth.
Not all the news is good. Organizational “belt tightening” is reflected
in the 2012 Employee Benefits data
(See Figure 6, below left.). Twenty of
25 benefits categories were reduced or
eliminated this year. Taking the biggest
hits, the categories of EMS reimbursement (5%) and college tuition reimbursement (6%) and new employee
relocation expenses (4%) were eliminated by organizations reporting.
Salary Workplace Survey
continued from page 39
Figure 8: Salaries by Call Volume
Less than 1,000
1,001 - 5,000
5,001 - 15,000
15,001 - 50,000
Greater than 50,000
Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing
manger, fleet mechanic, information technologymanager, operations manager, administrative director executive director.
reported in 2010 and 2012. Figure 9: Calculating Alternative Shift Schedule Wages
As previously noted, selective
See bonus salary
All wages are calculated based on 2,080 hours annually (40-hour work week).
participation and a different
figure online at jems.
To calculate alternative shift schedules, divide an annual wage for a position by 2,080 hours to
pool of respondents year-tocom/journal.
find the hourly rate and then multiply the result by the annual number of straight hours for the
shift type of interest. Below are examples for the three most common average weekly hours.
year creates this situation outA just-released Pew
side of survey and researcher
Research Center survey
Average Work Week Straight Hours x 52 weeks/year Annual Straight Hours
control. Visit jems.com/jourreports that a $70,000 annual
40 straight hours x 52 weeks
nal and click on the salary surincome is needed for a fam48 hours
52 straight hours x 52 weeks
vey for an extended figure with
ily of four to lead a middle56 hours
64 straight hours x 52 weeks
additional job categories not
class lifestyle in the U.S. Using
shown here as well as a comthe Pew study definition of
EMTs and education coordinators demon- middle-class lifestyle, only three of the EMS
plete comparison of 2011–2012 data.
Out of 19 job categories, 14 reported sal- strated a moderate loss in wages, minus two job categories—operations manager, adminary growth in comparison to 2010 wages. The and minus four percent respectively. Chief istrative director and executive director—
billing manager position showed no growth financial officers (CFO) and supply coordina- would allow a single-income family of four
in wages between 2010 and 2012 (see bonus tors took the greatest wage losses at -9% and to live middle-class lifestyle .17 In comparison,
salary figure online at jems.com/journal).
a registered nurse receives an annual salary