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The ‘M’ in EMS stands for medical: Tackling fire/EMS challenges

Fire service leaders must handle four leadership challenges to maintain an effective fire-based EMS program


In this Jan. 9, 2013 file photo, an injured ferry passenger is loaded into an ambulance in New York.

AP Photo/Richard Drew, File

By Jay Fitch, PhD

As I pulled on my bunker pants, I started whining about taking a middle-of-the-night, low-priority ambulance call.

It was early in my career, and an older firefighter leaned over and said, “Son, remember that the M on your EMS patch stands for medical, so quit whining and just get on with it.”

Things didn’t get better on the scene.

I acted arrogant, annoyed and was thinking, “This patient didn’t need to call 911.” Truth told, I judged the patient and was just going through the motions.

What’s worse, in my rushing, I missed a key element in the secondary assessment that could have changed the patient’s outcome had not it been caught. The older/wiser firefighter quietly stepped in and whispered, “Why not let me handle this?” He had already spotted my error and, in doing so, helped avoid compromising the care of our patient.

When we talked about the call later, I realized the way he handled intervening also saved me from embarrassment with my peers and ultimately with the agency’s medical director. I learned several valuable lessons that night.

Four leadership challenges presented by EMS

There are four unique leadership challenges that EMS presents for fire service leaders:

  1. How to maintain clinical competencies;
  2. Ensuring that citizens receive the customer service we expect;
  3. Determining how much is too much; and
  4. How to balance clinical relationships and discipline.

Whether your department only provides first response or is a full transport program, each of these factors must be considered to maintain an effective fire-based EMS program. Let’s review each.

1. Maintaining competency and developing constructive remediation

Competence encompasses knowledge, skills, abilities and traits. It is gained through pre-service education, in-service training and work experience. The level of competence is a major determinant of provider performance as represented by conformance with various clinical, non-clinical and interpersonal standards.

Skill and aptitude must be regularly assessed. Measuring competency levels is essential for determining the ability and readiness of fire/EMS workers to provide quality services. Although competence is an obvious precursor to doing the job right, measuring performance periodically is also crucial to determine whether providers are appropriately using their skills on the job.

No one likes to feel like they are under the microscope, yet we need to ensure caregivers regularly demonstrate competency, particularly with high-risk/low-frequency procedures. Unfortunately, some of the in-station continuing education programs currently utilized don’t provide adequate opportunities or independent validation of required competencies. This is a disservice to the provider and the organization and could ultimately be detrimental to the patient.

Skill decay is a major issue for fire/EMS, just as it is for the nation’s pilots. Instrument-rated pilots are required to accomplish a minimum number of mandatory challenging skills every six months. In addition, on a regular basis, they have to demonstrate both knowledge and the ability to actually perform those practical skills/maneuvers to the satisfaction an instructor-pilot. If the skill can’t be performed, the penalty is that the pilot must continue to work with the instructor, on their own time, until they can demonstrate competency and correctly execute the maneuvers. Fire service EMS can learn something from aviators on this point.

2. Ensuring that customers receive the service that leaders expect

A culture of service has to be more than a platitude. Several years ago, I was talking with a firefighter about improving their customer service, and I got this response: “Look, we only handle critical calls. We don’t have customers, we have victims.” I was taken aback but regained my wits to respond: “You know, with that attitude, I think you’re right. Anyone you encounter is a victim.”

One of the best strategies to ensure you know what is occurring is to conduct independent customer surveys. There are multiple companies that can benchmark the levels provided by your agency to others of similar size throughout the nation. This is a significant improvement to sending comment cards with the bill, or only relying on the number of compliments and complaints received, to determine how the service is perceived.

3. Determining how much is too much

A key medical question is “how much is too much?” EMS responses are the predominate activity for most fire departments today. The question has become more complex as field personnel advocate for longer shifts, have other part-time positions, and as more departments seek to transport (which increases the time on task per call compared to first response only agencies). Typically, fire-transport agencies that are not doing long-distance transports like to consider a UhU of .30 or less. To maintain moderate workloads, some departments are adding shorter shifts for EMS crews. Others are pairing high- and low-volume stations to be able to address the issue of busy days mid-shift, to ensure adequate downtime without having to move to a more fluid deployment strategy.

[Read next: Fighting fire from the ambulance: A difficult but rewarding job]

4. Balancing relationships and medical discipline

Fire stations tend to be like a family. Familial relationships become trickier when mom says one thing and dad says another. The same is true when the fire chief and the medical director have differing opinions on how a clinical matter should be handled.

Fire leaders must be concerned about setting precedents and ensuring that due process provisions of the labor agreement are met. Medical directors must be concerned about the liability potential for not taking a definitive action when an error occurs. There should be a direct relationship between the physician’s delegated practice and the EMS worker’s functioning under their license as a caregiver.

The medical director needs to understand that employment decisions are not in their scope, and the fire chief should not interfere with the physician’s absolute control of delegated authority decisions. In other words, if the medical director determines that a medic should not engage in care-activities until a particular skill can be demonstrated, then that should be within their purview, and the chief should not interfere. Likewise, the manner in which the agency deals with their employees (e.g., reassignment, suspension or even termination) is not within the medical director’s domain, and those boundaries should be respected.

Move your people where they need to be

Awareness of each of these four factors is essential to keep the M in EMS. If we start from the perspective that all caregivers want to do a good job, then our task as leaders is to meet them where they are and help move them to where they ought to be.

Former first lady Rosalynn Carter once said: “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.”

In addition to being reminded that whining does not become me that night so many years ago, I learned that not only does the M stand for medical, the S stands for service, and while we think the E should stand only for real emergencies, it also stands for elegant leadership.

The art of intervening quietly to do the right thing while not embarrassing another caregiver was the most valuable of all. Although the older/wiser firefighter retired long ago, I wish I could say thank you for the lessons he provided. In retrospect, maybe the best way to say thanks is to pass it on.

About the Author

Jay Fitch, PhD is a founding partner at EMS/public safety consulting firm Fitch & Associates. He served as a volunteer firefighter in Fairfax County, Virginia, before becoming one of the early medics trained in the United States. He has directed and designed major EMS systems throughout the nation. Contact him directly at

For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit