Robert Vroman, M.Ed., BS NREMT-P

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EMS1 Daily News

Police need to call EMS early for erratically behaving patients

For medical emergencies that exponentially worsen over time, like excited delirium, rapid EMS intervention may be the difference between life and death

ER patient arrested after high speed chase in stolen ambulance

Police used spike strips to stop a 34-year-old woman who left a hospital's emergency room and sped away in an ambulance

Video: Responders rescue man impaled in crotch on security gate

The man, who was high on drugs, was cut free; the fence was still piercing his midsection when he was rushed to a hospital

Tornadoes hit Okla., Ark.; 1 dead, several injured

Officials said that at least nine people were hospitalized with injuries but that the total number of injuries wasn't yet known

Woman who had fetus cut from belly released from hospital

She faces a long and costly recovery after her unborn baby, which did not survive, was cut from her womb with a kitchen knife by a stranger from Craigslist

Co-pilot intentionally crashed plane into French Alps

Investigators say he barricaded himself in the cockpit and manually flew the plane into the mountains, killing all 150 people on board

Firefighter-medic dies of complications with brain tumor

After he felt sick on March 15, doctors found a mass that was in the cerebellum area of the brain, which controls coordination

Lawsuit: Patient in crash claims gurney was not locked in place

He's seeking $305,000 for injuries sustained in a 2013 fatal collision when a car crashed into the rig, causing him "to fly ... within the ambulance, colliding with objects"

Pa. firefighter-EMT among finalists for national community service award

Ed Smith spent months renovating the fire safety house used to teach kids what to do in a fire; he only agreed to the nomination because it comes with $10,000 for the department

What a changing 911 system means for EMS

Here's a look under the hood at Next Generation 911 and how one department has implemented it

EMS1 Topic Articles

Police need to call EMS early for erratically behaving patients

For medical emergencies that exponentially worsen over time, like excited delirium, rapid EMS intervention may be the difference between life and death

ER patient arrested after high speed chase in stolen ambulance

Police used spike strips to stop a 34-year-old woman who left a hospital's emergency room and sped away in an ambulance

Video: Responders rescue man impaled in crotch on security gate

The man, who was high on drugs, was cut free; the fence was still piercing his midsection when he was rushed to a hospital

Tornadoes hit Okla., Ark.; 1 dead, several injured

Officials said that at least nine people were hospitalized with injuries but that the total number of injuries wasn't yet known

Woman who had fetus cut from belly released from hospital

She faces a long and costly recovery after her unborn baby, which did not survive, was cut from her womb with a kitchen knife by a stranger from Craigslist

Co-pilot intentionally crashed plane into French Alps

Investigators say he barricaded himself in the cockpit and manually flew the plane into the mountains, killing all 150 people on board

Firefighter-medic dies of complications with brain tumor

After he felt sick on March 15, doctors found a mass that was in the cerebellum area of the brain, which controls coordination

Lawsuit: Patient in crash claims gurney was not locked in place

He's seeking $305,000 for injuries sustained in a 2013 fatal collision when a car crashed into the rig, causing him "to fly ... within the ambulance, colliding with objects"

Pa. firefighter-EMT among finalists for national community service award

Ed Smith spent months renovating the fire safety house used to teach kids what to do in a fire; he only agreed to the nomination because it comes with $10,000 for the department

What a changing 911 system means for EMS

Here's a look under the hood at Next Generation 911 and how one department has implemented it

EMS1 Columnist Articles

Driven to kill: EMS must focus on safety, not speed

Scenario: You are a baseball player. You're pretty with throwing that 5 ounce ball, getting it to other players the vast majority of the time. Rarely do you miss or drop it. One day, the coach brings out the regulation baseballs. These weigh 23 ounces — that's about 1.43 pounds. They're about 3 times bigger too.

Might your throw accuracy be affected" Probably quite a bit, right" At least for awhile. What about if the scenario was that the balls were switched out on game day" That would be just crazy, right"

Yet we don't think twice about putting drivers behind the wheel of an ambulance. Compact cars like a Honda Civic weigh about 3000 pounds; ambulances weigh anywhere between 9000 and 14,000 pounds — or more.

The baseball scenario doesn't fully apply to ambulances either. A higher center of gravity, decreased braking performance, and poor steering response all worsen the issue.

Then, the the vast majority of the industry does not train its personnel how to drive these vehicles. I've worked in places that "driver training" was an insurance ploy — fill out a workbook, spend 15 minutes driving around a couple of cones, and get a certificate. Very helpful, except that none of it related to real world hazard driving.

In fact, we place high value on the need for speed. Despite all studies showing how little — or no — effect there is on response times to even critical calls, we still drive with lights and siren blazing to virtually every call. Government contracts enforce that mindset, unwittingly placing members of the driving public at risk every day.

We have to stop this insane behavior and grow up. It's not fair to us, our patients and our community and place everyone at risk of serious injury or death. Provide the education and training that makes even a 19-year-old a safer driver. Severely punish those who flagrantly flaunt the rules because they think they can do better (hint: physics has a nasty way of reminding one that is so not the case). Stop writing response time contract requirements that sets the stage for unwarranted risk-taking.

By the way, how did the patient get ejected from the ambulance — in a head on collision" The kinematics forces involved just don’t make sense. One would hope that the patient was properly restrained on the gurney, and the gurney was properly fitted to the locking mechanism, and the lock was properly fastened to the floor. I imagine there might be some serious explaining to do.

Clinical solution: An eye injury at a structure fire

Eye injuries can occur as the result of many causes, though foreign body is a particularly common mechanism. According to the Bureau of Labor Statistics, 25,290 eye injuries occurred on the job in the United States in 2013; a rate of 2.4 injuries for every 10,000 full-time workers.[1]

Routine use of recommended personal protective equipment (PPE) can protect an employee from a potentially career-ending and disabling injury. We reviewed common medical PPE in ' dispatched for a sick teenager,' but it is important to remember that EMS providers, particularly those who fulfill multiple roles (including firefighting and rescue) are exposed to more hazards than just bodily fluids and substances during the course of their job duties.

Federal requirements for PPE

The Occupational Safety and Health Administration (OSHA), a division of the U.S. Department of Labor, publishes a variety of rules related to workplace safety. These rules include the use of PPE based on the anticipated hazards in a given environment. Hazards such as flying debris, liquid chemicals and chemical vapors are assessed and recommendations for PPE are issued as a result. [2]

Additionally, the federal guidelines dictate that employers must provide required PPE free of charge to employees with the exception of steel-toe boots and prescription eyewear. In cases where employees must wear prescription glasses, the interpretation of the law is that the employer shall provide PPE which can be worn over the glasses. Employers must also ensure that employees are trained in the use of PPE, including when to use protective equipment, what equipment is appropriate in a given situation and how to properly don and doff the PPE. [3]

Personal protection standards

While OSHA dictates what PPE should be worn based on a given hazard in the environment, the specific physical qualities of that PPE are based on industry guidelines developed by the American National Standards Institute (ANSI). The ANSI standard evaluates minimums for impact, splash protection and dust, among others.[4] Safety equipment which meets the minimum standard will be marked accordingly. The most recent ANSI standard for eye and face protection is Z87.1-2010.

Foreign body removal from the eye

In order to determine the proper treatment for a patient with a foreign body in the eye, the extent of involvement must first be assessed. Visualize the globe of the eye for obvious trauma to develop a treatment plan. For patients suffering from specks of dust or other small irritants, simply rinsing the eye with sterile saline may be enough to flush the particles out. If a patient appears to have a foreign body embedded in the globe, however, you should refrain from flushing the eye and transport the patient to the nearest, appropriate facility for additional evaluation and treatment.

For exposure to chemical irritants, the eye should be flushed with copious amounts of water or saline. If the call occurs at an industrial location, there may be an eye wash station available for your use. The Morgan Lens is an excellent tool for eye irrigation for EMS providers that are authorized and trained in its use.

Treatment of the injured firefighter

After assessing Frank you note that there appear to be several small particles of plaster in his eye and no obvious signs of trauma, just redness and irritation. You instruct Frank to lie back on the stretcher and to keep from rubbing his eyes. With a fresh bottle of sterile saline you gently irrigate both eyes while instructing Frank to blink frequently. After several minutes of flushing, Frank reports that the sensation of “something” in his eye has passed. You confirm that the redness in his eyes is improving and Frank confirms that his vision is normal.

After reporting your findings and treatment to the on scene safety officer, you contact your medical control physician who states that Frank should follow up with the department’s occupational health provider before returning to active duty. Frank’s battalion chief says that he will drive Frank over for further evaluation. You also recommend that Frank, as well as the other firefighters, utilize safety glasses when performing overhaul.


1. Bureau Of Labor Statistics. (2014, December 16). Nonfatal occupational injuries and illnesses requiring days away from work, 2013.

2. Occupational Safety and Health Administration. (2009, September 9). Eye and face protection. Retrieved from Occupational Safety and Health Standards website.

3. Occupational Safety and Health Administration. (2011, June 8). General requirements. Retrieved from Occupational Safety and Health Standards website.

4. International Safety Equipment Association. (n.d.). American national standard for occupational and educational eye and face protection devices.

Inside EMS Podcast: What can a medic do that an EMT can’t on scene?

Download this week's episode on iTunes, SoundCloud or via RSS feed

In this week’s Inside EMS Podcast, co-hosts Chris Cebollero and Kelly Grayson bring on guest and EMS1 columnist Bob Sullivan to debate ALS versus BLS EMS Systems.

Cebollero asks, “What is it that a paramedic does that an EMT couldn’t do for a patient on scene"”

Sullivan said you can give EMTs the skills to manage anything that’s a life threatening emergency, but questions whether they have enough education and clinical field time to carry out the interventions.

“I think the biggest benefit to ALS is, is the patient that doesn’t look sick, but they know what questions to ask because they’re taught that at a deeper level than EMTs in America are,” Sullivan said.

The benefit of ALS is the education and training that paramedics have to better assess patients, he said.

Sullivan, who has worked in a tiered EMS system, also argues that many calls that wouldn’t normally trigger an ALS response, such as medication administration for a patient suffering from abdominal pain, would actually benefit from a paramedic response.

“That’s an issue with medical priority dispatch system,” Grayson said.

Sullivan also brings up 12-lead assessment, saying EMS should be screening patients to at least determine if it’s a code STEMI.

“My partners know how to apply 12-lead EKG,” Grayson said. “They don’t know how to interpret one. But you know something; many of my paramedic partners don’t know how to interpret one worth a darn either.”

Implement a program to make your grant request stronger

“How do I make my application better"”

That is one of the most common questions I receive as a grant writer. Simply requesting funds for a piece of equipment is seen as singular and costly. Grants have become increasingly competitive over the past decade, with reduced budgets due to the economic climate and decreased donations from private foundations leading to more applicants. The Congressional Budget Office estimates an increase of 80 percent in the number of applicants applying for federal grants since 2006.

How do you assure your application stands out"

Why programs pay off

Implementing a program with your grant request can increase your chances of receiving funding. In fact, the majority of complex federal grants, such as the Innovation Grants through Center for Medicaid and Medicare Services, actually require the implementation of thorough programs. You can take this model for small-scale grants to get the funding on equipment projects by folding in a program.

Programs do not need to be complex, but an effective program needs to:

  • Have an objective and goal
  • Reach a target population
  • Be measurable
  • Have a timeline

An effective program will fit within your mission statement. For instance, if you are funding a vehicle, you are enhancing public safety and increasing the quality of care you provide. But a private foundation that is not educated in emergency services just sees a vehicle. From their standpoint, it’s an expensive piece of equipment that does not have the impact on the community the way that an outreach program does.

By building a community outreach program around the vehicle you can promote volunteerism by recruiting new members, educate the community on your service, build a young workforce through targeted youth programing, and meet the public in a positive space on your own terms instead in the middle of an emergency.

Program implementation has a high impact on your agency as well. Programs create career ladder advancements and lateral promotional opportunities that are scarce in our industry.

By increasing provider involvement in activities other than patient care you’ll see higher employee morale, increased retention rates, and diversify the knowledge and skills of your employees.

Cardiac arrest research dominates Eagles conference

New research in cardiac arrest care and resuscitation dominated much of the conversation as medical directors from some of the largest EMS agencies in the nation gathered in Dallas to talk about the latest developments in prehospital care at the 17th annual EMS State of the Sciences Conference in February.

Dubbed the “Gathering of the Eagles,” the conference consists of more than 60 presentations over two days, with most constrained to a 10 minute timeframe. As in past years, a wide range of topics were covered. While highlights included discussions of system design and technology, a look at naloxone use by first responders and bystanders, and groundbreaking research from across the country, many of the presentations focused on new studies in cardiac arrest patients and resuscitation

‘Morphine sucks for STEMIs’

As is tradition, Nashville’s Corey Slovis, MD, started the conference with a look at his five “most important” peer-reviewed papers published in the last year. All five concerned the care of cardiac patients, including one that questioned the use of morphine for patients suffering an acute myocardial infarction.

The study, published online in Circulation: Cardiovascular Interventions, found an association between morphine administration and decreased effectiveness of platelet inhibitors. They also found higher levels of nausea and vomiting among STEMI patients who received morphine. Slovis said there is more than enough evidence to suggest using fentanyl to treat pain in acute MI patients.

“Morphine sucks for STEMIs,” Slovis told the audience. “Stop using it.”

Concerns about hands-on defibrillation

Slovis also discussed a paper published last year in Circulation that concluded hands-on defibrillation was not safe. But the study, he said, cannot be considered conclusive because it measured electrical energy in cadavers being defibrillated.

“This is the first hands-on defibrillation trial not to use hands-on defibrillation,” he said, suggesting that a “real-life” study was needed before drawing any conclusions.

Gravity-assisted CPR

Perhaps the most surprising cardiac arrest research presented at Eagles this year, however, involved much simpler technology—just the mechanism that tilts the head of the stretcher.

Paul Pepe, MD, the conference’s entertaining emcee and a veteran EMS physician, presented the early results of research on “gravity-assisted CPR,” which entails placing the patient at a 30-degree angle so their head is elevated. The theory" Decrease intracranial pressure so that CPR-assisted circulation to the brain has less resistance.

Pepe showed that on pigs, elevating the upper body produced significantly higher cerebral perfusion pressures thanks to the lower intracranial pressures—in other words, drain more venous blood from the brain so that more oxygenated blood enters the brain with each compression.

“We are achieving our goal of getting better blood flow to the brain using this methodology, just by using gravity,” Pepe said.

When to stop resuscitation efforts

Brent Myers, MD, continued where he left off last year, discussing the Wake County EMS’s work with SAS, the statistical software company based in the county, to use EMS and hospital cardiac arrest data to determine how to decide when to cease resuscitation efforts.

“We think it is a combination of [cardiac] rhythm and ETCO2 values that help make these decisions,” he said.

The database has more than 3,000 patients and outcome information for nearly all of them, so researchers can look at which patients survive, not simply which ones have a return of spontaneous circulation (ROSC) in the field. Early results found that a small, but significant number of cardiac arrest survivors were resuscitated for well over 20 minutes before regaining brain function. The question is figuring out which patients have that chance in order to avoid prolonged resuscitations on every arrest.

While EMS might need to rethink its traditional 20 to 25 minute cut-off, every resuscitation does not need to go for 60 minutes,” Myers said.

Use of prehospital ultrasound

The resuscitation conversation continued with three talks on diagnostic tools not typically used in the field that are now being tested in EMS systems.

Drew Harrell, MD, with the Albuquerque, N.M., Fire Department, said that he was skeptical that prehospital ultrasound for trauma exams added any value—but that EMS use of ultrasound might be useful for evaluating whether a patient in pulseless electrical activity (PEA) has any cardiac activity.

“No patient who had cardiac standstill survived, regardless of the initial presenting ED rhythm,” Harrell said of one study, suggesting that ultrasonography could be used to determine whether a patient’s heart truly wasn’t beating or if a pulse is just undetectable due to low blood flow.

Transesophageal echocardiogram in the field

Another technological solution to determining whether a patient is truly in asystole or fine ventricular fibrillation, or a PEA with cardiac activity versus one without, was presented by Scott Youngquist, MD, of Salt Lake City, where they are studying the utility of transesophageal echocardiogram (TEE) in the field.

“PEA is a dangerous rhythm,” Youngquist said. “In two out of three cases, the patient has a heart beat … How accurate are pulse checks" This is probably one of the most inaccurate diagnoses we do.”

Youngquist demonstrated how TEE could also be used to determine if asystole was truly asystole or possibly fine VF. It can also be used to evaluate chest compressions and potentially guide hand placement during CPR.

While the true efficacy of ultrasound or TEE for field resuscitation is not known, and both are expensive and not designed for use by ground ambulance crews, what is clear is that new technologies and innovative research are changing the way cardiac arrest is perceived—patients who were once dismissed as “dead” are now considered to have a treatable condition that can be reversed.

Following the heart or the head"

Another new way of viewing cardiac arrest was presented by RJ Frascone, who suggested that the focus of determining the futility of resuscitation should be the brain, not the heart. After all, with mechanical CPR, ventricular assist devices and extracorporeal membrane oxygenation (ECMO), as well as heart transplants, a patient whose heart is not functioning properly can still survive.

“The condition of the brain might be more important than the condition of the heart when determining if and when to resuscitate and terminate,” said Frascone, the medical director for Regions Hospital EMS, in St. Paul, Minn..

Frascone presented the case for using bispectral index monitoring (BIS) to measure brain activity. At the time of his talk, Frascone and his colleagues had only used it on 11 patients, but the audience was clearly intrigued at the idea of finding ways to measure a patient’s potential for a good neurological outcome.

Other discussions related to CPR included:

  • The need to educate practitioners on discussing death with families and bystanders, especially following pediatric cardiac arrests.
  • Practicing a systematic method for applying mechanical CPR devices and slightly delaying their use to avoid pauses in compressions.
  • Using metronomes to prevent excessively high compression rates.

Why an EMS leader's vision needs ‘grunts’ to buy in

“Culture eats strategy for breakfast.” ~ Peter Drucker

My girlfriend is a bit of a management and leadership junkie. She comes from a business management background, and she spent years with a management service organization that provides staffing, training and consulting to volunteer EMS squads throughout Connecticut.

Whereas I, on the other hand, am a career street medic, the quintessential grunt. Even when I was a field supervisor or member of management, I approached my job with a grunt’s sensibilities.

As you can imagine, debates about EMS between us can get a little… lively. As likely to pepper her arguments with quotes from Peter Drucker or Jack Welch as I am to salt mine with pop culture references and quotes from Mark Twain, she gives me a run for my money. Sometimes, I even lose.

But one of her favorites is the quote that leads off this column, and it’s one I can’t refute.

Culture does eat strategy for breakfast

For those of you who have never heard of him, Peter Drucker was a management consultant who is widely considered “the father of modern management,” and what he meant was that leadership, strategic vision and a sound business plan mean absolutely nothing if the grunts don’t buy into it. What good is a visionary leader if nobody is willing to follow him" Forming a strategic plan for your agency’s future is the easy part. The hard part is getting the people who will carry it out to believe in it as much as you do.

In other words, the established culture of the agency makes all the difference in the world. If the leader is an excellent cheerleader and salesman, sometimes he can sell his vision to the troops, and the agency culture changes.

If it doesn’t, the only answer left is to fire all the unhappy people, and hire new ones that do share your vision. Obviously, that can be quite traumatic, and the agency might not survive the transformation.

Shaping an agency’s culture

What brought this Drucker's missive to mind is the recent news articles about misconduct and scandals at EMS agencies around the country. Whether it is firefighters using excessive force to restrain a patient, lurid stories of sex in firehouses amid allegations of sexual harassment and hazing, or the scandal du jour for DC FEMS, only so much of the blame for such goings-on can be laid at the feet of the chief.

Sadly misconduct can become part of the agency culture. And no matter how much the current chief – or the new one hired with a mandate to clean house and root out all the bad apples that his predecessor couldn’t – wants to transform the agency, if the grunts don’t share his vision, the plan is doomed to fail. The culture endures.

That’s a phenomenon I’ve witnessed myself. During Hurricane Katrina, I met and worked with EMTs from other parts of the country who wore the same uniform. Their ambulances had the same logo on the side. Yet their attitude, training, leadership … everything was markedly different. We were owned by the same national company with a shared strategic vision, but the culture of the old agency lingered despite new leadership from the big conglomerate that bought them out.

And often, that culture lingered until terminations and attrition replaced the old workforce with a new one who never knew what it was like to work for Old Company X. Only then did the agency culture change.

There’s a lesson to be learned there, for managers and grunts alike.

Change begins with you

For the grunts, the way to transform your agency starts with you. You shape the culture. Beating up a combative patient in retaliation for a punch will continue to happen until it is condemned in the ranks.

Sexual harassment of female medics will continue to happen until the males in the organization no longer subscribe to the philosophy of “Hey, it’s a man’s game. If you wanna fit in, you gotta act like one of the boys.”

Personal and professional accountability will not be a priority for the crews – or the unions that represent them – until the crews themselves decide that pencil-whipping continuing education paperwork, sharing test answers, rendering shoddy care to patients, or ignoring customer service, are unacceptable from their peers.

Don’t wink at problems or ignore the poor performers. Call them out. Peer pressure can work in positive ways, too.

For managers, it means that you have to do more than bludgeon your subordinates with the rank hierarchy and the policy and procedure manual. You have to lead. You have to practice responsibility upward. You have to sell the agency’s vision, and make your subordinates believe in it every bit as much as your chief does. And the only way to do that is to occasionally get in the mud with the troops, and share a little of their misery. They have to be convinced that not only are you willing to do everything they’re asked to do, but that you can do it better. That’s why they made you a manager.

Everyone contributes to culture change

In the early days of World War II, USMC Major Evans Carlson appropriated a Chinese term, “gung ho,” as the unofficial motto of the 2nd Marine Raider Battalion. In modern parlance, most people consider “gung ho” synonymous with “enthusiastic” or “overzealous.” In reality, the term means “strive together in harmony,” a somewhat heretical statement at the time for an organization with a rigid rank hierarchy and command structure like the U.S. Marine Corps. Indeed, many of his peers and commanders considered Carlson a kook influenced to an unhealthy degree by Chinese communist doctrine and philosophy.

The 2nd Marine Raider battalion’s raid on Makin Island was a tactical failure. Though they managed to annihilate the Japanese garrison on the island, few of the raid’s other objectives were met. Yet Carlson’s leadership concepts and tactics resonated far beyond a tiny atoll in the south Pacific. The Marine Raiders are now considered some of the forerunners of the modern U.S. Special Forces. Carlson abandoned the traditional USMC eight-man squad in favor of a 10-man squad composed of a squad leader and three-man fire teams, an innovation that the Marine Corps still uses to this day. Even with what is widely considered a rigid command hierarchy in the USMC today, every Marine, down to the lowest PFC, is expected to contribute to the planning process of a mission, and speak up if they perceive any flaws in the plan. Carlson was able to fundamentally transform a culture.

Not bad for a quasi-communist kook, eh"

As a manager, if you want to transform your agency’s culture, you have to employ the persuasion and force of personality of a man like Carlson. If charisma and salesmanship are not in your repertoire, then you need to identify subordinates who possess those qualities, and turn them loose to do your thing.

As a grunt, remember that you can be just like the Marine grunts. You may be the lowest man on the totem pole, but the profession needs you to contribute to the plan, and speak up if you spot flaws.

Only in this way will you transform your agency’s culture, and by extension, the culture of EMS.

7 tips for dealing with negative online comments

You’ve probably seen comments about your organization on social media and have considered responding. But how to jump into the fray—particularly when your agency is drawing negative attention" Here are seven tips to help you navigate criticism on social media in a way that reflects favorably on your organization:

1. Pay attention

Simply put, you can’t deal with comments you don’t know about. Set up Google Alerts for your organization and industry keywords. Keep a close eye on your Facebook page. Monitor Twitter. Make a list of any forums or communities where stakeholders congregate and regularly check in on them. Whether you’re paying attention or not, the conversations are happening. Staying on top of what’s being said makes it easier for you to catch negative buzz and spot issues before they build momentum and become much harder to turn around.

2. Determine if a response is necessary

Not all negative comments are worth a response, and not all critics are worth trying to win over. Sometimes, as hard as it can be, it’s best just to move on.

The following are examples of when it may be best not to respond:

The criticism is on a really small blog or forum, and your response will only bring attention and credibility to an issue nobody saw in the first place.
It’s a blatant attack that’s clearly rude and outrageous—and anyone who reads it can see the critic has a personal problem.
The comments come from a known troll who is only looking to pick a fight.

There’s just no way to win in these scenarios. So stay out, move on, keep your head up and focus on the wrongs you can right.

3. Respond appropriately

Reading a negative comment about your agency, caregivers, vehicles or service can make you want to justify actions and claim that the commenter is just plain wrong, misinformed or simply off the mark. While these are natural reactions, they won’t help the service or its social media presence. Pay attention to what’s been said, then respond in a balanced, appropriate and professional way.

4. Be brief

You don’t want to reveal too much in your response to a negative comment. Social media is a public space, and airing dirty laundry isn’t going to help the organization and could subsequently be used in court. Try a simple “We’re sorry we didn’t meet your expectations. Please call my office if you'd like to talk about the specifics of your situation.” Keeping it brief will help avoid problems down the line, and can encourage the individual to contact you directly to resolve the problem.

5. Use the feedback

Rather than just being peeved about comments, try to see them as valuable. Keep a record of comments as you respond to them, and make a note of any suggestions, tips, questions or issues people mention. The commenter may be providing some valuable information that you’d normally have to dig to find. Remember that perception is reality—if you feel the comments are unjustified or based on falsehoods, it could be that you and your agency need to do a better job explaining the truth.

6. Remember everyone is reading your responses

Probably the most important reason to respond to comments is that everyone else is reading them. Although many people won’t comment themselves, they’ll read the comments of others, and they’ll pay close attention to how your agency responds.

Responding to negative comments is a chance to demonstrate how caring, thoughtful and engaged your organization is, and how it solves potential problems. If you show that your agency listens to and responds to feedback in an appropriate manner, you’re creating a sense of trust that will go far beyond the particular commenter you’re dealing with at any given moment.

7. Don’t take it personally

That’s easier said than done. If you find yourself taking comments personally, then consider hiring a social media manager to stay on top of interacting with the public. Making sure there is someone consistently handling all the negative comments will help keep your agency’s image intact.

No one likes to be flamed on-line. When it happens, it’s best to take a deep breath and consider these seven strategies to increase your success.

About the Author

Jay Fitch, PhD is the founder and president of emergency services consulting firm Fitch & Associates. Find them on-line at Dr. Fitch also serves as the program chair for the Pinnacle Leadership Forum. Contact Jay directly at

Job titles: A leader’s approach to making them better

“You can call me anything,” an EMS leader declared. “It’s not the job title, it’s the job I do that counts.” But his title mattered more than he was willing to admit. Later in the conversation, when someone suggested changing his title to better match the structure of his organization, he suddenly became angry and protective of his title.

What is it about job titles"

On most days we don’t give titles a lot of attention. But start messing with titles and watch people engage. Watch the passion rise among field staff around the issue of calling all field providers 'paramedics.' Check out the ubiquity of the title “chief” on the leadership page of the International Association of EMS Chiefs website.

Note the importance of titles when people introduce themselves at a conference. Consider the feelings you have around your own job title. Is it the one you really want" Is there another you wish you had"

Titles are important signifiers. Along with uniforms, stars, bars and badges they are indicators of positional power and authority. Titles shout messages about the organization and the person. This is an invitation to pause and reflect on job titles from a leader’s perspective.

A dearth of uniformity and meaning

The EMS industry in the U.S. has a dizzying array of job titles. There are directors, chiefs, presidents, executive directors, CEOs, administrators, managers, coordinators and general managers. We have operations chiefs, deputies, operations directors, managing directors, division chiefs, associate directors, assistant chiefs, battalion chiefs, supervisors, leads, shift leads, coordinators, captains, lieutenants, sergeants, basics, intermediates and on and on.

All of this title vertigo is a testament to the hodgepodge development of EMS. Two not-for-profit EMS agencies in the same county can share borders and have similar operations and yet one titles its positions like a club and the other like the military. A hospital service down the road has position titling that mirrors typical hospital departmental structure. And further down the road a fire department with traditional fire service titles interfaces with a private transport company with titles straight out of the for-profit corporate world.

Determining if this has a significant impact on everyday mission success is difficult to say. In asking around some say “no,” but many are suggesting that the lack of uniformity creates complexities that show up on scenes, in political settings, in making jobs meaningful for new generations and in personal career development.

An executive director sees her title as a handicap when leading an MCI where “chiefs” have more recognition. The “chief” of an organization with a rigid military structure is finding millennials turned off by bars and stars. A CEO admits that his title is a liability as he seeks a subsidy for low volume 911 operations. A captain, planning a career move outside EMS, wonders if his title would be viewed as providing the needed managerial experience. The EMS Director of a county-owned third service complains that he struggles for recognition when his equals in the county have titles such as fire chief, police chief, and sheriff.

Adding to this lack of common nomenclature is a paucity of common meaning. For example, what one organization calls a director may not have the same meaning or represent the same organizational layer or function in another.

The personal side of job titles

We often underestimate the social significance and personal identity issues that are embedded in the labels we wear. The leader who said, “You can call me anything,” is reflecting a common desire to show ourselves as selfless and completely comfortable with who we are without a title. But self is largely a social construct, and from the perspective of social psychology, job titles figure prominently into how we construct ourselves in today’s world.

We may not like to admit it, but we are always thinking, evaluating and perceiving ourselves and constructing an internal description of who we are. This self-concept impacts how we show up, take action, make decisions and display confidence. It is integral to our ability to influence others, and the titles we wear are a prominent part of the confidence we need to lead.

When we have a title we respect and are proud of, the title compliments the story we want to tell about ourselves and we will often act with more confidence. The opposite is also true. When a provider believes that the rocker on her shoulder that says “Basic” is a “less-than” title, it may impact how she sees herself and acts.

Notice your personal relationship with your title. When do you proudly use your title and when don’t you" Imagine going a month without using your title to describe yourself.

Job titles and the organization

In today’s work milieu job titles are critical parts of who we are, as well as a reflection of an organization’s structure. They speak to the organizational layers, the job functions and the responsibility and accountability of the person with the title. In an ideal world job titles would accurately reflect structure and function and communicate to others (both inside and outside the organization) meaningful information about the position.

An unchangeable inheritance

So, if job titles are so important, why don’t we give them more thought and attention" It’s simple. We see job titles as an unchangeable inheritance. Long ago, when the organization was created, a structure and titling system was chosen. And the old “we’ve always done it this way” continues to chain the organization to its history.

Here is a leader’s thought: inheritance need not be destiny. Your organization should not be imprisoned by a system that was decided long ago and decided without an understanding of today’s issues and needs.

Taking the leader’s perspective and action

Great leaders are continually asking, “where are we headed"” and “what needs to change, be improved, be created or stopped on our path to getting there"” I’m convinced individuals, organizations and the industry could benefit from giving more attention to job titles. Job titles should:

  • Match the vision and direction of the organization
  • Enhance the actual doing of the job
  • Be understandable outside the organization
  • Be compelling to those who wear the titles

At a minimum, we need to be able to tell the younger generations a compelling story about the “why” of the job titles we have.

So what can you do" Begin a conversation about job titles in your organization. We think together by holding conversations. Here are some questions to seed that conversation:

  • How do you feel about your current job title" If you could change it to bring more pride, respect and career opportunities, what would it be"
  • What is the history of our titling system" Was it simply inherited" Have we become imprisoned by it"
  • Does our current titling systems make sense" Does it serve our mission"
  • What do the frontline people want" What messages do we want to send"
  • Do our titles serve our vision of the future"
  • What does the public expect and why"
  • Does our titling system contribute to the positive development of leaders"

This conversation may result in a need or opportunity for you to lead change. At a minimum, it should ensure that the story you tell around your job titles is compelling and consistent with organizational direction. As always, let us know what you think in the comments below.

Poll Call: How do you earn continuing education?

EMT and paramedic certifications, depending on the state, are valid for two or more years. All state certifications or licenses, as well as the National Registry, require continuing education. EMS providers regularly report that they can't find the right category of courses, can't find courses near to them, or can't find CE that is appropriate to their skill and knowledge.

Take a few moments to answer these questions about your successes and challenges earning continuing education.

Create your own user feedback survey

Thank you for taking a few minutes to answer these questions. Read more about EMS education and training from

Hero of the Week: Ambulance charity helps terminally ill patients

This week, our EMS Hero goes to the Ambulance Wish Foundation (Stichting Ambulance Wens) a Netherlands charity that has granted nearly 6,000 wishes since it Kees Veldboer founded it in 2007.

We were particularly struck by the story that inspired him.

During a hospital transport, he asked an old man if there was anything he wanted to see while he was outside. The man told Veldboer he had sailed for many years when he was healthy, so Veldboer stopped by the canal.

"We stayed there for an hour on a beautiful sunny day, and tears of joy ran over his face due to this experience," Veldboer said.

Veldboer promised to take the man sailing a final time. Working with a tour boat company and his boss, Veldboer was able to bring the patient on a stretcher aboard, for one last trip through the Rotterdam harbor.

Many of the patients and their wishes are chronicled on the foundation's Facebook page.

Recently the foundation brought a terminally ill woman to Amsterdam's Rijksmuseum for an in-demand Rembrandt exhibit.

"Our foundation adds a quality of life to (last) days," Veldboer said.

And he adds quality of the health care profession.


EMS1 Tips

7 ways to best use, or avoid, capnography in the field

EMS1 readers shared their suggestions on how to get the most out of the method

Active-shooter response: Are you physically ready?

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active-shooter incident is going to require repetitive bursts of significant physical activity.

Energy-saving tips for your station

Earth Day 2012 takes place this Sunday, with events planned held worldwide to increase awareness and appreciation of the Earth's natural environment. So, it's a good time to see what you can do at your agency to save both resources and money.

How this video can "Keep Yourself Safe"

Consider using this PPE safety video in your EMT Basic or Refresher Class.

CPR class instruction tips: 5 ways to make it great

My most recent healthcare provider recertification was memorable for all of the things the instructors did well.

Patient assessments: How to avoid free-for-alls

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

Patient assessment is a non-linear process

On a skill sheet, patient assessment is presented as a linear process: First size up the scene, then complete the primary assessment followed by the secondary assessment.

Blood pressure reading tips and tricks for EMS

One of the things I'm most often asked by students and rookie EMTs is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

How to use Slideshare for EMS education and training

Slideshare is an online community and tool for sharing presentations.

How to get optimal battery life from your devices

The batteries in your wireless cell phone, tablet or laptop are probably not the same old Duracells you used in your childhood walky-talkies.

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