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

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Texas ECMO ambulance transports dying patients

The unit includes advanced equipment and a specially trained team to recover patients from hospitals where nothing more can be done for them

Texas city looks to recover millions spent on EMS at festivals

Taxpayers covered $4.25 million for police, ambulances and fire protection at festivals last year; a city panel is exploring ways to recover the funds

Ky. EMT speaks for first time on surviving fatal crash

"Not thinking about it helps me keep working forward and try to focus on where I want to be and not what's happened in the past"

Police chase stolen Ind. ambulance to golf course

The ambulance was stolen while an EMS crew dropped off a patient at an area hospital

NJ hospital president, wife killed in house fire

The fire was contained to an upstairs bedroom, where they were found unresponsive; Jon Sheridan had a role on Gov. Chris Christie's transition team

CPR instructor's father saved with procedure

Sheri Sklar teaches CPR at a medical center, and said learning an early response saved her father's life makes it that much more important

Video: Monster truck plows into crowd, kills 3

Graphic footage shows truck driving over the top of a row of cars, then veering off course into a group on onlookers

Unvaccinated medic nearly killed by flu

He was put on a ventilator for 13 days in January and is still recovering nine months later; once skeptical, he says he will not go without a flu shot again

How virtual hospitals may change EMS

As virtual hospitals spring up in care facilities or patients’ homes, EMS will essentially take on the role of out-of-hospital nursing staff

Top 5 EMS videos of September 2014

Top videos include a time-lapse video of the construction of the 9/11 Memorial Museum, and an emotional scene where a man uses CPR to save a dying dog
Top

EMS1 Topic Articles

NJ hospital president, wife killed in house fire

The fire was contained to an upstairs bedroom, where they were found unresponsive; Jon Sheridan had a role on Gov. Chris Christie's transition team

CPR instructor's father saved with procedure

Sheri Sklar teaches CPR at a medical center, and said learning an early response saved her father's life makes it that much more important

Video: Monster truck plows into crowd, kills 3

Graphic footage shows truck driving over the top of a row of cars, then veering off course into a group on onlookers

Unvaccinated medic nearly killed by flu

He was put on a ventilator for 13 days in January and is still recovering nine months later; once skeptical, he says he will not go without a flu shot again

How virtual hospitals may change EMS

As virtual hospitals spring up in care facilities or patients’ homes, EMS will essentially take on the role of out-of-hospital nursing staff

Top 5 EMS videos of September 2014

Top videos include a time-lapse video of the construction of the 9/11 Memorial Museum, and an emotional scene where a man uses CPR to save a dying dog

FDNY EMS capt. arrested for alleged child molestation

The 21-year veteran was arrested on a child sex crime warrant for a Sept. 12 incident in Hollywood; he's been suspended without pay for 30 days pending charges

Va. town looks at billing residents for rescue calls

Estimates based on last year's calls indicate that billing insurance companies would bring an additional $356,000 into the county coffers

Mayor says 'no' to cries for S.F. chief's ouster

Chief Joanne Hayes-White's supporters say the criticisms are unfair; the mayor has rejected calls for her departure

Ark. county to vote on rural ambulance funding plan

Officials are cautiously optimistic and have been educating voters on two plans that would raise taxes to help cover services in unincorporated areas
Top

EMS1 Columnist Articles

How virtual hospitals may change EMS

With predictions that one in six doctor visits in the U.S. and Canada will be virtual in 2014, telemedicine has the potential to greatly influence how EMS operates.

Glenn Leland, chief strategy officer at ProTransport-1, a San Francisco-based ambulance transport company, said it also has the potential to offer a foundation for new models of care collaboration and continuity of care between EMS and other health-care providers, hospitals, urgent care centers, and primary care doctors.

Not to mention, telemedicine could save U.S. employers as much as $6 billion every year, and some predict telemedicine revenues will top $13 billion in the next four years.

We sat down with Leland to see what someone at the forefront of new EMS models thought of telemedicine.

Paramedics as hospital consultants

“Increasingly, the EMS team in the ambulance is connected,” Leland said. “They have a computer. They have a camera. They have the ability to gather information about the patient ─ images and biometric measurements.

"More and more, we’re going to want to make that available in a network-like environment where various providers, who will be involved in the patient’s care, can collaborate in real-time.”

With technology enabling better collaboration, paramedics may have an expanded role in directing patient care as an integral part of a health-care team and a connected health-care system.

“You could think of the paramedic as a consultant with the hospital, helping to decide whether this patient needs to go to the emergency department, directly to surgery, or whether they need to be admitted and to what floor and what hospital,” Leland said.

In some cases, paramedics may initiate the decision to bypass the emergency department altogether in favor of taking the patient to an urgent care center, referring them back to primary care, or scheduling follow-up care through home visits or community paramedicine. In some many places, this is already happening.

In the future, paramedics may also have the option to admit a patient into a virtual hospital by setting up a patient’s bed in the home for on-going telemedicine monitoring and treatment.

How EMS will respond to virtual hospital emergencies

Today, hospitals are defined by physical structures that house patients and health-care professionals who provide medical care. Yet telemedicine, better patient monitoring and data collection systems open the door to caring for some patients in virtual hospitals.

Virtual hospitals are not contained within one physical structure, but instead refer to collections of patients who are being monitored or treated from different physical locations.

“You will still be treating patients in beds, but it might not be a patient in the fourth floor, room 417. It’s no longer traditional hospital bed structure,” Leland said. “It might be a bed in a skilled nursing facility or a bed in the patient’s home. It might be a bed in the back of an ambulance.”

The challenge, of course, is when something goes unexpectedly wrong. Leland sees responding to these emergencies in virtual hospitals as another role for EMS in the future.

“EMS is essentially going to need to have the ability to be that out-of-hospital nursing staff,” he said.

Leland also pointed to how virtual hospitals could also make hospitals visits completely unnecessary for some patients, or shorten hospital stays for others.

“If you go back a few years the average hospital stay was seven or eight days,” he said. “With remote monitoring technology such as wearables, mobile technology, and video conferencing, we could discharge some patients much earlier in their treatment and still care for them at home.”

Inside EMS Podcast: Tips for resuscitating kids in cardiac arrest

Download this quick clip on iTunes, SoundCloud or via RSS feed

In this week’s Inside EMS1 Podcast, hosts Chris Cebollero and Kelly Grayson start off the show on a humorous note, and discuss a story where an Idaho teen crashed after a friend set his armpit hair on fire while he was driving.

“Jokes just write themselves,” Grayson said.

They also take a serious turn and tackle a vote of no confidence from rank-and-file San Francisco firefighters calling for the chief’s resignation. The issue stems from an ambulance shortage, and an inability to meet response time standards.

Grayson also referenced reports that the city has had money to buy 16 new ambulances since 2012, but hasn’t done it yet.

“[The city’s] position seems to be we’re throwing good money after bad, and they’re not using the money wisely,” Grayson said. “Whether that’s true or not remains to be seen.”

They also discuss whether high school students are psychologically and emotionally able to handle the stress of being an EMT. As part of a “put Arizona to work,” mission, students enrolled in the state’s only certified EMS high school program complete the training tuition-free.

“I think, depending on that individual, the answer is yes,” Cebollero said.

Grayson agreed.

I think a highschooler can successfully complete an EMT course and move on to a career in emergency medical services,” he said. “But not just any teenager.”

In the clinical issue, Chris and Kelly are joined by Dr. Peter Antevy, who discusses treating pediatric patients in cardiac arrest.

A lot of it comes down to confidence, Antevy said. When EMTs get to the patient, it can be unnerving to have mom and dad staring at you. But EMTs feel almost energized when responding to adult arrests.

“How could it be that for the adult arrest they feel like Superman but when a pediatric arrest comes along, they kind of feel like Shaggy from Scooby Doo,” he said. “Right then I realized it’s all about knowing the information prior to arrival.”

He suggests using an age-based mechanism rather than a length-based mechanism, and the Handtevy System he created.

He also goes over benefits of treating pediatric patients on-scene rather than doing a rapid transport.

In the adult world, unless you get ROSC, EMS knows that every second that goes by reduces the neurological outcome and survivability, Antevy said. For that reason, many agencies mandate that EMS stay on-scene for 20 minutes.

“Why don’t we do the exact same thing for kids"” Antevy asked. “How come kids don’t get that same exact chance"

Here are links to some of the articles and other items mentioned on the show:

More medical calls may lead to fire department overhauls

It’s great to see this feel-good article about Milwaukee firefighters growing more reliant on medical responses. It casts a positive light on the work EMS providers do, day in and day out.

But when you look closer, there are several areas of concern that point to overworked responders and the need for management changes.

For instance, 4,801 calls for service annually translates to about 14 calls per shift. If you assume it takes about 70 minutes to clear a call in an urban system and return to quarters, that’s about 16 hours of being in service.

Even if it was a mere 60 minutes per run, that’s still 14 hours. And that’s just for EMS calls. Add in daily activities surrounding the fire station, and that means the medics are up for most of their shift. We know that’s not healthy, either mentally or physically.

In 2013, 60,500 of the department’s total 73,632 runs were for medical events. That’s about 82 percent of the call volume. Yet with 12 ambulances, the department uses 19 percent of its rolling fleet for transport.

I’m not suggesting that the Milwaukee Fire Department is doing anything out of the ordinary. In fact, this is very much the norm throughout the industry.

Structure fires are down; EMS calls are up. It's time for the fire service to look at fundamental changes in the way it manages its infrastructure in response to a changing work environment.

There are departments in the nation that have been moving in that direction for some time, and it hasn’t been easy. Cultural inertia ─ i.e. traditions ─ is a major barrier to progress.

But given that the community’s needs have evolved over time, it clearly makes sense to respond in a wise, proactive way to provide security and protection.

3 steps to spot danger on EMS scenes

This past year, I was involved in a film project recreating a firefighter close call event that occurred during a basement fire. While interviewing the firefighters who were on the hose line in the basement, I recognized an interesting dynamic.

The firefighter who was on the nozzle heard the least amount of radio traffic and recalled the least about the changing conditions in the basement.

As my interviews progressed through the firefighters farther back on the hose line, the descriptions of the radio traffic and interior conditions became more detailed. Ultimately, the firefighter who was the first to recognize that the fire had moved behind the crew and was threatening their exit was the firefighter farthest back on the hose line.

The differences in these firefighter’s stories and observations are a classic example of the difference between task orientation and situational orientation. Each moment that we are on scene, we are choosing to devote our attention toward specific tasks and skills, or the details around us.

Every task and skill that we devote attention toward robs us of a little bit of our situational orientation, or our awareness of the environment around us.

Task orientation

When we are primarily involved in skill orientation, most of our attention is dedicated to the task being performed. In these moments, the details of the task or skill tend to consume us.

Where is the best site to establish an IV" Am I getting a good seal on the BVM mask" Which blade should I select for this intubation attempt and where is it located"

The more complex the skill being performed, the more of our attention it will require. Securing a patient to a spine board may require only a small percentage of our awareness, while an oral intubation attempt may draw upon all of our focus and attention.

Situational orientation

When we are not engaged in tasks or skills, our attention naturally turns to the details of our environment. We notice the color of the curtains, the ash tray filled with cigarette butts and the closed bedroom door at the end of the hallway. This orientation is more commonly referred to as situational awareness.

This broader awareness allows us to see the big picture. Only when we are unburdened by complex skills and uninvolved in tasks can we truly devote our mental focus to situational awareness.

In our scene safety lectures, we often pay a lot of lip-service to situational awareness, but we don’t always mention how to achieve it.

Tasks need to be accomplished. Someone needs to do the work of assessing and treating the patient. So how do we get the work done and still maintain our awareness of the whole scene"

Here are three ways to improve situational awareness.

1. Practice your front-door survey

Inexperienced providers often charge forward into the scene and become involved in tasks. We do this for several reasons.

First, we are often insecure that any hesitation will be interpreted as uncertainty. When we are new EMS providers, we struggle to appear confident and in charge, so we begin patient care without hesitation.

Scene management can also be far more difficult than basic assessment and care for one patient. The larger and more complex a scene, the more enticing and comforting task orientation becomes. Practicing a front-door survey, or scene survey, is one way to overcome this challenge.

Remember the scene survey" It’s not just for the national registry skills test.

Try to actually stop for a moment as you enter a scene and let your senses take in the whole picture. Before you rush to the patient’s side, spend a few seconds and take in the sights, sounds, smells, mood and emotional tempo of the scene. Ask yourself if everything fits. Consider what resources you are likely to need.

2. Reorient yourself after a task

Sometimes, you will be the person doing the bulk of the task work. That doesn’t mean that you need to completely disregard your surroundings.

After each task that you complete, look around. Take in everything for just a few seconds before you begin your next task. Reconsider if the scene is being managed around you appropriately, or if a change in tactics is necessary.

You can also use the natural pauses in the flow or progression of the scene to shift back into scene survey mode. While strapping down the patient on the pram or waiting for someone to hand you a blood pressure cuff, shift your mental focus back to the environment and prepare for your next task.

3. If you’re in charge, act like it

Scene presence, leadership and delegation can be some of the toughest skills to learn, especially when we are personally good at the tasks and skills that need to be completed. Doing things yourself is comfortable; leading others on the scene is not. This is why we so often see those who are supposed to be in charge carrying backboards and holding c-spine.

A huge part of scene leadership is maintaining situational awareness and looking out for the folks on scene who are involved in tasks. Their task orientation leaves them in a high-risk mode where they could easily miss an important big-picture detail.

Is the person holding the end of the backboard too close to the passing cars" Should you find out if anyone is in that back bedroom" Is the patient’s drunk husband becoming agitated"

In training, it’s OK to talk about scene safety being everyone’s job. It is.

But mostly, it’s your job. Someone needs to stand back and maintain situational awareness. If you are the leader, that is your primary job. Put down the blood pressure cuff and lead.

Saving the dying agency: The value of transformational leadership in EMS

By Dr. Shana Nicholson and Scott Crouch
InPublicSafety.com

Maintaining strong leadership within Emergency Medical Services (EMS) has always been a challenge, particularly for agencies in rural areas that depended heavily on volunteers. Today those leadership challenges have shifted, as the need for continual care coverage rises and paid crews are increasingly necessary. As these paid EMS agencies have taken root around the country, volunteers have dramatically faded.

When an organization transitions to an all-paid staff, the financial burden is immense and, without strong leadership, an agency can bleed money like a patient in hemorrhagic shock. In addition, morale often plummets and the organizational structure can buckle.

Shifting to a Transformational Leadership Style

So how do you turn an agency around when it’s circling the financial drain" The answer is transformational leadership. When a new administrator takes over a financially challenged organization, an initial assessment of the agency’s personnel, apparatus, equipment, finances, and care protocols should take place.

Read full story: Saving the Dying Agency: The Value of Transformational Leadership in EMS

Why EMS should put compassion before protocols

“No smoking. Oxygen in use.”

“No family in the back of the rig.”

“Food or drinks allowed in cab only.”

“No pets in the rig.”

Rules abound in EMS — algorithms, protocols, policies and procedures. As a profession, we put great stock in the rules.

They’re so prevalent in EMS and health care; the accreditation process intended to be the stamp of an agency’s legitimacy focuses primarily on how many rules and policies they have in place. Everywhere you look there’s a mechanism for addressing every conceivable situation.

But often we forget that it is impossible to conceive of every possible situation, and that the only unbreakable rule is that every rule has an exception.

The messiness of human grief

Real life has a way of throwing you curveballs. That’s because we’re people, caring for other people, and people are inherently fallible creatures. We’re complex, irrational, emotional, unpredictable beings, and most of our patients haven’t read our rulebook.

It’s easy to get bogged down in the minutiae of the protocol book, and ignore the mercies we are meant to bestow.

I’m sure your rig, like mine, is festooned with little decals that say, “No smoking, oxygen in use.”

But when your patient has just watched his 17-year-old daughter get taken away in another ambulance for the intentional overdose that may very well take her life, he doesn’t care about your safety regulations. And the bleeding from the cuts on his arms he sustained when he broke her apartment window is well-controlled, but his fear isn’t.

So when he pleads with you to let him smoke a cigarette just one, he begs – to settle his nerves before you put him in the rig, will you tell him no" How long will that cigarette take you out of service"

Is that extra couple of minutes going to cause your patient or the system to crash" Is the minutiae in the rulebook more important than the mercy"

There are plenty of reasons not to allow family members in the back of the rig. But when all your training and experience tells you the frail old man you’re transporting to another hospital two hours away isn’t likely to survive the trip, or the infant you’re doing CPR on probably won’t regain a pulse, will you deny the people who love them the chance to be by their side during their last moments"

A firm, “Sorry, no. Company policy,” is the expedient answer, the convenient lie that shields you from the messiness of human grief. But is it the merciful thing to do"

Yes, I know a hysterical family member can interfere with a resuscitation, even be a safety hazard in the back of the rig. But when the wife has signed a DNR for the trip, or the mother is emotionally devastated but still holding it together, is your comfort or the company’s policy worth their pain"

When the person on your stretcher isn’t likely to survive despite your best efforts, who is your real patient" What is best for them"

Is the rulebook more important than mercy"

OSHA has rules about food or drinks in the back of the rig, and for good reason. But when your patient has spent close to 12 hours in the ED with nothing but a limp turkey sandwich and a bag of chips to sustain him, and his wife brings him a burger before he is transferred out, do you deny him a simple meal, especially when he isn’t NPO"

Or do you delay the transport that has been holding for several hours just a few more minutes until he can wolf down his heart attack in a sack, or simply pretend you didn’t see it when he munches on it in the rig"

No doubt your agency has rules against animals in the rig. I know mine does. Maybe it includes exceptions for service animals, or maybe it doesn’t.

But all I know is that when I think my patient really needs to go to the hospital, I will pull out all stops to convince him to go. And if that requires me making friends with his psychotic little ankle biter, and detouring five blocks off my route to the hospital to drop off the dog with a friend, that’s what I do.

The cops were unsympathetic — “Not my job,” their body language quite clearly conveyed. And when the victim is a histrionic, HIV-positive gay man bleeding from multiple lacerations, they were quite happy to make him my job. The fear and revulsion were plain on their faces.

So I made friends with the dog, and I promised the man I’d see to his welfare. And I violated company policy to do it. I put the little critter in the front of my rig, where he cowered in the passenger floorboard until the man’s partner opened the door five minutes later.

But one man got to see that not everyone is like the homophobic thugs who beat him up for nothing more than their own amusement. That man saw that not all big, white rednecks are the same, and that not everyone he calls for help will treat him like a leper.

And when I told my supervisor about the encounter, he didn’t much care about my violation of company policy.

“Was the dog bloody, too"” he wanted to know.

“Yep.”

“Did you disinfect the rig thoroughly"”

“Yep, front and back.”

“Sounds like you did what was necessary, then,” he shrugged. “Good job.”

I’m not telling you to do anything that will get you fired. Don’t flaunt company policy just on my word. What I am saying is that most rules have some wiggle room, and a compassionate provider will exploit that wiggle room for the good of his patient.

If the letter or the law is more important to you than the intent, and you place more value on the minutiae than the mercy, then perhaps EMS isn’t the career for you. And if your employer puts the protocol book and the policy and procedure manual ahead of patient care, then perhaps you’re working for the wrong people.

There are a hundred little mercies we can bestow every shift we work, and believe me, those little things are more appreciated by our patients than any medical expertise we can muster.

Where to look for nongovernment EMS grants

Has your agency ever been denied from AFG or any other federal resource"

Have you been so frustrated by just missing a deadline or realizing at the last moment that your agency is ineligible for a government grant"

It might be time to start looking outside the box.

Private foundations often, if not always, have great funding opportunities for EMS agencies. Though this avenue takes some research, you will often find that they have more flexibility in allocating funds to your agency for a variety of projects.

Take a look at local trusts, companies, and charities in the area.

For instance, does your county have a railway or oil pipeline running through the district" BNSF Railway and Enbridge Inc. have a history of funding EMS projects in communities they service.

In 2014, Enbridge's Safe Community Grant funded four EMS and fire department agencies. Exxon-Mobil and BP are also some of the largest charitable contributors to communities they service.

Does your agency have a Bank of America or Wells Fargo in its area" In 2010, they respectively gave back $208 million and $315 million. Community foundations are another overlooked option. They are typically funded by a multitude of local trusts that are vested in the community; this includes a strong EMS system.

Large corporations are also great avenues to pursue for alternate funding. Pharmaceutical companies like Pfizer and AstraZeneca allocate funds toward health initiatives and contribute to organizations that help make a difference in the health and well-being of patients and communities — something that is foundation of an EMS agency

Do not let your agency get stuck in the government-resource bubble. There are plenty of alternative opportunities surrounding you — if you know where to look.

Clinical solution: A three-hour fall in the bathtub

In the previous scenario, you responded to a call for a 65-year-old obese woman who has been sitting in the bathtub for three hours and is unable to stand up. She denies any pain or other complaints, and says she simply wants help out of the tub.

Assessment

Calls to 911 for lift-assists are common but are also scenarios potentially filled with risk. Depending on state and local requirements, these patients may be entitled to a full medical assessment.

Regardless of those requirements, they should be accurately assessed prior to completing patient movements or treating and releasing them. For lift-assists particularly, any possible underlying causes should be evaluated. An important question to ask is: “Is this situation different than the baseline"”

For a patient who fell from his wheelchair while transferring to bed, ask whether he can normally transfer on his own. If the answer is yes, then the follow up question should be: “Why is today different"”

If the patient normally requires assistance to transfer and chose not to wait for his home health nurse, then it is possible that nothing is different from his baseline. The subsequent assessment and treatment of that patient depends on determining if today is consistent with his normal level of activity.

Also consider that potential underlying medical conditions for fall patients are numerous. At a minimum, EMS providers should be screening for cardiac, neurologic and diabetic symptoms.

Assessment tools like ECG (if available), stroke scale and blood glucose should all be performed. Vague complaints "like general weakness" or "just not feeling well" may be a presentation of an underlying infection or possibly sepsis.

Completing a patient history, physical exam and vital signs on fall patients can assist in ruling out some of these diseases. Particular emphasis should be paid to questions about infection, especially respiratory and urinary symptoms.

Treatment

Once a patient has been screened for medical and traumatic complaints, the focus of the call turns to moving her from her present location.

Before attempting to move a patient, it is important to ensure that there are enough resources on scene. For overweight and obese patients, it may be necessary to request additional units or agencies.

In most cases, it is far better for a patient to remain in the current situation for several extra minutes than to risk a career-ending injury by attempting a lift with an inadequate number of personnel.

Once you have adequate resources available, discuss a plan of attack. Think carefully about what devices (if any) will be used, and where each provider will be positioned.

Consider where the patient will wind up after the lift. Will it be on the gurney, a wheelchair or simply standing" Think about how each responder will need to move to get the patient to the final location. What is the abort plan if something goes wrong"

When preparing to actually lift the patient, one responder should communicate a count to the others. Make sure that directions are simple and clearly stated. Ask if anyone has a concern about the plan.

Be sure to explain the plan to the patient and ask if she has any questions. Caution the patient against reaching out or making any sudden movements; the patient shifting her weight during the lift could cause injury to one of the responders.

Above all, maintain sympathy and compassion for the patient; this is not an ideal situation for her either. There will be time after moving her to coach about prevention of future falls, but right before lifting her out of her bathtub is not an appropriate time to do so.

After moving the patient to the final location, reassess or perform any additional assessments which may be indicated. If appropriate, and consistent with your medical direction, perform any necessary paperwork or ready your patient for transport.

Outcome

While you continue to assess the patient, your partner calls dispatch and requests that an engine company respond to the residence for manpower.

The patient's assessment is normal and she does not appear to have any underlying medical conditions. She denies any dizziness or weakness before her fall and states that she "just got tired."

She acknowledges that she needs to purchase a shower chair but has been putting it off. Her daughter states that she will buy the chair today.

Once the engine company arrives, you discuss your plan with everyone present. The patient states that she thinks she will be able to support her own weight if she is assisted to a standing position. You ask her daughter to position her walker (which she normally uses to ambulate) in the hallway for her to use once she is standing.

Using a bed sheet under her arms, you determine that four responders should be able to lift the patient to a standing position. The patient confirms that she understands the plan and is comfortable with it. After she is standing, you assist the patient in stepping out of the tub and into a seated position on her walker.

After assisting her in getting a bathrobe on, you complete your assessment and find no complaints or apparent medical conditions. You and your partner thank the engine crew for responding and clear them from the scene.

You complete the refusal paperwork and contact online medical control for a consultation. After being thanked by the patient and her daughter you clear the scene and go available with dispatch.

How powerful EMS leaders can do more by delegating

By Jay Fitch, Ph.D.

It's hard to believe, but Sept. 4, 2014 marked the 10th anniversary of the death of James O. Page, who is often referenced as the father of modern EMS. In a more personal sense, he was my mentor, colleague and friend.

Jim served in many leadership roles throughout his career, including such diverse positions as EMS chief, fire chief, state EMS director, entrepreneur, and lawyer, which surprisingly doesn't even start to describe his unique characteristics as a leader.

Jim had many lessons for developing leaders; delegation was just one. This may seem pretty mundane, but it allowed Jim to accomplish so much more than if he had done everything himself.

"What do you think we should do""

One of the most debilitating characteristics of an underachieving leader is to be a micro manager, someone who constantly undermines his subordinates, questioning their choices while making decisions for them. It severely limits your ability to influence people beyond your direct sphere.

Jim was adept at hiring the right kind of people — in terms of ability, ambition, and values, and in spite of any job description — and figured he could train the rest.

So now, as you think about the efficiency of barking a command to your next-in-line, try this question instead, which may not be as efficient, but in the long term is more effective: “what do you think we should do"”

Jay Fitch is the founding partner at Fitch & Associates, which has provided leadership development and consulting for emergency services for more than three decades.

Spotlight: Everyday Hero Housing Assistance Fund helps first responders achieve the American dream

Company Name: Everyday Hero Housing Assistance Fund
Headquarters: Denver, Colorado
Website: http://usehhaf.org/

Our mission is to help our heroes buy homes by expanding housing opportunities to EMS, law enforcement, fire, teachers, doctors and nurses; and to promote the value of home ownership as the foundation for building strong communities and financial security for men and women serving their communities.

Where did your company name originate from"
Back in 2005 when we first launched EHHAF, it was called Legacy Housing Fund. The idea behind the initial name was that the organization would be helping our first responders achieve the ‘American dream’ of home ownership and be able to start and leave a legacy for their children and grandchildren. As the economy turned, the founders were forced to close the doors to Legacy Housing Fund. They quickly seized the opportunity to re-launch several years later and renamed the company Everyday Hero Housing Assistance Fund. This new name, they felt, properly describes our clients and expresses how we see them as heroes as they go about their daily lives serving and protecting us all.

What was the inspiration behind starting your company"
The inspiration behind the foundation of EHHAF stems from the fact that our clients nurture and educate our future leaders, they preserve our health and put their lives on the line every day to uphold order and keep us safe, yet they are members of a workforce that is extremely underpaid and underappreciated. As many hours as they work and the preparation and effort they have to put in to be able to excel and do their jobs well, they are grossly underpaid and find it hard to save up the thousands of dollars it takes to be able to achieve the American dream of home ownership. Not enough is being done for them and EHHAF is proud to be leading the charge towards a higher level of appreciation as a grateful nation. This is the least we can do for them considering what they do for us on a daily basis.

Why do you believe your products are essential to the EMS community"
The services we provide are extremely essential to our everyday heroes because it is not an easy task to save thousands of dollars to put towards a home purchase, especially if they have a family to take care of. Closing costs can be as much as 3% of the purchase price of the property and the average everyday hero will most likely have a hard time putting that aside to help make their dream of home ownership a reality. Also, buying a house can be a challenging process and to have an organization like EHHAF in their corner to help make the process a lot less stressful is priceless. Our services are free and the gift funds never have to be repaid under any circumstance.

What has been the biggest challenge your company has faced"
Awareness within the first responder market has been the most challenging for us. Once the community learns about us they are thrilled beyond belief to have found us. Because we strive to operate as a lean company it allows us to push more benefits to our clients, but this means we do not have big marketing budgets to spend. We need to be very smart about each and every dollar we spend to create market awareness.

What makes your company unique"
EHHAF is unique because we are one of the very few organizations that offer this type of financial assistance. Other similar organizations place too many stipulations on the clients making it difficult to impossible for them to use and then benefit from their services. We have heard all too often that a client will be forced to stop during the process as the competitor places too many hurdles for them to overcome.

With EHHAF, there are no restrictions on the type of home you can purchase (foreclosure, resale or new construction). EHHAF does not limit our clients to a specific list of homes they must choose from. More importantly we do not place any restrictions on the length of time they choose to live in their new home. EHHAF gift funds are 100% free gifts that NEVER have to be repaid and EHHAF services are absolutely free. We are not aware of any other organization out there that provides this direct type of assistance.

The EHHAF Customer Service team is also very special and unique. We strive to make the process simple and easy by removing the stress that comes with trying to find agents they can trust to work hard for them and communicate well while putting them first at all times. EHHAF has developed a trusted network of agents that they have been carefully chosen, interviewed and trained to work with the EHHAF program across the entire U.S. Our clients can rest assured that these agents will leave no stone unturned to get them the best deal for their home.

What do your customers like best about you and your products"
Our clients appreciate the personalized attention we offer and impeccable service and assistance. They also are so relieved to learn that we stand behind our word and when we say we are offering FREE gift funds – we speak the truth. EHHAF gift funds are absolutely free and never have to be repaid under any circumstance!

What is the most rewarding part of serving the first responder community"
The most rewarding part of serving our Everyday Heroes is the feeling of fulfillment and pride our employees feel whenever we successfully help another community hero close on their home. They send us testimonials expressing their gratitude and pictures of them and their families in front their new homes. It is the most awesome feeling knowing that we played a part in their journey on their road to home ownership. We feel like we are giving back to a community that gives our nation so much! Also, when a client calls to say they heard about EHHAF through a colleague of theirs who we helped to purchase their home and they were so pleased that they passed on the word about EHHAF. That brings a huge smile to every EHHAF agent's face. I mean, they are our community heroes and we feel honored to be playing a role in their dream of home ownership. This is truly the least we can do considering how much they do for us. The founder's letter says it all… http://usehhaf.org/about-ehhaf/founder-letter/

Our mission for 2014 is to help 1,000 community heroes and their families achieve the American dream of home ownership. Please help pass on the word to your colleagues about the assistance we offer so that they can have our services as an option.

Do you support any charitable organizations within public safety"
Yes, we are partners with The Virtual Sports Academy (VSA) www.thevirtualsportsacademy.com. VSA, is a charitable organization that has joined the fight against childhood obesity. Their effort along with the EHHAF program helps support healthy communities through healthy living and home ownership thus healthy and happy families.

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