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

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EMS1 Daily News

Inside EMS Podcast: Why EMS needs to get back to helping people

Our co-hosts discuss the hot topics in this week's news

Quick Clip: Bullying and workplace harassment in EMS

Our co-hosts talk about the tragedy and disgrace of bullying after the death of firefighter-paramedic Nicole Mittendorff

What is the appropriate discipline for driving 17 mph above the speed limit?

An ambulance crew is suspended without pay after a news crew plays highway "gotcha"

Mich. lawmakers urged to make CPR training mandatory for high school students

Thirty-one states have already passed laws requiring students to learn CPR before they graduate

NJ Supreme Court: Fired dispatcher should get new trial

A new jury will decide if Patricia Del Vecchio was the victim of disability discrimination and retaliation when she was fired in 2009

FDA reconsiders training requirements for painkillers

Under the current risk programs, drugmakers fund voluntary training for physicians in safely prescribing their medications

Paramedics, dispatcher reunite with baby after emergency

Sophia Smith made a full recovery and is back home with her family, who thanked the responders for playing an integral part in her survival

Editorial: Newborn's death reveals dispatcher shortage

Parents of a 3-day-old baby, bitten by the family dog, drove their baby to the hospital themselves after two 911 calls went unanswered

Colleagues save Tenn. EMT in cardiac arrest

Tyler Johnson, 24, was with another EMT when he suddenly became lightheaded and collapsed. (Courtesy photo)

EMT pleads not guilty to sexually assaulting patient

Sam Conkel, 24, was arraigned on sexual battery and gross sexual imposition charges

EMS1 Topic Articles

Inside EMS Podcast: Why EMS needs to get back to helping people

Our co-hosts discuss the hot topics in this week's news

Quick Clip: Bullying and workplace harassment in EMS

Our co-hosts talk about the tragedy and disgrace of bullying after the death of firefighter-paramedic Nicole Mittendorff

What is the appropriate discipline for driving 17 mph above the speed limit?

An ambulance crew is suspended without pay after a news crew plays highway "gotcha"

Mich. lawmakers urged to make CPR training mandatory for high school students

Thirty-one states have already passed laws requiring students to learn CPR before they graduate

NJ Supreme Court: Fired dispatcher should get new trial

A new jury will decide if Patricia Del Vecchio was the victim of disability discrimination and retaliation when she was fired in 2009

FDA reconsiders training requirements for painkillers

Under the current risk programs, drugmakers fund voluntary training for physicians in safely prescribing their medications

Paramedics, dispatcher reunite with baby after emergency

Sophia Smith made a full recovery and is back home with her family, who thanked the responders for playing an integral part in her survival

Editorial: Newborn's death reveals dispatcher shortage

Parents of a 3-day-old baby, bitten by the family dog, drove their baby to the hospital themselves after two 911 calls went unanswered

Colleagues save Tenn. EMT in cardiac arrest

Tyler Johnson, 24, was with another EMT when he suddenly became lightheaded and collapsed. (Courtesy photo)

EMT pleads not guilty to sexually assaulting patient

Sam Conkel, 24, was arraigned on sexual battery and gross sexual imposition charges

EMS1 Columnist Articles

The critical pediatric patient: Test your knowledge

Pediatric patients are challenging and infrequent. Adding criticality to the pediatric call is even more unnerving. This quiz is designed to test your knowledge of critical pediatric situations.

How did you do" Make sure to share your results and challenge your EMS colleagues to match or beat your score.

Learn more about pediatric assessment with these EMS1 articles.

Is adding paid staff to a volunteer agency the beginning of the end or the start of a new future?

Is adding paid staff the beginning of the end for your volunteer agency"

Or is it an opportunity to make your service better, stronger, faster and smarter"

The answer to these questions depends on how the decision to integrate career personnel into your organization is arrived at and managed. What may initially seem overwhelming or an admission of defeat is in reality the opportunity to build a stronger, better, faster, smarter volunteer EMS agency with the capability to provide reliable and excellent medical response to your community.

Commitment to the community
If your agency is considering supplementing volunteer EMT and paramedics with paid EMS providers, chances are good that you already recognize one or more of these problems:

  • The schedule is not filled for every shift, every day.
  • You are passing calls or abusing mutual aid agreements.
  • Multiple tones are needed to scramble a crew resulting in response delays.
  • The core group of responders is getting discouraged, resentful and burned out.
  • Members have begun to rationalize that occasional failed responses are OK or normal because the surrounding towns have the same problem.

If any of these are true for your department, it is time to get help with staffing.

Failure to do so because of pride, tradition or fear of outsiders staffing the ambulance does not excuse a volunteer service from failing to provide the safety net it has committed to providing the community.

Taking responsibility for employees and the community
Many volunteer ambulance agencies and rescue squads began generations ago with little or no formal planning. Often bylaws, policies, leadership roles and culture have developed piecemeal over the years.

As a result, the organizational structure has likely been built on personalities and emotion rather than sound business principles. The informal, often clannish nature and sometimes questionable operating practices of some agencies may have worked 80 or even 20 years ago with the respect and support of a grateful public, but the world and EMS has changed dramatically. EMS will continue to change at light speed.

As your volunteer agency moves forward with adding paid staff, it needs a clearly defined mission statement, vision statement or strategic plan for the near and distant future. These documents are a foundation that must now be in place to effectively run a modern EMS organization.

Your agency will from now on be in the business of saving lives and providing for the livelihood of EMTs who have chosen to make EMS their vocation. This is a responsibility not to be taken lightly, and the groundwork needs to be in place to manage this change successfully.

Making the transition to paid staff successful
The first step is to hold a special meeting of your members with mandatory attendance. Insist on polite and respectful discourse and stick to the facts:

  • There must be scheduled coverage 100 percent of the time.
  • Adding paid staff is the morally and ethically responsible thing to do for the community when volunteer participation alone cannot accomplish this.

To achieve buy in, every member must have a voice. If decisions about major changes, including staffing, are made by officers or a board of directors without the input of the membership, there is exactly zero hope of successfully implementing those changes, and likely no hope of salvaging the organization as a volunteer effort for any length of time. Resentment, conflict — a hostile us versus them environment — and the continued attrition of volunteer members is the probable result.

" The most important thing in communication is to hear what isn't being said."
Peter Drucker

A new beginning for the department
This is a perfect opportunity to reimagine, rethink and redesign your volunteer agency. Strong leadership will be needed to guide the conversation towards focusing on the positive. Ask, "What do we want for the future"" not on, "How do we avoid what we don’t want""

Ask your members to answer the following questions:

  • In a perfect world, how will your volunteer squad operate"
  • What is preventing a perfect vision from happening today"
  • What is the department's role — 911 response, education and prevention, community outreach — in the community"
  • What traits and characteristics are you seeking in new paid staff, as well as new volunteers"
  • What qualifications are required for paid position applicants"
  • Who should lead the new paid staff" Why"
  • How can the department take advantage of the opportunity provided by bringing experienced and career-oriented EMS providers in-house to help make those changes"

Focus on creating a partnership
Bringing in the right people is critical to the future success and stability of your squad, regardless of pay status. Be thoughtful, focused and deliberate with the job description and interview process. Look for applicants who will have the patience and experience to mentor new recruits and bring confidence to part-time volunteer members.

Consider hiring a crew chief or operations manager who can provide shift coverage and take care of day-to-day administrative functions including scheduling, inventory management, equipment checks, in-service training and chart review for continuous quality improvement. Having the daily operations taken care of will take a big load off of the volunteer members who have been running the business part-time, and allow those members to focus on the patient care aspect that they originally signed up for.

Be proactive in adding paid staff
Make the decision to add paid staff before being forced to by a sentinel event. Panic hiring just to put meat in the seat because a response failure resulted in a poor outcome or death of a patient, will send your department down a rabbit hole of chaos, shame, resentment and possibly financial ruin.

Managing the change deliberately with a positive outlook, and the support of the membership and community will prevent the division, morale issue and human resource problems that can plague this initiative. Intentionality also honors your department's commitment to the safety of the community.

Scheduling EMS personnel: 5 best practices for paramedic chiefs and HR managers

The shift schedule for EMS personnel is one of the most important, vital and often overlooked aspects of EMS operations. It determines an agency’s ability to effectively provide service, it sets call receiver and dispatcher expectations of resources available to respond and it has a direct impact on the morale of providers.

In order to make the most out of your agency’s schedule to benefit the organization, the patients it serves and the providers, here are five best practices for scheduling EMS personnel.

1. Clearly communicate the schedule
While communication plays a vital role in everything that we do, clearly communicating the schedule is essential. The schedule should be accessible to agency management, operation supervisors and especially the providers so that they actually know when they are expected to be on shift.

The easiest way to accomplish across the board accessibility to the schedule is to use an online scheduling application. There are many systems available, some geared specifically for the EMS industry and others that are more generic.

If your agency continues to do scheduling via spreadsheet programs or by hand, communicating that schedule is both harder and time-consuming but must still be done. Make sure to follow a consistent and predictable schedule to announce the schedule, accept change requests, grant schedule changes and to announce the final schedule.

Although tedious and time-consuming, this will ensure that your schedule has been communicated, that your providers know what is expected of them and most importantly that everything has been documented should an issue arise down the road.

2. Have the schedule ready in advance
Having a schedule available in advance has benefits for both the agency and the provider’s planning purposes. An agency can plan for resource management, such as the number of vehicles needed on any given day and time, which allows vehicles to be scheduled for preventive maintenance and downtime. A provider can plan for childcare, class schedules or some much-needed sleep.

How far in advance the schedule can be set and available to providers depends on agency operations. Agencies with hyperdynamic scheduling, where every week is different than the week before, will at best be able to schedule a week in advance. Agencies that divide their scheduled resources between core always available units and flex units to dynamically cover special events or peak demand times will be able to schedule their core units two weeks or more in advance and add the flex units as needed. Agencies that have a set schedule with few changes can schedule a full month or more in advance.

3. Consider provider preferences
Provider preferences play a large role in both the ability to provide service and the quality of that service. Managers should be looking to make things easier, not harder, for everyone involved.

Knowing your provider’s preferences will make scheduling easier for you, makes their ability to balance the things outside of work easier for them, and that makes coming in for their shift more enjoyable for everyone. Not taking their preferences into consideration can lead to poor morale, a negative disposition towards the agency, more work for the scheduler and directly result in a poor quality of service that they provide.

Shift trading is a common occurrence in EMS. If your agency allows shift trades, make sure to approve or deny the trade as soon as possible. The same applies to when someone requests time off. There is a reason they are requesting the time off or looking to trade the shift. Not knowing whether a request has been approved can result in both unnecessary anxiety for the provider and a harder time covering the shift from the operational end.

In a hyperdynamic scheduling model, it is important to set the deadline for the submission of provider availability. Make sure this deadline and what is expected of it is clearly communicated to everyone. Provide friendly weekly reminders of the deadline. Once that deadline is set, stick to it and make the schedule available on time.

4. Prioritize agency needs
The needs of your agency must be prioritized. Is it more important to cover a shift or manage overtime" Can two providers from last week’s orientation class work together or are experienced providers being paired with new providers for a certain length of time or hours"

Once you fully understand what your agency has as the main priority, you can better adjust the schedule to ensure those priorities are met. Create a scheduling priority matrix or flowchart and communicate it to operational staff and management. This will help provide consistency in scheduling during all hours by the operational team.

Deciding par levels of unit resources will also help to establish the base number of resources your agency needs. Define what the levels are and at what point going below those levels triggers an agency-wide alert. This internal state of emergency can result in a number of actions to help rectify the situation, including mandating employees to stay past their scheduled shift end time.

If you find that you are mandating your employees to stay past their scheduled end time greater than 10 percent of the time, this is perhaps an indicator that you need to revisit your base schedule and make adjustments. While mandating is an option, it should be used sparingly since doing so often results in lower morale, frustration, and general anger from the providers who it affects. Low morale can manifest as sub-standard customer service, higher absentee rates and a lack of efficiency.

5. On-call lists
Life happens, even to EMS providers. Sickness, doctor appointments, court dates, childcare issues and sudden situational emergencies will happen over the course of time. When they happen at an EMS agency the effect can be disastrous in terms of being able to meet response times and other metrics that measure the agency’s performance.

To fill vacancies quickly, maintain an on-call list of personnel who are not scheduled to work, but able to cover a shift if needed. The list should be accessible to anyone on the operational end to utilize.

What are your best practices for EMS provider scheduling" Share your ideas and questions in the comments.

Medical supply inventory management systems for EMS

Today’s complex EMS environment requires administrators to constantly juggle issues like tightening budgets, drug shortages, strict governmental regulations and a highly engaged and connected staff — all while operating in a litigious society. Using yesterday’s approach to inventory management and supply and logistics is no longer an acceptable practice [1].

There are several significant aspects to automated inventory control and management for today’s EMS agencies, in both the public and private sectors. Having a reliable, effective and efficient inventory management system can help an organization reduce costs, limit waste, improve employee relations and limit liability. It can also positively impact patient care by having the right supplies and drugs available when needed [1].

For some time now, private-sector EMS agencies have used automated solutions to improve their fiscal bottom line by reducing costs and limiting waste. Increasingly, public-sector EMS agencies are seeing a similar need as their local funding from government or donations from stakeholders have declined or remained stagnant.

EMS agency leaders cannot continue to rely on emotional appeals to their stakeholders to justify their fiscal needs. The trend in local governments is for transparency and accountability to show taxpayers where and how their money is being spent [1].

EMS agencies across the board are also facing more demanding requirements for reimbursement from medical insurance companies, Medicare and Medicaid for the supplies and drugs used when rendering patient care. The health care environment is rapidly changing with reduced reimbursements, new government regulations and an increased focus on compliance. This added complexity makes managing billing and coding in house much more challenging [2].

Inventory control and management software benefits
Current and developing technologies in ICM can enable EMS agencies to improve both their efficiency and effectiveness in a variety of ways including, but not limited to [3]:

  • Preventing medical inventory from expiring or being overstocked
  • Centralizing inventory control among departments and vehicles
  • Improving EMS medical staff productivity and performance
  • Ensuring that every ambulance is fully equipped with life-saving medications and devices
  • Logging the movement or usage of medical inventory

Inventory control to prevent narcotics diversion
Diversion is the theft of any pharmaceutical to be sold or traded for personal gain. Resale of narcotics is not limited to common street crime but also can involve Medicare fraud, theft from other providers, organized crime and a host of other crimes [4].

In its simplest form, detection of the loss of pharmaceuticals is a basic inventory control function. The three variables are replenishment of warehouse or central inventory, documented usage, and replenishment of in-station or in-ambulance inventory. Depletion of inventory is fairly predictable over time and can therefore be forecast as well [5].

Here is a common sense, simplistic example of monitoring inventory: You order what you use. There is no reason to order anything more than at the rate you use it and by using percentages of increase, the variances become highly recognizable. Use percentages because in drug inventories, units may not raise a flag [5].

For example, an increase of 10 units of morphine in this months requested inventory for Station #6 may not seem out of line compared to the stations ordering history, but if those 10 additional units of morphine represent a 15 percent increase over what’s previously been ordered each month that might be cause for a closer look.

Electronic tracking of supplies
Barcoding has become the basis for the majority of ICM systems on the market today. A barcode-based system streamlines the process by enabling an agency to track the life-cycle of any item: from the initial receipt of an item at the warehouse; the distribution of the item into the supply chain such as sending it to a specific EMS station; use of the item for patient care. Key inventory management and control functions that lend themselves to barcoding include [5]:

1. Managing Inventory of Standard Medical Consumables
Keep it simple by barcoding and tracking standard inventory items by location, number and quantity. Track a variety of standard stock inventory like bandages, gauze, and more.

2. Tracking Medication Inventory
Categorize medication using batch-lot numbers to efficiently and effectively keep track of expiration dates. Having an accurate picture for medication ins and outs, as well as on-hand quantity and reorder levels, can ensure that each EMS vehicle has the right medication inventory on board when an emergency strikes.

3. Serialized Inventory Tracking
Track chemicals and oxygen tanks individually using serial numbers to meet government mandated requirements, and to better prepare yourself when serialized inventory items are needed.

Electronic medication dispensing systems
Cart-mounted electronic medication dispensing systems, also known as med carts, have been a fixture in most medical facilities, such as hospitals and nursing homes, for many years and are now making their way into the EMS realm. Keeping medications under lock and key is an inventory security control measure for sure, but it’s not an effective strategy for managing and controlling how those medications are used.

Electronic medication dispensing systems provide benefits for both EMS providers and managers. Providers benefit from:

  • Secure, automated access to narcotics and supplies
  • Better adherence to controlled substance policies
  • Intuitive and easy-to-use software to accurately and completely document usage
  • Integration of usage into the patient care/billing report

The management/ownership benefits of an electronic medication dispensing systems include improved:

  • Compliance with state and DEA regulations for medication storage and dispensing
  • Inventory control and dispensing of narcotics
  • Control of EMS provider access rights
  • Inventory tracking and documentation of drugs used in patient care
  • Billing accuracy for medications used in patient care

Biometric security
One of the top components of inventory control and management is biometric security, which uses an individual’s biometric finger print to verify all transactions. This prevents someone from making false transactions or supervisors or managers having to make sense of illegible paper signatures. For added speed and security the biometric reader can also be used to login to inventory control software.

Beyond paper-based data collection and information management
In addition to inventory control and management, today’s electronic information management systems for EMS operations can include a host of other data collection and reporting features that improve an EMS agencies efficiency and effectiveness. One example is performing vehicle inspections with an electronic check sheet. If the inspection check sheet is integrated with inventory management and fleet maintenance software it can greatly enhance an agency’s operational intelligence. By replacing time-consuming paper check sheets crew members can be more accountable for supplies and equipment. All information captured during the inspection processes can be used to manage and report on an agency’s operations performance and needs [6,7].

Another example is the use of a web-based inventory check sheet to conduct inventory of on-hand supplies. Expiration dates on medical supplies are also captured to ensure that inventory is safe and ready for administration. On-hand inventory is balanced against par stocking levels to automatically generate supply requests. Optimally those supply requests are sent electronically to the supply room and processed based on an agency’s operational procedures.

Asset verification
The equipment used by EMS providers to provide patient care, particularly biomedical equipment such as defibrillators and medication pumps, represent a significant financial investment by the agency. Keeping track of that equipment as it moves through the operation is a critical risk management activity.

Electronic asset tracking enables end users to verify that equipment checked out to a station or vehicle is indeed at the location or report the missing equipment. If equipment is subsequently located, they can add it to their inspection and automatically transfer ownership to the new location or vehicle allowing missing assets and assets in motion to be recovered. If an asset requires maintenance the user can also record the maintenance while in the field using the check sheet.

Logging supplies by call
Using electronic reporting also enables the EMS provider to capture the supplies used on a per call basis. Crew members can enter the run number or ePCR number and enter the supplies used on the call. Once completed, the vehicle's inventory is updated and a supply request is created. These electronic call records can later be used to report on supply usage and matched up with an agency’s ePCR records for quality assurance reviews.

General inspection questionnaires
Electronic reporting programs on the market today enable an agency to create customized questionnaires for any type of location or equipment inspection. These questionnaires are a basic element to any inspection process and provide supervisors and fleet managers with timely alerts on anything from narcotics usage to vehicle mileage and repair orders.

Fleet management integration
Fleet managers can receive information from electronic reporting check-sheets that will provide them with vehicle mileage, operating hours and any repair orders in real time. This makes planning scheduled maintenance and handling off-schedule repairs much easier.

Before you get started
Before purchasing any software vendor's product, it is useful for an agency’s leadership to conduct a self-assessment to answer some key questions.

  • Why do we need to collect and analyze data"
  • What data should, or must, be collected"
  • Who will be responsible for entering the data"
  • How will the responsible parties enter the data"

These are important internal assessment questions. Far too often software purchasing decisions are made by those in leadership or technology positions within an organization without much thought about one of the most important components in any automated system: the end user who needs to integrate use of the software with their primary mission of patient care.

A majority of the data that most EMS agencies need to collect and analyze for their ICM originates at the level in the organization where the services get delivered. The earlier in the process that an agency’s managers gain input from these stakeholders, the greater the chance that whatever reporting software is eventually chosen will be the right one.


1. 4 ways to better manage EMS inventory

2. Avsec, R. 5 steps to buying fire department reporting software.

3. McKesson. EMS Medical Billing & Revenue Cycle Management.

4. ASAP Systems. Barcode Inventory System for Fire Rescue & EMS.

5. nMed. Prescription Drug Theft & Pharmacy Security.

6. ASAP Systems. Barcode Inventory System for Fire Rescue & EMS.

7. OperativeIQ. Electronic Check-sheets. [Available on-line]

Pharmaceuticals in EMS: Are you compliant?

Today's EMS agencies purchase pharmaceuticals from a variety of sources [1]. Whether you purchase/ obtain your pharmaceuticals through a hospital, wholesaler/ distributor or other entity, it’s important to know your responsibilities in ensuring the integrity of the pharmaceutical supply chain as well as ensuring you are in compliance with State and Federal Regulations.

Before 2013, EMS services were not considered part of the pharmaceutical supply chain and were generally beyond the radar of the U.S. Food and Drug Administration. However, due to the Drug Supply Chain Security Act requirements, EMS entities are now considered an accountable part of "dispenser-to-first-responder transactions" and subject to DSCSA requirements [2,3]. Although EMS can continue to purchase drugs and supplies from most of their previous vendors, certain track-and-trace documents need to be maintained.

The Affordable Care Act has mandated numerous pharmaceutical-related regulatory changes that affect EMS and the Medicare ambulance community. These changes include [4,5,6,7]:

  • State-driven Medicaid requirements
  • Increased monitoring of ambulance billing suggested by the Office of the Inspector General at the U.S. Department of Health and Human Services
  • Ambulance claims processing changes from the Centers for Medicare Services
  • Requirements of Drug Quality and Security Act and the Drug Supply Chain Security Act
  • Requirements of the International Statistical Classification of Diseases and Related Health Problems or ICD-10 diagnosis codes

Implementing the DSCSA requirements likely remains a challenge for many EMS agencies. Conveniently, some components of the required DSCSA provider-level documentation correlate with the recent ICD-10 diagnostic code documentation recommendations, which also affect EMS reimbursement.

What is the DSCSA"
On November 27, 2013, the Drug Quality and Security Act became law. Title II of the DQSA, the Drug Supply Chain Security Act mandates new definitions and requirements related to pharmaceutical product tracking and tracing [5,8,9]. Product tracing includes identifying transaction information for each drug while tracking includes keeping records for six years of those entities that have been in possession of the drug starting with the manufacturer to wholesale distributors to dispensers including EMS services [5,8,9].

The intent of the law is to enhance the FDA's ability to protect consumers from exposure to drugs that may be counterfeit, stolen, contaminated, or otherwise harmful by improving detection and removal of potentially dangerous drugs from the drug supply chain to protect patients. The development of the system will be phased in with new requirements over a 10-year period [5]. The market has responded by offering many software programs to help all parties in the pharmaceutical chain achieve compliance.

How can EMS agencies maintain DSCSA compliance"
EMS agencies can only accept ownership of a prescription drug if the previous owner — wholesale supplier or distributor — provides an official transaction report. These transaction reports must be maintained for six years. In most cases when an EMS entity purchases a medication, the wholesale supplier will provide the transaction report in the shipment. Since the supplier must also keep copies of the report, if an EMS agency misplaces a report they should be able to contact the supplier for another copy. This mandate may be problematic for EMS agencies with limited administrative capacities or financial resources.

Details required to be provided on a transaction report include the:

  • Proprietary or established name or names of the
  • Strength and dosage form of the product
  • National Drug Code number of the product
  • Container size
  • Number of containers
  • Lot number of the product
  • Date of the transaction
  • Date of the shipment, if more than 24 hours after
  • Date of the transaction
  • Business name and address of the person from whom ownership is being transferred

In addition to the transaction report a transaction statement is a paper or electronic form which documents that that the entity transferring ownership in a transaction:

  • Is authorized as required under the Drug Supply Chain
  • Received the product from a person that is authorized as required under the Drug Supply Chain Security Act
  • Received transaction information and a transaction statement from the prior owner of the product, as required under section 582
  • Did not knowingly ship a suspect or illegitimate product;
  • Had systems and processes in place to comply with verification requirements under section 582
  • Did not knowingly provide false transaction information; and
  • Did not knowingly alter the transaction history.

EMS services can only purchase prescription drugs from a supplier that has a federal and state license. Drug suppliers must be licensed in the states that they ship into. A supplier holding a license in their home or headquarters state doesn’t necessarily mean the supplier can ship drugs into other states.

Before purchasing medications from a supplier verify the supplier's licenses. License verification, by state, is available on the FDA Verify Wholesale Drug Distributor Licenses website.

Also, each EMS agency must also have on file a copy of their medical director's Drug Enforcement Administration license to purchase drugs and a vast array of other drug administration related supplies from the licensed vendor. This requirement affects all training entities. If a training entity, such as a college, university, or private school, wishes to purchase intravenous supplies, simulated medications, or even normal saline for the sole purpose of education, they must produce for the vendor the same required documentation.

EMS agencies should carefully order only the pharmaceuticals they need. Although it is near impossible to use all stored medications before they expire, ordering more than is needed is costly. Due to the DSCSA requirements, most suppliers are expected to not allow returns of prescription drugs [8]. Returning unused medications may be allowable for hospital-based EMS systems in which drugs are obtained from the hospital's own pharmacy service.

However, regardless of the EMS system, a tracking system must be in place to trace where the drug went once it was received from the distributor. In most cases the drugs will either be in a storage room, on an ambulance, or in another vehicle such as a supervisor's vehicle. Although some of the DSCSA requirements remain unclear, many EMS agencies are also preparing to track the administration data of each drug, such as who administered the drug, when — date and time and to whom it was administered, and from what ambulance it was dispensed.

The role of the field care provider
EMS field providers can assist with drug tracking-and-tracing by implementing medication documentation standards and by strictly adhering to their established EMS agency restocking, storing, and administration policies. As previously mentioned some components of the required DSCSA provider-level documentation correlates with the recent ICD-10 diagnostic code documentation recommendations. Therefore, adhering to medication documentation and administration standards will improve compliance with both DSCSA and ICD-10 code requirements while improving your service's opportunity to maximize reimbursement [10].

Document with DSCSA and ICD-10 codes in mind
Field care is rarely mentioned when national clinical practice guidelines and professional standards are developed. However, when it comes to DSCSA and ICD-10 code requirements, EMS is held to the same standards as other health care providers [10,11]. Here are some important documentation considerations.

1. Document medication orders and administration in the following format: Drug, dose, route, frequency [12,13,14,15].
For example, contacting Medical Command might be necessary for analgesia when caring for a patient with acute abdominal pain. The order should be documented as "Contacted Dr. Langenkamp who ordered Morphine Sulfate 5 mg intravenous push every 30 minutes". If offline medical direction permits analgesia without direct medical control, simply documenting the procedure as "Morphine Sulfate 5 mg administered intravenous push" is sufficient.

2. Avoid nonmedical or slang terms when documenting medication administration.
For example, while the phrase "Hung bag of NS KVO" is understandable to most field providers, this type of documentation does not meet any documentation standards.

3. Avoid confusing and vague terms of fluid administration such as keep vein open (KVO), to keep open (TKO), and wide open (WO).
Since 1998, professional standards have called for all intravenous therapy fluid orders to contain a specific infusion rate [15,16,17,18,19]. A common infusion rate for KVO is 25 mL/hour, but this may vary. An example of a properly documented IV infusion would be "Intravenous 0.9% normal saline infusion at 25 mL/hour " or "IV 1 liter bolus 0.9% normal saline infusion at 1000mL/hour initiated".

In addition, your administration practice should also represent sound medication safety by using an IV pump or a simple rate flow device. There are many safe low cost products on the market.

5. Document why certain medications were not given.
For example, not all patients with ischemic chest pain symptoms can receive nitroglycerin. Perhaps the patient took tadalafil (Cialis®), vardenafil (Levitra®), sildenafil (Viagra®), or another medication for erectile dysfunction in the past 48 hours. Document why the medication was not given because of the patient meeting exclusion criteria in the chest pain treatment protocol.

Certain states have implemented time critical diagnosis programs that require EMS documentation to be more specific for conditions such as stroke, STEMI, and trauma. For example, if a TCD process for the treatment of Non ST elevation myocardial infarctions (NSTEMI) includes heparin and clopidogrel (Plavix®), carefully document why these medications were given, the inclusion criteria, or not given.

6. Document reassessment findings after treatments.
Reassessment after medication administration should always include objective and subjective findings. This is important because it measures and evaluates the therapeutic value of the medication. For example, after administering albuterol 5 mg by nebulizer, objective findings would include post treatment work of breathing, respiratory rate, pulse, blood pressure, lung sounds, pulse oximetry, and waveform capnography. The patient reports the subjective data by describing his interpretation of the therapy, such as "breathing easier now".

Both components of your reassessment are important findings to support DSCSA requirements, ICD-10 codes and CMS reimbursement. If there was no change in the patient's condition, or if the condition worsens, these too must be reported.

7. Perform serial physical exams and diagnostic tests as applicable.
For example, the patient who received the albuterol treatment would most likely need several lung sound assessments. The patient who received sublingual nitroglycerin for chest pain would most likely receive another 12-lead ECG when his chest pain resolves or becomes worse. Performing and documenting all appropriate reassessments assists EMS agencies in satisfying DSCSA and ICD-10 code requirements.

Implementing the DSCSA requirements will no doubt remain a daunting task for EMS administrators, medical directors, and field professionals. Although some of the requirements are clear, they may elicit more questions than answers. Successful compliance with the requirements, as well as billing for services, likely requires an open and frequent dialogue with reliable legal counsel with specific knowledge of your EMS agency and its protocols. You can also submit questions to the FDA through the FDA's DSCSA website.


1. The Kaiser Family Foundation. (2005, March). Follow the pill: Understanding the U.S. pharmaceutical supply chain. Retrieved from

2. Barlas, S. (2011). Track-and-trace drug verification: FDA plans new national standards, pharmacies tread with trepidation. Pharmacy and Therapeutics, 36(4), 51-68. doi:10.1201/b18697-5

3. Ducca A. (2012, October). Re: Determination of system attributes for the tracking and tracing of prescription drugs. (docket no. FDA-2010-n-0633). Fed. Reg. 2011 January 7;1182:76. Retrieved from!documentDetail;D=FDA-2010-N-0633-0012.

4. Centers for Disease Control and Prevention (CDC). (2016). International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from

5. U.S. Food and Drug Administration (FDA). (February 2016). Requirements for transactions with first responders under section 582 of the Federal, Food, Drug, and Cosmetic Act—Compliance policy guidance for industry.

6. Government Health Administrators. (2016). Ambulance providers ICD-10 CM planning and preparation.

7. Centers for Medicare & Medicaid Services (CMS). (2015, October). Medicare claims processing manual: Chapter 15—Ambulance. Retrieved from

8. Brennan, Zachary. (2016, February 29). New FDA guidance for first responders as track-and-trace requirements take effect. Retrieved from

9. U.S. Food and Drug Administration (FDA). (2013). Drug Supply Chain Security Act (DSCSA). Retrieved from

10. American Pharmacists Association (Apha). (2015). Apha Policy Manual. Retrieved from"ids=p-929421&tids=t-929417

11. American Medical Association (AMA). (2017). CPT 2017 Professional Edition. Washington, DC: AMA.

12. Institute for Safe Medication Practices (ISMP). (2011). ISMP acute care guidelines for timely administration of scheduled medications. Retrieved from

13. Institute for Safe Medication Practices (ISMP). (2011, February). Preventing medication errors during codes. Retrieved from

14. Institute for Safe Medication Practices (ISMP). (2015). ISMP safe practice guidelines for adult IV push medications. Retrieved from

15. Institute for Safe Medication Practices (ISMP). (2016). 2016-2017 medication safety best practices for hospitals. Retrieved from

16. Infusion Nurses Society. (2006). Infusion nursing specialty practice. Journal of Infusion Nursing, 29(Supplement), 1s, S18. doi:10.1097/00129804-200601001-00005

17. Infusion Nurses Society. (2006). Infusion nursing specialty practice. Journal of Infusion Nursing, 29(Supplement), 1s, S35-36. doi:10.1097/00129804-200601001-00005

18. Hadaway, L. C. (2004). Closing the case on the keep-vein-open rate. Nursing, 34(8), 18. doi:10.1097/00152193-200408000-00015

19. Infusion Nurses Society. (1998). An infusion of independence. Journal of Infusion Nursing, 21(1), 1st ser., S1-S91. doi:10.1097/00000446-199804000-00015

How labeling a patient's problem 'impaired consciousness' keeps me objective

Alcoholism affects people from all walks of life. There is no escape from its clutches for those afflicted with the disease. The rich, the poor and everybody in between has their share of alcoholic persons.

Responding to calls to treat intoxicated persons is frustrating, time consuming and has the potential to be the undoing of any well-meaning EMT or paramedic.

Remembering that a 911 call for an intoxicated person is the same thing as a call for a person with an impaired consciousness helped me keep things in perspective, and not judge the people entrusted to my care. When I learned to stop hearing the "intoxicated person" message from dispatch and replaced to words I heard to "impaired consciousness" my frustration diminished greatly.

Ultimately, people suffering from alcoholism deserve the same level of professionalism as everybody else.

Not so healthy
Fleas flutter around the sleeping man, land on his face, his hands, bite him, then fly off.

"Rubin!" I said, crouching down.

He was sixty, looked seventy, wrinkled, tired and just about done.

Sixty years. That’s longer than most street people last. They don’t have longevity.

Tonight, Rubin is inside, lying on a flea-infested air mattress at one of the state’s largest homeless shelters. He considers the place his home. It’s where he lays his head at the end of long days spent wandering the streets of Providence. They let him stay here, tucked away in the corner of the day room, along with anywhere from ten to 100 other homeless folks.

At six or seven in the morning, they are all shown the door, left to their own devices for the day. For some, that means looking for work. For most, it means looking for a high: booze, heroin, crack, pills; whatever works. Rubin depends on vodka in little half pints.

"I’m sleeping," Rubin said. "Leave me alone."

"They’re kicking you out."


"Because you are intoxicated."

He’s nearly always intoxicated.

I watch as he closes his eyes and falls back asleep. The fleas return to his face. I brush them off, he swipes at my hand, thinking I’m a giant flea. He misses.

I pull a sleeping bag over his face and leave him where he lies.

The girl at the desk apologizes for calling us, but also lets us know that she’s not going to be responsible for him if he gets sick. Or seizes. Or dies.

I tell her to call us back if he wakes up and walk back to the truck.

Rubin returns to his dreams.

At the end of the road, fifty yards from the river on the front steps of a well-maintained home, sits a 60-year-old woman. Her brother stands close by, apologetic and concerned.

"We tried to get her to go, but she won’t budge."

The woman stayed seated, defiant. She knew what little control was hers was about to be taken away, and she had no intention of giving it up willingly.

A little dog scurried over. I knelt and scratched behind his ears as the intoxicated woman looked on.

"She’s been drinking for 10 days. Says she wants to drink herself to death. My sister is inside getting some things."

I looked her in the eye while petting her dog.

"We’re taking you to the hospital."

"Bullshit," she slurred.

One of the firefighters who was on scene before us chimed in.

"We can do this the easy way or the hard way, it’s up to you."

I never was a fan of the strong-arm tactic.

"In five minutes we are going to be at the ER. I know you don’t want to go but I am required by law to intervene if family members present a strong case that you may harm yourself. And, you are intoxicated, so I can’t leave you here."

She tried to rationalize, claim her freedom was being compromised, get up and run, be a rock and simply not cooperate.

Years ago, I would have called police and let the firefighters help me wrestle her and tie her to the stretcher and drag her away from her home. Today, I let go of the dog, took hold of her arm, had my partner take the other and lifted her to her feet. We walked to the stretcher, put her on it and fastened the seat belts. The struggle lasted about 20 seconds.

Then the crying began. She cried all the way to the hospital, taking a break now and then to glare at me, but her resolve was broken, along with her spirit. She did make one desperate lunge for the rear door, but before the seat belt was undone I had her back down.

As I walked out the door of the ER, the woman’s sister who had accompanied us in the back of the rescue stopped me. She took my hand and looked me in the eye.

"I want to thank you for being so kind."

She held the gaze for a moment, her eyes filled up and she turned and walked away.

I quickly wiped my own eyes and got back in the truck.

Alcoholism is a crafty, evil disease.

A little too wise
Monday she was drunk at home, a concerned friend called 911 to have strangers check on her well-being. I guess it is easier to call the fire department when a friend is in need than getting up and doing something yourself.

We found her inside her apartment, empty beer cans littering the floor, highly intoxicated. There is no law against being drunk at home, but our patient clearly needed some help.

After a small brawl, we talked her into going to the hospital for detox, hopefully eventual rehab.

Wednesday she was home again, drunk. This time she called 911 for a ride to the hospital because she wanted to go to detox. Apparently, rehab wasn’t in the cards on Monday.

Saturday we got a call for an intoxicated person at an address on Broad Street. Our friend, drunk again, this time at an acquaintance’s place. He was tired of her, wanted us to get rid of his problem guest.

By now I thought we had become friends with the woman. It’s a short trip to the emergency room, but a bond quickly forms between patient and caregiver, especially a frequent customer.

Monday we got a call for a person down in the bushes. I saw a hand rise from some hedges in front of one of the high-rise buildings where the elderly and disabled residents of Providence reside. Walking closer, I saw my newest old friend, drunk again, unable to extricate herself from where she fell.

She fought for a while, learned quickly that a 60-year-old former prostitute is no match for five firefighters sent to help her. "I have a knife," she said, enraged now that we had her out of her nest.

You would think that after all of these years I would learn never to let my guard down. Because familiarity sets in by no means diminishes the potential threat on every call.

To the patients we are sent to treat, we are no more than a blur, a momentary diversion from their otherwise dreary existence. Once we part ways we are forgotten, the next person who enters their lives more important than the last.

She ripped open the front of her coat and brandished a 12-inch butcher’s knife. Her eyes were wild, full of hate.

Before she had a chance to hurt herself, or us, we disarmed her, put her on the stretcher and took her to the hospital. There was no real malice once the knife was out of her hands, but for one moment, when she was capable of murder, she could have altered a lot of lives.

These three 60-year-old people have one thing in common. They call it alcoholism.

For me to remain objective, I call it impaired consciousness.

Why a bully-free EMS workplace is 'just correct'

The news that a female firefighter, who died by suicide, had also received numerous sexist and harassing comments in social media should give us pause for concern. At this point in the investigation, it's very unclear whether there was a causal relationship between the death of Nicole Mittendorff and the messages; time will tell.

However, there have been other recent, well-publicized suicide deaths that may have been triggered by such bullying behavior. One of the most recent is the death of Evan Ziemniak. He was bullied at school and his parents are speaking out to prevent other tragic deaths.

The vast majority of public safety providers genuinely care about each other and their communities. We work alongside folks who don’t look like us, but feel the same passion for the work we do. The desire to serve the community crosses all boundaries: race, sex, gender identity, religious beliefs, sexual orientation and socioeconomic status.

Nevertheless, it’s perturbing and disturbing that in 2016 bullies continue to roam EMS and fire stations across this nation. It's even more alarming that bullying behavior can be so ingrained in a department’s culture that mid- and senior management allow it to flourish through benign neglect.

A major role of leadership is to provide a safe workplace, including one that is free from harassment. Common sense, not federal law should be the driver of creating strong, fair policies that guide workplace behavior, rewarding those that promote teamwork and just culture, and punishing acts that can harm not just one individual, but a whole class of employees and the entire department.

Staff is also not absolved from being responsible to each other. We sit through hours of mandated training, reading the same bulletins year after year. But until it becomes an organizational norm that personal bias has no role in workplace behavior, we’ll continue to numb a lot of brain cells just going through the routine.

As for the accusations that all of this harassment-free stuff is just "political correctness," it’s not. Just call it "correct." This is stuff that parents should have told their children and school teachers should tell their students, long before they ever get to the workplace.

Personal bias is fine. You are entitled to your opinion. But we don’t live in caves by ourselves.

Our lives today are tightly connected, both online as in person. Things that are said out of ignorance and meanness get amplified and take on greater meaning in an always-on world. It becomes very difficult to understand what impact such behavior will have on individuals, groups of people or entire departments.

But there is an impact. We can make sure it’s a positive one, through good words and deeds, not disparaging ones.

State EMS directors discuss hot topics in rural EMS

SAN ANTONIO — Four state EMS directors shared the stage at the National Rural EMS Conference to discuss some of the more unique and pressing issues that rural EMS agencies are facing in the United States.

  • Jay Bradshaw, retired Director of Maine EMS
  • Joe Schmider, Texas State EMS Director
  • Andy Gienapp, Manager of the Wyoming Office of Emergency Medical Services
  • Tom Nehring, Director of the North Dakota Division of Emergency Medical Services and Trauma

The Recognition of EMS Personnel Licensure Interstate CompAct is model legislation written by the National Association of State EMS Officials that would allow EMTs and paramedics to have one license that is recognized by all states that have signed the compact. REPLICA would support providers that practice across state lines, a situation many urban providers never need to consider, but one that would help some rural communities gain access to a wider array of providers.

When asked what advice they would give to rural EMS leaders the panel recognized that individuals running these agencies are balancing more than their fair share; often working full-time, being there for their family, all while managing their respective organizations. They recognized that rural EMS was created to fill a gap in care, and that this gap has only continued to grow, leading to a greater reliance on rural EMS with a shrinking level of support.

When someone in the audience asked about lowering educational standards to allow for a greater number of applicants, the panel shut down that logic immediately. Nehring recognized that this was a tempting solution to current problems, but reiterated that for EMS to move forward as a profession, "going backwards would be a big mistake." The panelists also made sure to advocate for increased educational opportunities for leaders on the non-clinical components of running an EMS organization.

After the panel Nehring and Gienapp reiterated that rural EMS has the capacity to bring lessons learned to the national conversation, and that the experiences of rural agencies could serve as learning opportunities for their urban counterparts. They also shone a light on the increasing number of hospital closures in rural areas, something of an underutilized window of opportunity for rural EMS leaders.

Memorable quotes on rural EMS
"It’s about funding, it’s about workforce, and it’s about leadership that doesn’t know how to get the first two."
– Andy Gienapp

"Stop trying to be an island within ourselves … it’s a community approach."
– Joe Schmider

"The more complex EMS becomes, the more competent leadership has to become."
–Jack Stout, attributed

Key takeaways
Here are three key takeaways from the panel discussion:

  • Rural EMS faces many barriers to success that their urban counterparts never need to consider, but they also exist in environments that have less of an issue with bureaucracy and red tape.
  • Legislative changes such as REPLICA can be a big step forward for the industry.
  • Solutions must be found that allow for the industry to remain solvent, without lowering any educational or hiring standards.

The tragedy and disgrace of bullying in EMS and fire

Since the body of Nicole Mittendorff was found in the Shenandoah National Park on April 21, allegations of bullying and harassment by her co-workers have surfaced on social media, in the news and in private messages to EMS1.

It's a profound tragedy, and the bullying angle in particular has struck a nerve among many in fire and EMS after it was confirmed that Mittendorff had taken her own life.

We don't know whether bullying was a primary factor in her suicide, but we do know that starting in December 2015 lewd comments and rumors about Mittendorff’s personal life were posted online by people claiming to be Fairfax County Fire and Rescue Department firefighters, the department where she worked as a firefighter-paramedic. The despicable nature of the language in the online posts certainly points to the strong possibility that the bullying had an impact on Mittendorff’s mental health.

Bullying: No Reason. No Excuse.
This is not the first time bullying and harassment has potentially been a contributing factor to a first responder suicide. The availability of seemingly anonymous message boards and other social media channels have made it easy for lewd comments and rumors to spread rapidly.

Since the comments and postings about Mittendorff have been reported, the common phenomenon that is "victim blaming" has surfaced on social media and even in messages to the EMS1 editor-in-chief. People are quick to try and justify the online harassment by claiming there is more to the story or that the victim somehow brought it on themselves.

Whether or not bullying was a direct cause in her suicide, it forces us to engage in discussion about one unequivocal truth: There is no excuse for bullying in the workplace.

Repeat after me.

There. Is. No. Excuse. For. Bullying.

The truth or falsity of rumors is completely irrelevant; nothing excuses bullying and harassment. It is not your place to publicly humiliate and shame a co-worker.

As any kid who wears glasses can tell you, true statements can still be used in a tortuous manner. Being a first responder can be traumatic enough without one’s peers adding to the stress and trauma.

Workplace bullying is real and women are disproportionately impacted
Bullying in the workplace is not a new or uncommon issue. In the 2013 WBI Industry report, the two fields with the most bullying reported were hospital-based health care and public services, which included fire and EMS [1].

The 2014 Workplace Bullying Survey showed that 27 percent of workers have experienced bullying at work [2]. In that survey, 69 percent of bullies were male, while 60 percent of the targets of bullying were female.

In the fire service, bullying and harassment have been identified as ongoing problems, especially among female firefighters. According to the NPFA in 2012, the most recent year available, only 3.4 percent of career firefighters in the United States were female [3].

Female firefighters have expressed that they do not feel like they are treated as equals with their male peers and report significantly higher rates of workplace bullying and harassment than their male co-workers [4]. In a study of 339 firefighters, 54 percent of female firefighters indicated they were not treated as equals, however 84 percent of female firefighters said they would still enter the fire service [5, 6].

The 2008 National Report Card on Women in Firefighting interviewed 675 firefighters in 48 states, 175 of which were female firefighters. Eighty-five percent of the females surveyed reported that they had been treated differently due to their gender versus 12.4 percent of the males surveyed. Fifty-one percent of females reported being shunned versus two percent of males. Forty-three percent of females reported experiencing verbal harassment versus three percent of males [4].

Females also reported experiencing exposure to pornography, unwanted sexual advances, and hostile notes at rates at least 15 times greater than the male respondents reported [4].

A study in Norway found that adult victims of workplace bullying were twice as likely to have suicidal ideations than those who were not bullied [7].

What is being done to stop workplace bullying
There do not appear to be any studies directly looking at what affects workplace bullying and harassment of first responders may have on their mental health. However, I feel safe saying that adding an additional stressor to someone who is already a member of a high-risk profession is not likely to have a positive effect on their mental health.

In an effort to curb bullying and particularly cyberbullying, laws have been passed making it easier to find the identities of online attackers and to prosecute them. As of 2014, 48 states had anti-bullying or anti-harassment legislation that mentions the use of electronic communication methods.

Virginia law calls a time out on the statute of limitations on defamation cases if the investigators have something like a username or IP address of a harasser, but don’t have the bully's real identity yet. Virginia also has a law clearly outlining what is considered online harassment, and people found to be in violation may be guilty of a class 1 misdemeanor.

What you can do in your fire department or EMS agency
The 2014 Workplace Bullying Survey showed that 72 percent of people were aware workplace bullying happens [2]. This means there are a significant percentage of employees who are witnessing bullying. If you are a witness to bullying behavior, here are some things you can do to help:

  • Let the victim of the bullying know that you’re aware of what is going on and are willing to make a report.
  • Encourage the victim of the bullying to stand up for themselves.
  • Talk to the person doing the bullying. Explain why their behavior is not OK.
  • Discourage people from spreading rumors.
  • If the bullying is on social media, use the website’s report function to notify administrators about it so it can be removed.
  • Report it to a supervisor, human resources or via another appropriate avenue.

What chiefs and leaders must do
Chiefs, owners, managers and supervisors of fire departments and EMS agencies need to foster an environment where mistreatment will not be tolerated and where complaints are evaluated in a fair manner. The fire service, and to a lesser extent EMS, have a reputation as a ‘good ol’ boys club’, and where that culture dictates mistreatment of those not fitting the standard mold, it must be aggressively addressed and corrected. Here is what we should expect from every public safety workplace:

  • Make it clear during the initial hiring process that bullying and harassment of any kind is not permitted.
  • Have comprehensive policies outlining how bullying and harassment should be reported and investigated.
  • Educate employees annually on bullying and harassment policies. Make sure bullying and harassment are specifically covered in workplace violence. Look to national professional associations and training vendors for bullying prevention training programs.
  • Do not dismiss complaints of bullying without investigating. The behavior you see from the accused employee may not be the behavior everyone else sees.
  • Calls to toughen up, that is how things have always been, it’s just men being men and other similar excuses should never be used to dismiss a complaint or justify behavior.
  • Even if a rumor is deemed truthful that does not mean it is appropriate for workplace discussion.
  • If permitted, consider bringing in a neutral 3rd party to conduct investigations of workplace bullying and harassment.

As mental health becomes a more common topic of discussion among first responders, it stands to reason that discussions of bullying and harassment are going to follow since we know there is a link.

As part of changing first responder culture to destigmatize mental health, we also need to work on eliminating bullying and harassment. Having a mentally healthy workplace cannot happen if we only focus on the traumatic calls and not the trauma we inflict on each other.

1. Namie, Gary, PhD, Daniel Christensen, and David Phillips. 2013 WBI Bullying By Industry Survey. Rep. Workplace Bullying Institute, 2013. Web. 24 Apr. 2016.

2. Namie, Gary, PhD, Daniel Christensen, and David Phillips. 2014 WBI US Workplace Bullying Survey. Rep. Workplace Bullying Institute, 2014. Web. 24 Apr. 2016.

3. Firefighting occupations by women and race.

4. Hulett, Denise M., Marc Bendick, Jr., Sheila Y. Thomas, and Francine Moccio. A National Report Card on Women in Firefighting. Rep. International Association of Women in Fire & Emergency Services, Apr. 2008. Web. 24 Apr. 2016.

5. Does the Fire Station Have a Glass Ceiling (Griffith, Schultz, M. C., Schultz, J. T., & Wakeham, 2015)

6. Bullying on the job: A new threat to the fire service

7. Morten Birkeland Nielsen, Geir Høstmark Nielsen, Guy Notelaers, and Ståle Einarsen. Workplace Bullying and Suicidal Ideation: A 3-Wave Longitudinal Norwegian Study. American Journal of Public Health: November 2015, Vol. 105, No. 11, pp. E23-e28.

Frequent Flyers: Navigating 'land mines' on calls


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.

3 energy-saving tips for your EMS station

Earth Day, or any day, is a good time to see what you can do at your agency and home to save both resources and money.

How this video can "Keep Yourself Safe"

Consider using this PPE safety video in your EMT course 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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