What we do, what we don’t do


EMS is funny in that we are good at crisis management, but generally not so good at long term management.

If you think about it, we don’t cure anything. We temporize. We buy time for the patient so that we can get him or her to a hospital for definitive care. We come in and fix, for the short term, the patients catastrophe. Even the patients we seem to work miracles for aren’t cured. Diabetics, patients in CHF, even narcotic overdoses. Those are patients that we can bring back from near death, but we don’t correct their underlying problem. The diabetic still needs insulin, the CHF patient is still going to get progressively sicker, the Heroin addict is still going to be addicted.

As a result often the best paramedics make the worst managers. The fix it now mentality means that we don’t have to think about the long run. One of the things I like about EMS is that I don’t have to spend a lot of time with my patients. 30 minutes is fairly long for a call in my system. Unlike the Emergency Department, we aren’t with the patient for hours on end. As a result we don’t have to think very much about what the long term consequences are.

Management is, or should be, about long range planning. A good manager should have a plan on how he is going to implement a new process or introduce a new piece of equipment into service. That takes knowledge of how long it takes to evaluate, decide to purchase, purchase, train the staff, and then put the new equipment out in the field. If you’re in the public sector, you also have to take the Fiscal Year into consideration. A lot of variables to juggle over a longer period of time than we’re used to planning for.

We in EMS are not the most patient people in the world and many of us seem to be more than a bit cynical. We are the prototypical instant gratification demographic. If we see a piece of equipment and it doesn’t work perfectly the first time out, we’re likely to just toss it into a closet and never use it again.

That might be fine for field providers, but managers need to have more of a long range view and understand product development and implementation. As importantly, they have to be able to explain that to the field staff and make sure that the field staff complies with the plan. Oh, and planning the training is another task that needs to be addressed.

The other side of this coin is that pure management people, with little or no field experience, don’t understand or appreciate that the field staff has a different world view. From what I’ve seen non provider managers seem to have the Monday-Friday 9-5 mentality that just drives field providers nuts. If a piece of my equipment or my vehicle breaks down at 0300 on a Saturday morning I want a replacement or repair right then and there. I don’t want to hear that it will be taken care of Monday morning or after the holiday. I don’t want to hear that we can’t fix that annoying rattle in my ambulance because no one thought to set up a routine maintenance plan, they just figured that fix it as it breaks will work fine.

Thus the conflict is built into most EMS systems.

I’m sure that there is a solution to this, but I’m damned if I know what it is. I wonder if most other EMS systems have the same problems?

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.


  1. We need to improve the long term view of the field providers, because it is relevant to what we do.For example, after intubation we should not do just one assessment of placement. Having our desire that the tube be in the trachea supported by a single solitary lonely isolated coincidental assessment of placement is just the wrong approach. We need to take a longer term approach to assessment. Too often we do not look at the possibility of a complex presentation and we accept the first result that confirms our prejudices.When we arrive at the hospital, our patient may have a very high oxygen level in the stomach, but a brain that has been without oxygen for too long.Conversely, for management, we need to understand the critical role of time in the treatment of EMS patients. We may be able to get away with a day late and a dollar short for a while, but eventually the odds will catch up with us and we will have to find some unpopular hourly worker to take the blame for our bad decision.

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