How To Create a Paid Fire/EMS Department

As of late, I’ve posted a fair amount about the local politics involved with the various tax-funded emergency services districts in my part of Texas basically ending volunteer participation. Truth be told, I definitely think there’s some shenanigans from paid staff and their union locals. But folks, if we’re going to talk about the end of volunteer participation, we need to take a long hard look at the volunteer culture.

As I often teach through sarcasm, I present the following recommendations for ways to ensure that your volunteer department becomes a combination department and eventually a completely paid department.

  1. Run the department as your own private social club.  By gosh, this is a place for the connected locals to hang out, use as a private lounge, and maybe go travel on someone else’s dime.
  2. Training?  Why do it?  And if you do feel you have to do it, focus on cool, fun stuff instead of the basics of being able to operate at a fire, rescue, or medical call.
  3. Membership? Who needs that?  If people want to join us, they’ll find us. And if they do figure out how to join the department, ensure that the process is all about who you know rather than what you’ll bring to the department. And if you do a membership drive, make it a joke.  Either try to recruit “heroes” (as opposed to members who want to help others) or do the same tired routine that you do every so often and then claim “nothing’s working.”
  4. Speaking of what you bring to the department, always make sure to turn down free help. If the person can’t make the arbitrary number of meetings or responses, or lives “too far,” don’t show any flexibility.  If you’re a combination fire and EMS organization, be sure to turn down someone only interested in one discipline. It’s not like having an extra medic frees up a firefighter or vice versa.
  5. Accountability and transparency is for the birds.  You’re heroes!  There’s no need to justify your budget or be accountable to those politicians at the county or the city who “don’t understand what we do.”
  6. Speaking of budgets, let’s be sure to spend like drunken sailors on shore leave. Buy those big-ticket, rarely used capital expenditures regularly, then run around scavenging for IV needles and working radios.
  7. Responses?  We’re volunteers.  We don’t have to go to a call if we don’t want to.  And we sure don’t go to “old so-and-so’s” house or the local nursing home.  It’s not like they really need help. And especially if you have paid staff working with the volunteers, there’s no need to go to all calls, only the fun ones.  And if you show up on the fun calls and don’t get to do “fun” stuff, by all means, complain loudly.
  8. Uniforms?  They need to fall into one of two extremes.  Either no uniforms and look like “People of Wal-Mart” or uniforms that make you look like an Italian Field Marshal.  No need for things like photo ID cards, t-shirts, polo shirts, and jackets.  It’s either the Redneck Yacht Club or the full parade dress.
  9. Be sure to remind new members that they don’t know how “we do things around here.”  Be especially unwelcoming to experienced people who have significant prior experience.  It’s not like they bring anything to the table.
  10. Don’t create strong relationships with the other members of the public safety team.  No need to play well with the surrounding fire or EMS agencies, much less law enforcement.  It’s not like you’ll ever need any of these guys again.
  11. And if you have a state organization for volunteer fire and EMS, don’t join it.  And if you do end up joining said organization, ensure that your organization is quiet at the state capitol.  We don’t want to antagonize the paid guys or advocate for volunteers.

So, if you follow my  program, what will you get?  Simple.  Eventually, the taxing entity and taxpayers will tire of your antics. They will point to your lack of training, transparency, fiscal responsibility, and shrinking membership roster.  First, they’ll bring on a small duty crew during the day to “supplement” the volunteer staffing.  Eventually, that supplement supplants the volunteers.  And somewhere during this process, your department becomes absorbed by the taxing entity.  Congratulations! Your non-profit volunteer group has now become a fully paid local government department.  But of course, the fun only begins.  All of the time and effort that you could’ve spent on having a functional volunteer or combination department can now be spent on lengthy political and legal battles over who gets the property from your department.

This story repeats itself over and over again, yet we don’t seem to learn.  The average volunteer emergency services provider is often their own worst enemy and the biggest reason why departments go “professional.”

And so it goes.

Cleared To Practice, AKA: The License To Kill

I booted up the computer fully intending to write a long screed, aka rant, on the issues currently facing Austin/Travis County EMS, its medical direction, and their relationship with the multiple county first responder agencies and their ability to provide EMT-Intermediate, oops Advanced EMT (showing my age) and paramedic level care.  I’ll still comment on that, but in terms of ATCEMS’s model being an example of one of two extremes of the EMS field training or credentialing process.

This cartoon/meme has been making its way around EMS social media and has popped up on my Facebook feed more than once already today.

Having been in EMS for roughly 14 years now, I’ve seen a variety of methods of providing field training.  They run the gamut from “here’s the keys” to “you’re repeating your paramedic clinicals with us for the next six months.”  As with anything in EMS, we run between two extremes and rarely find the “Goldilocks” point of being just right.

In some EMS systems, the FTO and credentialing process exists in name only.  At one unnamed EMS service, my official FTO process consisted of one ride with a field training officer for twelve hours.  Since I’d been off the truck for a while before starting there, I asked for more time before I even got that.  I got a shift before that where I was officially riding as a third crew member, until the paramedic FTO didn’t show up. Combine that with a chest pain call and the EMS director showing up on scene and asking if I was comfortable with taking the patient 40 miles and my field training process existed primarily on paper.  Of course, when you’re at a rural service that’s already short on staff, much less advanced providers, a field training process seems like a luxury that you can’t afford.  In my opinion, that’s a risk management nightmare.  When a clinical (or operational) failure happens — and it will, the discovery process that a lawyer will engage in will expose these shortcomings and present them to a jury of twelve citizens who couldn’t figure out how to get out of jury duty.

Then, there’s the other extreme.  Let’s take a large, unnamed third service EMS system that’s had an extensive process for bringing on new paramedics.  For many years, that process consisted of several months of a new hire academy then a field training process of several more months.  In short, the process to become a paramedic in this system became a virtual repeat of paramedic clinicals. Then a different medical director came in and decided that there were “too many paramedics” and required new hires to function at a modified EMT level for one to two years before being eligible to “promote” to paramedic.  Let’s now throw in the dozen or so fire departments in the county that provide EMS first response. Ever since before I got into EMS, this EMS system was unwilling to credential first responders above the EMT level. That’s their prerogative. But don’t say you’ll allow it and then make a process that’s so obtuse and arbitrary that it’s a virtual impossibility to credential. The previous medical directors and the department’s clinical management created this mess and they’ve now given the fire departments the rationale to create their own EMS programs. In fact, said county (cough, Travis County, cough) just created its own medical direction to give the county fire departments the ability to run their own paramedic first response program.  And that doesn’t even include two of the fire departments that have created their own paramedic-level ambulance service.

There’s a saying in the law that those who seek equitable relief must come to the table with “clean hands.”  In this case, I have to say that neither party have clean hands.  The EMS system wanted to be the sole provider of advanced life support in the name of “patient safety” and other benevolent sounding reasons for turf protection.  The various county fire departments want paramedic first response and in some cases, transport, to justify their budget and existence and to satisfy the various firefighter union locals that want their members to be an “all hazards department.” In short, to quote Mel Brooks as the governor in Blazing Saddles, “Sheriff murdered! Innocent women and children blown to bits! We’ve got to protect our phony-baloney jobs, gentlemen.” Fire codes have dramatically reduced the number of fires out there.  In Texas, many of the fire districts are funded by property taxes. Also in Texas, there’s a healthy skepticism of government and taxes.  Without EMS call volume, many citizens would wonder what they’re paying a fire department for.  Personally, I’d have much less heartache about the county’s decision to provide its own medical direction for the fire departments if this outcry for separate medical direction had been occurring for years, rather than over the last couple of years that have also been associated with the virtual elimination of volunteer response in the county and the addition of a second tax district in some of these fire districts to “support EMS.” If I feel for anyone, it’s the current medical direction of the EMS system.  They’re passionate about good medicine and supporting the practice of good prehospital medicine.  They’re also in the unenviable position of fixing a system that believed its own public relations for too long and had frayed, if not outright violated the trust of its supposed “partner” first response agencies.

So, what is the happy medium for field training and bringing on new people?  I don’t have studies or statistics to support my general concept of what works.  What I know doesn’t work is handing someone the keys to the controlled substances and saying “Good luck.”  But I’d also question the value of a lengthy process that is a virtual repeat of paramedic clinicals.  In theory, the certification exam for initial certification should provide some assurances of entry level competence. (That in itself is an argument for another day.)  In my ideal world, I’d argue for a field training and credentialing process that is competence based, rather than based on calendar days, clock hours, or getting a certain magic number of certain patient populations.  And in some cases, we’re rarely going to see certain patients in the field.  That means access to a skills lab and/or simulations and scenarios. The process should focus heavily on the unique clinical aspects of that particular EMS system, whether in regards to airway management, medications, or other uncommonly encountered interventions. The process also needs to focus on the operational aspects of being a provider in that system. How many of us haven’t been taught which channels/talkgroups are on our radios?  That, along with resupply, fueling, and documentation requirements often get overlooked in the FTO process. As much as we need to ensure clinical competence, we also need to ensure that a new medic (at any certification level) in the system knows what’s supposed to happen to make good patient care happen.  And let’s not even discuss transport destination determination, which is regularly overlooked.  Getting the right patients to the right hospitals is a core function of EMS and neither initial EMS education nor the processes to bring a new provider into an organization usually address this.  As a result, we routinely end up taking critically ill patients to hospitals incapable of caring for them.

I’ve ranted for a while and I appreciate the indulgence.  The short version is that, like much of EMS, field training and bringing new providers on board a system is a collection of bad practices and extremes. We can do better.  Both our profession and our patients (aka: customers) deserve it.

Do Something!

Late Sunday night, a madman killed people in Las Vegas.  Predictably, both sides have drawn their lines in the sand and demand that politicians “DO SOMETHING!”  Those on the left demand that politicians enact gun control and hector, cajole, shame, and belittle those who don’t believe as they do.  Conservatives argue that gun control doesn’t work and that the solution doesn’t include disarming the public.

In the spirit of full disclosure, I tend more toward the conservative view of things. I also have a Texas license to carry a firearm and do carry.  But I’m also a realist.  I doubt that a person carrying a handgun can stop a situation like in Las Vegas where a rifle is being shot from a high place at a large crowd.  Individual street crimes may be a different situation, but even in those cases, a “good guy with a gun” can only do so much.

So, we all want to “DO SOMETHING.” Here’s my opinion.  You can absolutely do something above and beyond “thoughts and prayers,” changing your profile picture on Facebook, or contacting your politicians for or against guns.  First things first. Learn some basic life-saving skills.  Learn CPR.  Learn basic first aid.  Learn bleeding control — including how to use a tourniquet.  And make sure you have current supplies at your home and/or in your car.  Some basic gauze, gloves, and a tourniquet can go a long way to make sure that a violent assault doesn’t become a homicide.  As an added bonus, your knowledge of CPR and first aid is valuable in other situations above and beyond shootings.  Car wrecks and sudden cardiac arrest kill just like a shooting — and a concealed firearm isn’t as useful in those situations. There are plenty of first aid and CPR classes out there.  If you can’t find one or have questions, feel free to ask me — or ask your local EMS organization.  You do know who your local EMS organization is, right?

Next.  You do need to contact your politicians.  But not necessarily about guns.  Ensure that your community has a well-funded EMS system and trauma facilities. Too many communities rely on the “low bidder” to provide 911 response.  Too many communities are holding bake sales so that their volunteer fire and EMS organizations can have the bare minimum equipment.  We can always have a debate about the role and scope of government and taxes.  However, all but the most radical anarchists or extreme libertarians would agree that a fundamental role of government is to send help when you call 911.  A high-quality EMS system is not a luxury.  Whether a car wreck, a mass shooting, or chest pain, the fact remains that early access to definitive care saves lives.  An Emergency Medical Services system does exactly that. For all of the comments on social media about so-called “First World Problems,” Americans should demand a quality EMS system that ensures access to clinically current, professionally delivered, compassionate medical care 24/7.

And if you still want to “DO SOMETHING,” consider getting training and volunteering.  The reality is that you might be near a volunteer fire or EMS department that needs people and just might even train you.  A basic first responder course is often less than 80 hours.

These are the steps you can take to “DO SOMETHING.”  Or you can keep changing your profile picture on Facebook.  The choice is yours.  Choose wisely.

Longhorn Student EMS

The University of Texas has decided not to provide insurance or legal protection to a student EMS group on campus.  Since this is my alma mater, I felt compelled to share my $0.02 with University of Texas President Gregory Fenves.  If you feel compelled to reach out, do so (and keep it polite).  He can be emailed at [email protected]

Dear President Fenves:

It’s rare that I find myself writing an email that hits multiple areas of who I am – a Texan, a Longhorn (BA 1996), an attorney, and a paramedic.  But the decision of the University to deny funding for Longhorn EMS’s liability insurance and/or assumption of liability hits home for me.

The University of Texas and the University of Texas System are blessed with many outstanding attorneys, both of counsel to the University and the System and throughout the faculty.  I would never take away from their counsel or guidance, but I would note to you that the liability for the provision of emergency medical services in Texas, especially by a governmental entity, is exceptionally limited. Texas Civil Practices and Remedies Codes §§74.151-74.154 and Texas Health and Safety Code §773.009 provide broad protection and multiple Texas appellate court decisions have broadened said liability protection.  As such, I would assert that the legal liability for the provision of emergency medical services, particularly at the EMT/basic life support level, is exceptionally limited and that the costs of any liability insurance would reflect such limited exposure. In short, this concern about legal liability on behalf of the University is a red herring at best.

University spokesperson Bird’s statements that the University wants students to be students and not to take on potentially dangerous professional responsibilities is, at best, ignorant of many students who are already certified as EMS personnel or might even be in the armed services.  Wanting students to be students first ignores that many students already are working including as employees of the University. Several UT students already work as emergency medical services providers in other venues even including as employees of the organizations that provide EMS coverage for University athletic events.  Additionally, many students of the University already volunteer in many campus organizations, several of which provide direct services for the University. And finally, there’s the eight hundred pound gorilla in the room that shatters the illusion that students should be only students – namely, men’s and women’s intercollegiate athletics. I am pretty certain that the time involved to become an emergency medical technician and remain active with a student EMS organization is a small commitment in comparison to the time that student athletes spend in service to the University.

From a public safety standpoint, having an on campus EMS system makes sense.  Even on an urban campus like the University, EMS response time takes time. The closest Austin Fire Department stations to campus, Station 2 on Martin Luther King, Jr. Boulevard and Station 3 on West 30th Street do not have ambulances.  The closest ambulance, if available for assignment, is Medic 3, located in the parking garage of the old Brackenridge Hospital.  At best, there is a delay in getting emergency care to campus.  Having responded to the University campus as an EMS provider, I can tell you that calls on campus are a challenge, especially in getting emergency resources to the right location because of the combination of obstacles in terms of vehicle access, determining the right location, and getting access/entry into University buildings, many of which are secured.  In a critical emergency such as cardiac arrest, severe allergic reaction, or uncontrolled bleeding, having a trained set of hands on scene sooner can, will, and does regularly make a significant difference in patient outcome.  In some cases, that difference in patient outcome is life as opposed to death.  Waiting for City of Austin resources and also waiting for someone from the University to provide access to a building just doesn’t make sense. And in case of a severe emergency or disaster, having “all hands on deck” and a force multiplier in the form of a University recognized and accredited group of EMS providers can and does make a difference.

The University has always encouraged public service.

As an undergraduate government major, my spirit of public service and engagement was encouraged and nourished by Dr. Janice May’s classes on state government and her public service internship program which gave me a foundation and prepared me for a career in state government. Especially as the University develops its own medical school and expands its involvement in all aspects of healthcare, encouraging a student volunteer EMS program is a no-brainer decision.  Encouraging students to volunteer and to become engaged in healthcare is, plain and simple, an outgrowth of the University’s mission to educate.  Such a program should be encouraged, not stopped. Many notable physicians and healthcare leaders got their first exposure to EMS, medicine, and volunteerism through campus EMS programs.

Texas A&M University has long had a student-run EMS.  In fact, Texas A&M University has student-run EMS for university events as well as a separate EMS program that provides paramedic-level ambulance coverage for the university campus as well as providing mutual aid backup coverage to the cities of Bryan and College Station.  Rice University has a student-run EMS program operating under the supervision and guidance of their campus police department. Rice’s EMS program operates as a campus first response organization, providing advanced EMT level care until the arrival of the Houston Fire Department’s ambulances. Colleges and universities throughout the United States have campus EMS organizations.  In fact, there’s even a National Collegiate Emergency Medical Services Foundation that exists to guide and promote campus EMS programs.  At the University of Texas, we are a “University of the first class,” as described by Article 7, Section 10 of the Texas Constitution.  More bluntly, to quote our former athletic director, DeLoss Dodds, “We are the Joneses.”  The University of Texas shouldn’t take a back seat to anyone. And that includes providing emergency medical services to the University community and its visitors.

Bluntly, the idea of a student EMS on the Forty Acres has grown in fits and starts.  Good intentions alone are nowhere near enough. And some of the attempts to provide this service have been, at times, amateurish. That is why it’s even more imperative for the University to recognize, fund, and support this effort, if for no other reason than to provide the resources of the University to supervise these students and ensure that what goes on with this organization is a credit to and not a harm to the University.

If I may offer my services to you, the University, or these students, I stand ready to do so – as a volunteer.  I am a Texas licensed attorney, a Texas licensed (and nationally registered) paramedic, a Texas EMS instructor, and a proud Texas Ex.

I encourage you to reconsider the University’s decision and strongly commend you to take steps to help this fledgling EMS program get the right start it needs.

Respectfully submitted (and Hook Em Horns!).


A Time To NOT Volunteer

If you know me or you’ve come by this blog a few times, you know I’m very passionate about the role of volunteers in the world of emergency services, particularly in the fire and EMS world.  Today marks a change.  One, I’m about to give some very broad, generic “free” legal advice.  Two, I’m about to tell you NOT to volunteer.

Event medical standbys. At least in Texas, those fall into a massive loophole where they’re not subject to any regulation from the state. In Texas, transport providers (officially called “EMS Providers”) and “first responder organizations” are subject to state regulatory requirements.  Because event medical standbys don’t fit into Texas’s definition of EMS Provider or First Responder Organization, they’re completely outside the purview of our state EMS regulatory system.

These events always say “BLS only” or “CPR/first aid” but seem to recruit heavily from the ranks of EMS providers. If they truly only want “BLS” or layperson aid, why are they recruiting so heavily from EMS?  Simple.  They want EMS providers on site, but they’ve gotten some legal or risk management advice to not call it an “EMS standby.”  They think that by saying it’s only first aid that their liability will somehow be limited.  Truth be told, I’m not sure if it would or wouldn’t be limited.  But I know this much from law school — anyone that can be sued will be sued, both collectively and individually.  While you may not end up being found liable, I can guarantee that will not protect you from either a suit or the lawyer’s bills to represent you.  (Speaking of which, you do have your own EMS liability insurance to protect you and provide for legal representation, don’t you?)

This is the closest you’ll ever get to free legal advice from me. Just say no. You’re unlikely covered by any medical direction or protocols, which begs the question of what you’re doing there and whether you’re practicing “medicine” or delivering EMS care. And if all they want is “BLS” or first aid, why are they asking you to be there by virtue of you holding an EMS certification? I’ve helped at these events before and it feels very odd to be there without the ability to function at your certification level, assuming they’ve even verified your certification.

In the very best case, you’re probably going to be poorly equipped.  You’re even more likely to be expected to supply your own gear. And I will virtually guarantee that if something bad happens, you will be on your own. The worst part? Many of these events are for profit. Those that aren’t are usually run by nonprofits that have plenty of money for everything besides real EMS coverage. Many of these so-called event medicine companies have a business model based on you being an “independent contractor,” meaning that they’ll throw you to the sharks and claim that they had no oversight of you.  In other words, helping some of these events out for free as a “volunteer” isn’t much better than offering to drive Lyft or Uber for free.

If you truly want to “feel good” by volunteering, get a t-shirt, and/or be thanked for your service, there’s probably a volunteer service within an hour’s drive of you that would actually benefit from your volunteer hours. To me, it’s really ironic is how many paid firefighters/EMTs jump at the chance to work at these events and then say how volunteering “holds back the profession” and artificially lowers salaries.  If that’s the case, then it’s high time that we tell each and every one of these large public events that they need to provide EMS coverage just like they have porta-potties, trash collection, food service, and security on site.

Charity Begins At Home

Recently, I’ve seen more than a few EMS types posting requests for crowdfunding for them to engage in medical work, either as a medical missionary or in solidarity with various protest movements.  I get it.  The urge to help others, especially in moments of extreme need, is a huge motivator for many of us in public safety or medicine. (And yes, that’s controversial right there.  EMS is a mix of public safety and medicine.  We use a public safety model to deliver medical care.  Prehospital care is what I like to call “operational medicine.”)

But, to me, asking for crowdfunding to subsidize your passion reeks of so much that I don’t like about EMS.  There’s a vocal portion of people in EMS who are all about “LOOK AT ME!  VALIDATE MY EXISTENCE!  I’M DOING SOMETHING NOBLE AND YOU SHOULD APPRECIATE ME!”  It’s so common throughout EMS, as we see with the t-shirt and bumper sticker brigade. I get it.  We want to help.  But it seems that, for a vocal portion of EMS providers, we only want to help when we’re getting attention. (Bonus points if you appeal to social justice and get subsidized for being a medical activist…)

Bluntly, if you’re having to get others to pay for your altruism, you probably aren’t in a financial situation to be taking the time off to travel to a faraway land, whether overseas or even in the USA. It’s, at best, highly irresponsible.

The honest-to-God (or insert your deity of choice) truth is that there’s plenty of places local to each of us without access to medical care.  Heck, there’s plenty of places within an hour’s distance of each of us that are probably lacking access to quality EMS care and would love to have a passionate, dedicated volunteer provider on board.

Way too many folks in EMS make fun of volunteers and claim that volunteers are responsible for poor EMS standards and low wages.  Yet way too many people in EMS volunteer — when it gets them attention and a partially funded trip out of town.

As the old saying goes, charity begins at home.  Find your local service or local medical organization where you can begin to address the lack of care locally.  Ok, rant over.

It’s Never About the Pay

Years ago, as a new attorney working in state government, I worked for a state agency that determined they had a problem retaining attorneys.  They did a lot of surveys, most of which revealed discontent with working conditions.  The reality was that management used junior attorneys as glorified paralegals and gave them little professional discretion and routinely micromanaged.  Of course, management did not want to hear this.  Instead, a new pay scale was issued, which gave everyone an immediate raise and also decreased the time before being eligible for the next promotion.  Management made the decision that it was easier (and possibly cheaper) to give everyone a raise than improve working conditions.  Needless to say, the retention improved, but only slightly.  At that point, I told one of my colleagues, “It’s never about the pay.  It’s about what people are willing to put up with for that pay.”  People know the salary when they accept a job.  What they don’t know is what the job is going to be like.

But my blog is (usually) about EMS and my EMS experiences.  What does this have to do with EMS?   Everything.  We routinely hear that there’s a shortage of EMS providers.  We regularly are inundated with stories about a shortage of volunteer EMS providers. There have been numerous committees studying the issue of a perceived shortage of providers.  Some states have done a terrible job of promoting becoming an EMT or paramedic.  The Pennsylvania “Roll With It” campaign comes to mind.

What remains is a shortage of EMS providers willing to put up with the working conditions made available to them at the salary offered.  And this is even more the case for EMS volunteers.  I will fully admit that as a volunteer medic, I will put up with relatively little BS in return for providing free paramedic care.

So, to those of you wondering where your volunteers are or why you aren’t keeping volunteers, I’ll ask you a few questions.

  1. How easy do you make it to volunteer?   Is your application online?  Do you have a point of contact?  Do you even have a webpage?
  2. How soon can you get people on shift?  Is the process tied up with committee meetings, orientations, and other obstacles?
  3. Do you provide the volunteer everything they need?  Or do you make them spend money out of pocket on uniforms?
  4. Do you have an open, transparent on-boarding and field training process?  Or does your training staff regularly play “hide the ball?”
  5. Do you truly make your volunteers part of the team?  Or do you make things difficult (even unintentionally) and say “we’re holding you to the same standards as everyone else?”
  6. Do you have some flexibility in the process?  Or do you rigidly refuse to deviate from your processes?
  7. Do you truly welcome new people?  Or do you have cliques and the “old guys” club at your station?
  8. Do you welcome those with prior experience? Or do you force them into a model of starting from scratch because your organization is “special?”
  9. Do you learn from previous issues?  Or do you act as if “this is the first time we’ve heard about this?”
  10. And finally, have you told your staff (both paid and volunteer) that they’re appreciated?  More importantly, do you back those words up with action?

There’s not a shortage of EMS volunteers.  I know many people with EMS certifications who’d like to get back on the truck.  The real shortage is the number of EMS organizations that truly want and appreciate providers, whether paid or volunteer.

I’m baaaack

After some technical difficulties and some writer’s block, the blog is back up and I’m back.  I’m thinking of some EMS topics to inspire me.  For those of you who’d like to hear me live, in person, I’ll be speaking at the Texas EMS Conference in Dallas.  More to come — and glad to be back.

Things that make no sense in EMS

1) EMTs and paramedics are constantly told “We don’t want you to know how billing works because we don’t want you to let finances influence a decision to transport a patient.”  Makes sense.  But then we’re told, “If you don’t document this chart correctly, we can’t bill for it.”  So, are we supposed to have an understanding of billing or not?   Personally, I wouldn’t mind a better understanding of billing and reimbursement.

2) When a volunteer service fails, we hear the advocates for paid EMS argue that a community gets the EMS that it pays for.  Exactly.  Please remember that same maxim when a private operator argues that they can provide EMS service to a community for free or a very small subsidy.  These operators will continue to make money by scrimping on pay, minimal equipment, minimum staffing, lowest common denominator protocols, and posting crews at street corners.   And with these working conditions and/or wages, the community will get the kind of EMTs and paramedics they’ve paid for.

3) Final thought from someone who volunteers.  We hear about the death of volunteer EMS.  Sadly, I’m afraid that day may be closer at hand.  But I also think that there’s a place for volunteers still, even if just to supplement staffing and coverage.   All it would take is some organizational commitment and flexibility.  My question is whether we’re really losing volunteers or whether we’re losing organizations that accept volunteers.  Around my neck of the woods, it’s the organizations that don’t want volunteers….

On volunteering

A couple of the EMS websites have been talking about the lack of volunteers in EMS these days.  Each of them cite different matters as to why EMS volunteerism is on the decline.  Most cite either declining community involvement or the ever-so-popular red herring of “increased educational requirements.”  Several years ago, I wrote a piece on developing a volunteer program in EMS systems, especially those that are combination paid and volunteer staffing.  Since no one ever picked it up for publication, I present it here as discussion fodder for the dirty unwashed masses of the Internet.



Ever since Benjamin Franklin founded the first volunteer fire department in 1736 (the Union Fire Company), the United States has had a long, illustrious history of volunteers in public safety, whether volunteer firefighters, volunteer EMS providers, or even volunteer (or reserve) law enforcement officers.

However, as time has progressed, many organizations that started out as exclusively volunteer have since progressed to either a fully paid department or a department that has volunteers in name only.

I’ve had the privilege to work primarily as a volunteer in EMS, mostly because I’m employed in a profession outside of emergency medicine that I’m unwilling to give up. (Honestly, with as much as I didn’t enjoy taking the bar exam twice, I’m loathe to give up being an attorney for a full-time career as a paramedic!) I’ve had a variety of experiences in volunteer organizations, ranging from being “merely” a field provider (both at the EMT and EMT-P levels) to coordinating a volunteer program and serving on the board of directors of a fire department.

In my opinion, it’s actually easier to start or reinvigorate a volunteer program for EMS than it is for the fire service or law enforcement.   While in some states, there are different training and certification requirements for volunteer firefighters or reserve peace officers, the certification standards for EMS providers are almost invariably the same, whether you are full-time, part-time, or volunteer.

Justifications for Volunteer Programs

There are many reasons to have a volunteer program within your EMS organization, even if you’re primarily a career department.   The first is quite simple – additional manpower. Whether it’s staffing an additional crew member on each truck to assist with patient care or putting up additional ambulances during a disaster or peak volume event, volunteers provide a cost-effective way to supplement your career staff.

Additionally, volunteer programs can help control overtime costs and provide coverage for special events. One of my proudest accomplishments as the volunteer coordinator of an EMS agency was in ensuring that our volunteer providers staffed a PGA golf tournament held in our service area. Previously, our organization relied on our paid staff to cover this event, usually resulting in significant overtime expenses. With a lot of cajoling, coaxing, and some begging, the 2011 event was covered almost exclusively with volunteers aside from a few advanced life support positions covered with management/administrative staff who modified their work schedules for that week.

Almost the exact opposite story happened during the 2011 wildfires around Austin, Texas. Over the years, the other fire departments in Travis County surrounding Austin have transitioned from being almost exclusively volunteer to being small paid departments with relatively small (3-4 firefighters) duty crews staffing each apparatus.   The presumption has always been that, in a major incident, each department would provide mutual aid to the other. Over the past few years, most of these county departments had allowed their volunteer programs to dwindle to a few members, if not completely disappear. When the fires hit the Austin area (the Bastrop County fires, the Spicewood and Steiner Ranch fires in western Travis County, as well as several fires in nearby Williamson County), the majority of the surrounding fire departments were completely taxed for resources, with mutual aid resources coming from all over the state, including the Houston and Dallas areas. In fact, in Travis County, most EMS calls no longer received basic life support first response from the fire department. Of course, in a disaster such as this, it’s extremely unlikely that the event can be managed exclusively with local personnel. Regardless though, the ability to supplement local responders with volunteers, even for covering BLS EMS first response or firefighter rehab and scene logistics would have alleviated some of the manpower issues, freeing up firefighters for front-line duty.

Another possible role for volunteers is to expand your organization’s services. Volunteer providers can be an invaluable resource for covering public relations and community outreach events that might not otherwise be able to be covered. Additionally, volunteers can serve a crucial role in an EMS organization’s education programs, whether serving as “patients” in simulations, helping with skills practice and examinations, or even serving as instructors, provided they have the required qualifications. In fact, by conducting CPR or EMS courses, some of your volunteers may progress from saving your department money to actually making money!

And in more than organization I’ve been affiliated with, the volunteer program often serves as a ready-made hiring pool. A volunteer program allows for you to hire paid from a group of providers who are already within the organization and have at least been somewhat oriented to the organization. Additionally, for those volunteers who joined looking for a paid position, hiring from within serves as a motivation to stay active and involved.

Motivations of Volunteers

Based on my years in both fire and EMS departments as a volunteer, I’ve found that most volunteers fall into one of three categories. First, there are those volunteers who are volunteering as a way to get experience and/or a foothold to apply for a full-time paid position. Second, there are those volunteers who just enjoy EMS (or the fire service) and want to stay active and involved despite having a career other than being an EMS provider or firefighter. Finally, there are those volunteers who are community-minded and just want to volunteer with an organization. Some of these volunteers would be equally likely to join another community organization if they weren’t involved with EMS.

Particularly for younger (whether in age or experience) EMS providers, a volunteer EMS position is almost like an internship. It gives them the opportunity to gain experience and find out if EMS is right for them. These volunteers should be encouraged to ride with crews who set good examples to emulate. Also, since these volunteers aren’t yet on the payroll, take the time to expose them to other aspects of your EMS organization. When I was a volunteer coordinator, I often encouraged these new volunteers to spend part of a shift observing the communications center, riding with a critical care team to observe that aspect of EMS operations, or riding with a supervisor to expose them to high acuity patients. (In the service that I served as volunteer coordinator with, supervisors were automatically assigned to respond to certain high acuity calls including cardiac arrest, high mechanism collisions, and shootings.)

Occasionally, there are just some volunteers who just enjoy EMS (or the fire service) despite having another career. Some of these people are former full-time providers and some are just people who got “bit by the bug” and want to volunteer. These volunteers often end up as the core of your volunteer program. Since EMS is an avocation to them, they are often passionate about EMS and go above and beyond to be involved with the organization, particularly in acquiring additional certifications and skills.

The community-minded volunteer can be a challenge to develop. Many of these volunteers primarily pursue lower-level certifications. My experience is that some of these volunteers are less interested in the patient care aspect of EMS operations and much more interested in the management, financial, and community service/public outreach aspects of the organization.

One other subset of volunteers exists, especially in college towns. Some people volunteer in EMS in the hopes that volunteering as an EMT will help their chances of being admitted to medical school or some other graduate education in healthcare. These volunteers often run the gamut from enthusiastic participants in patient care to being little more than uniformed ride-alongs. My experience is that the unmotivated of these volunteers often end up leaving shortly due to the time commitments that most organizations require of their volunteers. Having said that though, some of these volunteers may end up our future medical directors and as such, it probably benefits us to mentor them as much as possible and present as positive of a view of EMS as we can.

Perils and Pitfalls

One of the biggest issues that I’ve experienced is that some career personnel see the volunteers as a threat to their position. The easiest way to address this issue is to remember that, for most organizations, volunteers may be supplementing current resources. For example, at both Harris County Emergency Corps and Cypress Creek EMS, the overwhelming majority of volunteer EMS providers ride as a third crew member to assist in patient care. Both of these organizations take care to ensure that volunteers who wish to work as the second or primary crew member go through the exact same field training processes that paid providers do. It has been my experience that, in most cases, the paid staff often enjoys having a third crew member to assist with patient care, particularly with critical or multiple patients. Also, check with your crews to find out which of them enjoy having a third crew member to ride with them. One of the surest ways to run off or discourage a volunteer is to have them with a crew that doesn’t want them.  In other organizations, there can be a rush to put these new volunteers into a field training program to “clear” them to independent duty, which may discourage newer volunteers who might still want the “safety net” of being able to ride as a third crew member.

Scheduling can be another pitfall. At one department I volunteered with, there was no organized schedule for volunteers on the fire crew. Several days could go by with no volunteers at the station and then, particularly on weekends, more personnel would show up than could staff the first-out rig(s). An online/web-based schedule is an absolute must for a volunteer program. My personal experience is that such a schedule is most successful when a volunteer can sign up for the shifts on their own, even at the last minute. Additionally, until new volunteers get a feel for which crews they work well with, I encouraged volunteers to ask me if they needed recommendations on crews to ride with.

One of the biggest pitfalls I’ve observed in my experience is the lowered expectations that so many career staff have for volunteers. It rapidly becomes a self-fulfilling prophecy. One must remind some volunteers occasionally that the same expectations exist regardless of payroll status as the certification status makes no differentiation. Volunteers should be expected, not encouraged, to participate in all aspects of EMS operations, including cleaning and restocking the truck.

A potential pitfall also exists with a lack of organizational support or buy-in. In some organizations, even with management’s support, the lack of buy-in from support staff can cause problems for the volunteer program as well as for the individual volunteer. These issues can range from getting uniforms issued, getting the new volunteer access to the various technology resources (electronic PCR, online scheduling, email, etc.), or even training requirements. If the senior/executive management is supportive of the volunteer program, a discreet conversation with them may alleviate the problem. For organizations that are fortunate enough to designate one person as the volunteer coordinator, the individual volunteer will experience less of this problem as the volunteer coordinator will be the interface between the individual volunteer and the organization’s support/staff functions.

Another issue arises when the volunteer coordinator is given the responsibility to develop the program but does not necessarily have the authority to manage the program. This issue may create difficulties with managing problem volunteers. When I first coordinated the volunteer program at one department, I was the point of contact, but did not have the ability to manage or discipline volunteers. After several instances of discussing problems with management as well as instances where there was no clearly identified person to “solve” a problem at that moment, I gradually received the authority to supervise and discipline volunteers. This is crucial if the volunteers are to truly see the volunteer coordinator as THE point of contact for the volunteer program.

Making it Work

I’ve found that the key to making a volunteer program work is flexibility. As I’ve commented more than once to other medics and to management, “It’s not as if you were paying these people to come in anyway.” In other words, you may need to work with your volunteers on a variety of issues.

At times, some volunteers, particularly those enrolled in school, may need to take time off. My philosophy when serving as a volunteer coordinator was that I would never drop a volunteer from the roster so long as they kept me updated as to their intentions.

The other absolutely essential ingredient to a successful volunteer program is to designate one person as the volunteer coordinator. The volunteer coordinator should be both a single point of contact for volunteers as well as the organization’s internal advocate for the volunteer program.

In order to get volunteers “addicted” to the organization, it’s important to be able to get the volunteer out in the field while they are still eager after submitting their application. Departments that require an orientation class and/or significant probationary time prior to being able to go out in the field often lose volunteers. My greatest successes as a volunteer coordinator came when I was able to minimize the time between getting an application in and getting the newbie in the field. I accomplished this by placing much of the volunteer orientation material in an electronic format to send to the volunteer rather than making them attend an orientation class on a specific day. In fact, on more than one occasion, a motivated new volunteer could be on an ambulance as a third crew member in less than a week. In addition to the required topics such as equal opportunity, blood borne pathogens, and HIPAA training, you should consider some operational matters such as equipment familiarization as part of the orientation as many volunteers may be completely new to EMS aside from their initial education which provided limited education as to EMS operations and almost certainly did not orient the volunteer provider to your organization’s operations in particular. When the volunteer rides as a third crew member supplementing the regular, the pitfalls of a “new guy” on the ambulance are somewhat lessened and the volunteer can benefit from the crew’s mentorship.

Another tip to operating a successful volunteer program is to find out what interests the volunteer. Never assume that the volunteer only wants to be a field provider. This means that your volunteer application should go well beyond asking for basic demographic information and certification verification. In my experience, the volunteer application should inquire as to the prospective volunteer’s other EMS training and certifications as well as their interests in the organization and any outside skills or hobbies. As a volunteer coordinator, I was fortunate enough to have one volunteer in particular who was absolutely overjoyed to cover public relations events, particularly for children. While she was an acceptable field provider, she really shined in the community education role, which ended up being much more of a service to the department. I’ve also had other volunteers who were certified as instructors in various EMS disciplines. Several of these volunteers became excellent instructors and even brought new training opportunities to the organization. Two of my volunteers were also photographers who we relied upon for public relations and training photos. Some of the best advice I remember about using volunteers came from Chief Buddy Crain, the chief of CE-Bar Volunteer Fire Department near Austin, who told me that he could almost always find a use for anyone who wanted to volunteer with his department.

Chief Crain also gave me an additional piece of advice that I strove to live by when I coordinated a volunteer program, namely that it should not cost anyone to volunteer. Chief Crain, being the chief of a well-funded department, was often able to “spoil” his volunteers with a variety of uniforms, personally issued medical bags, radios, pagers, and opportunities to attend outside continuing education. Regardless of funding, volunteers should not have to expend their personal funds for their basic uniforms and equipment. And if funding permits, additional uniform items such as jackets or the opportunity to attend outside educational offerings serve as excellent tokens of thanks to valued volunteers who continue to contribute to the organization. One organization that I’ve been involved with both at the EMT and paramedic levels provides a small gas stipend to its volunteers, most of who come from nearby communities.

Recruiting is crucial in maintaining a volunteer base. Most organizations currently maintain a web presence which may include a volunteer recruiting aspect. In this current age of social media, outreach via Facebook or YouTube may be particularly helpful in reaching the younger or more technologically savvy potential volunteer.   Organizations that I’ve been involved with have also found college-based EMS education programs a ready source of volunteers. Many of the students in the paramedic programs are ready and eager to get 911 EMS experience while still in school once they get their EMT-B certification. However, the best source of new volunteers almost always comes from current, happy volunteers. Just like in any business endeavor, word of mouth is still the most powerful advertisement for any organization.

And once you get your volunteer core developed, it’s time to recognize your superstars for their hard work as best as you can. Of course, volunteers don’t typically get financial compensation, but there are other ways to provide recognition. As previously discussed, some volunteers begin volunteering as a way to get a foot in the door for a paid career. If these volunteers perform well, the easiest reward is to transition them to a paid position. Other volunteers can be recognized at department awards events and banquets. In fact, I’ve seen more than one department that offers a “volunteer of the year” award, often with a plaque, small gift, and perhaps a medal/ribbon to wear on their uniform. Other volunteers who regularly contribute to their organizations can be recognized inexpensively with new titles and responsibilities. For instance, a volunteer medic who has covered many of the organization’s public relations events could become the community relations coordinator. In other departments, I’ve seen volunteers promoted into officer ranks such as lieutenant, captain, or shift captain. In my own experience at one department, I was given the opportunity to go through the field training process to transition from being a third crew member to being part of a two person crew. (Credentialing several volunteers to work as part of a two person crew or even to function solely as a driver ended up saving the department significant overtime costs.)


In short, it is more than possible for a combination department to continue to succeed with a volunteer program. A successful volunteer program provides additional resources to any department, whether in providing its core services to the public or providing services above and beyond what the department could provide with its paid staff.  Organizational commitment and a willingness to be flexible will help an organization recruit and retain volunteers who end up being more than just ride-alongs wearing the same uniform.