I would argue the communication link between Emergency Medical Service (hereafter EMS) providers and patients is not a topic that garners a great deal of formal attention. Academically, EMS providers are taught about the various forms of consent, how to best communicate with those who have hearing impairments, the polar ends of the aged (the very young and the very old), as well as tips and tricks to overcome a plethora of language barriers experienced in the field.

Formal education in the field of emergency services is often brief and focused.  There is an overwhelming need to educate individuals who are entering the this field across a broad array topics so they may assess and rapidly act upon foundational knowledge.   The implicit understanding is that true skill development will be subsequently expanded and refined through field training and experience.

If a department has a strong continuing education program, EMS providers may obtain some formalized training related patient consent or improved report writing.  This training often falls under two categories.  While valid and justifiable, I believe EMS providers are missing a critical opportunity.

  • Legal based training focuses on protecting the agency and provider from liability if and when a patient refuses care before later experiencing further medical complications. This lens tells providers which “boxes” must to be checked to safely allow a patient to refuse medical care.
  • Financial based training (often offered by EMS billing companies) focus on teaching providers key words to document within patient narratives to satisfy the “medically necessity treatment” threshold to improve the likelihood that insurance companies will pay subsequent claims ultimately generating operational revenue.

Placing patient care as the primary focus of an EMS agency should mean both tasks would be inherently accomplished.  However, we need to apply a medical lens rather than a traditional prescriptive problem/solution focus upon our practice of emergency medicine.

Upon reviewing research related to the link between overall positive patient outcomes in the presence of effective physician communication skills (Ha, Anat, & Longnecker, 2010; King & Hoppe, 2013; Rodin, et al., 2009), I am quite interested in formally studying this matter further.  Rapid patient care occurs in Emergency Departments nationwide, however a team of providers and established systems exist within a structured environment which helps support achieving such lofty goals.  Robust structured systems afford the opportunity for checks and balances, luxuries that are simply not possible in a dynamic field-based environment.  However we don’t know what we don’t know at this point.

Now, make no mistake.  EMS personnel are trained to deliver excellent emergent medical care, and they do so quite well- each and every day.  These providers operate within streamlined decision processes and protocols, using equipment that is arranged for rapid access by personnel who instinctively (muscle memory) know where to find supplies, often without ever taking their eyes off their patient.  Well operating EMS services are highly structured.  Crews often work seamlessly while one provider is gathering patient histories while forming an initial assessment, as the partner is actively taking steps to implement a care plan.  The assessment is rapid and focused, just as it should be.  Providers are trained to navigate through the noise of the environment (figurative and literal) and circumstances to get to the important aspects of whatever is occurring or contributing to the situation.  Further, EMS protocols are designed with the express intent to limit harm with the complete realization and acknowledgement, that information is limited and constraints do exist.  Care is provided in transit where advance skills take over upon arrival at emergency rooms.

But there is more to consider.

  • EMS providers operate in formal positions of authority innately granted by a public who ascribes personal liberty to responders based on tradition, respect, and trust.
  • Implied authority exists.  EMS is commonly provided and often delivered through a fire-based system where various statutory authority empowers public safety providers in ways no other caregiver is.  Additionally, EMS providers operate alongside law enforcement.  First responders are often categorized as Type-A personalities because the nature of the job attracts individuals who take charge and take action.  These characteristics are necessary as providers must rapidly select among a variety of options and rapidly implement necessary actions for the preservation of safety and security of both the public and responder.

A sober assessment of current practice can bring about positive change.  For example, permission to administer care is often assumed.  The rational exists that since the individual called 911, that person has made a determination that an emergency exits, and they want to go to the hospital.  The entire system is set up to provide emergent care and transport the patient rapidly to the hospital.  In an effort to provide swift care and save time, it is my experience that EMS providers infrequently offer an explanation of what they are doing as they are doing it, or more often the explanation lags just behind the care that was just immediately provided.

The example above offers an opportunity to explore how the patient-provider relationship could be enhanced within the emergency setting.

  • Studies by King & Hoppe (2013) and others have found that physician providers overestimate their ability to effectively communicate with their patients. Further, poor communication or the inability to overcome communication barriers leads to negative patient satisfaction or improper diagnosis, leaving patients frustrated and possibly grieved (Ha, Anat, & Longnecker, 2010).
  • Research shows that patients desire a setting where they are informed, and able to participate in the decisions that impact their personal health and well-being (King & Hoppe, 2013).
  • Additionally, physician providers who do not, or are unable to connect with their patients demonstrate low levels of empathy which often causes the patient greater distress or distrust (Ha, Anat, & Longnecker, 2010).  The presence of physician respect enhances patient outcomes and stabilizes patient emotions (Flickinger, et al., 2001).

With over 25 years providing emergency medical care, I have little doubt that these same principles and practices would positively affect patient and EMS provider relations as well.  One cannot assume that such connections are similar or significant.  Therefore, a formal study of this matter is warranted.  As indicated above, significant differences exist in the field compared to the controlled environment found in the emergency room, further justifying the need for formal study to effectively quantify and qualify each.

Works Cited

Flickinger, T. E., Saha, S., Roter, D., Korthuis, P. T., Sharp, V., Cohn, J., . . . Beach, M. C. (2001). Respecting patients is associated with more patient-centered communication behaviors in clinical encounters. Patient Educ Couns, 250-255.

Ha, J. F., Anat, D. S., & Longnecker, N. (2010). Doctor-patient communication: A review. The Ochsner Journal, 10:38-43.

King, A., & Hoppe, R. B. (2013). “Best practice” for patient-centered communication: A narrative review. Journal of Graduate Medical Education, 385-393.

Rodin, G., Zimmermann, C., Mayer, C., Howell, D., Katz, M., Sussman, J., . . . Brouwers, M. (2009). Clinician-patient communication: Evidence-based recommendations to guide practice in cancer. Current Oncology, 42-49.

The traditional image of firefighters sitting around the firehouse playing cards while waiting for fire to break-out is far from reality.  The fire service has been in a state of constant evolution for several decades.  Often, local fire departments specialize in Hazardous Materials, Vehicle Extrication, Specialized Rescue (including disciplines in High-Low Angle Rope, Confined Space, Emergency Building and Shoring, Swift-Water, Trench), Terrorism and Weapons of Mass Destruction (Chemical, Biological, Radiological, Nuclear & Explosive), National Incident Management Systems, Emergency Medical Services (ranging from first-responder, to treatment & transport of the sick and injured), Plan Review and Code-Enforcement, just to name a few.  All of this is taking place in an environment where the professionalism of the fire service is evolving as education advances from certifications to commonly including degrees ranging from Associates to Doctorates.

A leading industry safety-advocate recently approached me with a perplexing observation.  In her experience, she has noted a decreasing interest in Ohio’s fire service to commit both personnel and financial resources toward fire prevention efforts.  A recent call by the Butler County Sheriff (OH) to end school fire drills in the wake of the Parkland Florida school shooting would seem to support her theory.

A wave of anecdotal answers came to mind.  It is increasingly difficult to recruit personnel to this profession.  A tightening job market, a variety of recruiting practices and misaligned selection strategies are not connecting with a generation that lacks service-oriented childhood values (Neal, 2017).  Regionally, staffing issues are complicated by increasing mandated continuing educations requirements, and retirements.  Additionally, organizations have become overly reliant upon a workforce that shares the same employee among multiple jurisdictions.  Notably, wavering public opinion toward public safety forces, including firefighters and emergency medical technicians & paramedics, who now find themselves increasingly on the front lines of significantly violent scenes, which include hostile offenders targeting providers further complicate these issues.  Finally, a rapid rise in substance abuse call volumes only further complicates many other complex challenges facing our field.

The question is fair.  Can departments legitimately focus limited time and resources on fire prevention initiatives in this crowded environment?

Traditionally, many fire departments combine fire prevention activities and public education campaign efforts.  Such programs include firefighters visiting schools dawning full-personal protective gear in the classroom, door-to-door smoke detector campaigns, and in some areas of the country- efforts to maintain fire-breaks by increasing the distance between brush and structures in the zone known as the wildland-urban interface.  The synergistic relationship among these fields helps public safety advocates increase community awareness of hazardous conditions that can lead to property loss, injury, and death.  The range of consequences from a local emergency up to and including devastation ensuing from wide-spread disaster always results in the expenditure of public funds and commitment of limited public resources.

Community Risk Reduction (CRR) is a, “process to identify and prioritize local risk, followed by the integrated and strategic investment of resources (emergency response and prevention) to reduce their occurrence and impact.”  Thanks to funding supplied by FEMA’s Assistance to Firefighters Grant, I was honored to attend Vision 20/20: National Strategies for Fire Loss Prevention as one of two state representatives for Ohio.  A decade in the making, the 2018 gathering of nearly 350 participants was the fifth biannual gathering of safety professionals from across the United States, and a limited but growing international audience.

Symposium highlights include a collaborative advocacy toward coordinated national strategies for fire prevention initiatives.  Messaging in a crowded, instantaneous, communication and social network rich environment is challenging at best.  Public entities lack the necessary resources and expertise to develop and market-test fire safety messaging, let alone track and measure locally derived results from such efforts.  Additionally, emerging technology is rapidly changing the consumers ability to detect (NEST Protect), suppress (residential water mist systems) and prevent fires with fires using emerging technology and through code changes that can often prevent fires from occurring (UL 858 Standard for Household Electric Ranges).

Fire prevention is a legitimate and worthy commitment of scarce resources.

The Community Risk Assessment Guide is a free online resource that will help fire departments and other organizations launch their CRR planning efforts.  Additionally, resources from all previous symposiums are available on the Vision 20/20 website found at StrategicFire.Org. While staffing and funding challenges cannot be ignored, without the voice of local public safety advocates, changing the behaviors of the public will not be possible.

Change is difficult in the fire service, but fire prevention efforts must evolve to meet the new reality facing the community.  Aggregate data is no longer sufficient nor is it impressive.  The most direct way to achieving successful funding (public levy support and grant justification) is to quantify and communicate local need.  Citizens and local leaders alike deserve equal consideration.

Vision 2020 Logo

The point of Vision 20/20 and CRR is to Prevent the Next 911 Call from occurring.  To achieve this lofty goal, one must first understand the local problems and hazards that exist.  While over two-thirds of fire departments are collecting and reporting data to the United States Fire Administration (National Fire Data Center, 2017, p. 4), the resulting national database is largely ignored by local fire departments.  Data collected via the National Fire Incident Reporting System (NFIRS) and stored by the USFA is available for download.  However, there are challenges that explain why many departments are unable to utilize what is the largest data set of fires in the world.  Because reporting is technically voluntarily with few exceptions, the data set is not complete; nor is the data randomly collected since some states mandate reporting.  Therefore, analysis is not straightforward.  Consequently, fire professional instead rely on national statistics compiled, analyzed, and projected by organizations such as the NFPA, NIST, UL and others.  Additionally, there are many limitations of NFIRS data.  This reality limits a local fire department’s ability to make local connections that are meaningful.  Aggregate data in this manner does not assist nor allow local leaders to make necessary comparative assessments and decisions.

While data may be king, local data is emperor.

National database repositories are not capable of providing specific information about a local fire problem.  Data analysis initiatives targeting this this gap are underway.

  • The National Fire Operations Reporting System (NFORS) is a fire service analytical system that provides real-time information to fire service leaders. NFORS works to optimize fire operations, reduce injury and death of firefighters and citizens while attempting to minimize property loss.
  • Fire Cares identifies risks, analyzes performance, and establishes a ‘Safe Grade’ in a Dashboard environment while providing comparative data based on similar sized fire departments ability to deploy resources that match a specific community’s risk.
  • The National Fire Protection Association (NFPA) is also working to address this challenge by developing a National Fire Data System. Paired with an extensive resource catalog based on NFPA codes and supporting evidence-based decision making, this system hopes to provide an added layer of analysis not otherwise available.  This system is still in development.
  • Finally, the Integrated Reporting of Wildland-Fire Information provides ‘end-to-end’ fire reporting capabilities by reducing redundant data entry, improving data consistency, accuracy and availability.

What is the payoff?

Measurable results will occur when local authorities take steps to address a problem which they truly understand.  Collaboratively working with partners to implement solutions provide new opportunities for funding sources that enable new approaches that reduce overall demand of the fire service.  Or, put another way, achieved the goal of a person not needing to call 911.

Calls for service that do not occur in the first place have cascading beneficial effects.  For example:

  • A call that did not occur means a crew and apparatus are not exposed to the hazards of emergency driving and response on public streets.
  • Less stress on the responder can result in improved overall health.
  • Rested responders who are less fatigued (resulting from fewer interruptions of rest periods) can think more clearly, thus enhancing situational awareness and overall safety.
  • Reduced incidents lower operational costs to the community, enabling a shift from reactive response to proactive planning and prevention.
  • Exposure to products of combustion are increasing the risk of some cancers to firefighters.
  • Fires often bring injury and occasionally death to citizens and responders. Consequently, these types of calls have lasting impacts upon responders, and the community.

Prevention activities, such as CRR, is the one true way to limit any, if not many, of these negative outcomes.

For too long, fire service personnel have said that it is not possible to measure the results of fire prevention activities.  This simply is not accurate.  The information is before us.  The missing component is developing a mitigation strategy aimed at changing the undesired outcome, implementing the initiative, and then measuring the results within defined parameters of the study.

Technology is infiltrating all aspects of the fire service.  It is time that emergency service leaders measure and implement necessary programs, such as the Community Risk Reduction programs, to reduce and end the threats to our community and responders.  Existing fire department personnel may not be best equipped to take on this new role.  Changing business practices, exploring new opportunities with individuals who have different skillsets, and an eye toward data collection and analysis is part of the missing key to success.  Many of the presenters who participated in Vision 20/20 have demonstrated success with this approach is possible.  I argue, the model is replicable.

Works Cited
National Fire Data Center. (2017). Review and assessment of data quality in the National Fire Incident Reporting System. Emmitsburg: U.S. Fire Administration.

Neal, S. F. (2017). Millennials in the fire service: the effectiveness of fire service recruiting, testing, and retention. Monterey: Calhoun: The NPS Institutional Archive.

Jonathan M. Westendorf holds an MPA from the University of Southern California, Sol Price School of Public Policy and a BS in Fire Administration from BGSU.  He serves as Chief of Fire & EMS for the City of Franklin (OH) since Sept. 2000, is the current 2nd Vice-President of the Ohio Fire Chiefs’ Association and Chair of the Legislative Committee. Westendorf is the founder of WestPolicy.com and teaches undergraduate fire science, emergency management and communication courses for the University of Cincinnati in addition to being an active member in various regional collaborative initiatives.


Dinoland in Disney’s Animal Kingdom has a distinct feel that differs from other themed portions of the massive resort.  Known the world over for excellence, the Walt Disney Company provides unparalleled experiences to their guests, obsessing over the tiniest of details.  Imagine my surprise upon entering this section of the park that looks and feels like a local street carnival.  What catches your eye first?


How different does this scene look from your local parking lots?  Does anything stand out?  For me, the crack filled blacktop with faded striping was absolute theming perfection.  This effect carries through into the queue lines where most would never even consider looking.  It was so well done, I wasn’t convinced that this area wasn’t simply repurposed.  I’ve been assured by some longtime cast member ‘experts’, it wasn’t.

Attention to detail- so perfect that I am sure it goes virtually unnoticed.  There is a team out there who planned details such as these, and it is likely they wondered if the extra effort would be noticed, or appreciated.

The Pew Research Center reports that trust in public government is near historic lows.  The news isn’t all bad as a 2014 Gallop Survey reveals local government retains a much higher degree of public confidence (72% approval).  We each have a role to play in reversing these trends.

When have you ever known someone to complain about excellence?  As in life, negatives are more noticeable and provide fodder for citizen discussion.  Excellence often goes completely unnoticed, much like the parking lot in Dinoland.  Residents will notice a smooth ride to work only briefly following the repair of a much needed, and perhaps long neglected road damaged by seasonal changes or untold numbers of underground utility repairs.

I have adopted the motto ‘Striving for Excellence’ and placed it on each of the responding fire and EMS apparatus within my organization.  Intended to serve as a subtle reminder, each firefighter and paramedic has a role to play in our organizational commitment.  Likewise, the community should expect that we uphold this promise to them.  Find ways to build confidence by maintaining community trust.  Faithful provision of governmental services that are both consistent and compassionate will result in citizen confidence.  Citizen satisfaction should be just as important as consumer loyalty is to Disney executives.

There is a balance, and your citizens must be involved in assisting government leaders in striking it.  The opposing side of the scale is, of course, available fiscal resources.  The fulcrum must be adjusted as you incrementally raise the bar and the community increases the investment placed in the various divisions and departments benefiting the citizens.  Involve formal and informal organizational leadership in concert with community organizations and representatives.  Solve organizational problems by focusing on obvious pain points.  Find the ‘easy’ wins and build upon them.

Excellence is universally recognized.  Only those keenly focused will notice the subtle details.  Certainly the measures vary and the expectations differ, but good governance deserves just as much attention to detail, as Disney has invested in recreating a community festival- and all of the pleasant values of community that this theme park relies upon recreating.