Leadership Mindset with an Emphasis in EMS, Part Three

First responders at a crash scene.
Photo/National Highway Traffic Safety Administration

Editor’s note: This is part two of a three-part series by Dustin Axtell on what successful leadership can be in EMS. You can read part one here and part two here.

Core Values of Leadership

Identifying core values of leadership is difficult, although some common descriptors include charisma, selflessness, compassion and integrity. Core values, commonly found amongst leaders, should not be held to specific standards. Organizations need to define what makes up a good leader and cultivate employees who exhibit these traits. A few underlining themes continue to appear no matter the topic, the leader or the information.

Leaders are not superhuman people with unobtainable talent. Leaders deal with the same struggles all people face; nevertheless, they have the expertise to tap into natural abilities and work extremely hard to realize their goals. The pillars of EMS leadership consist of trust, transparency and communication. These values, through research, identify successful leadership in addition to themes realized through personal experience.


Trust is the most coveted value a leader should emote not only because it’s a pillar to leadership, but it’s essential to realize that trust creates safety. Trust is defined as “assured reliance on the character, ability, strength or truth of someone or something. One in which confidence is placed.”1

Without trust, relationships cannot be forged. If a leader lacks trust, counterparts and subordinates will not fully commit to the vision, and a fractured culture will exist. Regardless of your position in a company, appreciating the trust from the infinitesimal tasks to the most significant decisions becomes paramount. 

Simon Sinek is a visionary and shows on countless occasions what leadership can be, and frequently talks about trust, culture, transparency and communication.

“The world is filled with danger, things that are trying to frustrate our lives, or reduce our success, reduce our opportunity for success. It could be the ups and downs in the economy, the uncertainty of the stock market. It could be a new technology that renders your business model obsolete overnight. Or it could be your competition that is sometimes trying to kill you. It’s sometimes trying to put you out of business, but at the very minimum is working hard to frustrate your growth and steal your business from you. We have no control over these forces. These are a constant, and they’re not going away.

“The only variable is the conditions inside the organization, and that’s where leadership matters because it’s the leader that sets the tone. When a leader makes a choice to put the safety and lives of the people inside the organization first, to sacrifice their comforts and sacrifice the tangible results, so that the people remain and feel safe and feel like they belong, remarkable things happen.”2

Sinek understands what it means to build trust, and no more critical is faith within an EMS agency. Citizens’ lives depend on it. Trust is shown from the maintenance employees, ensuring the vehicles are appropriately maintained and functionally appropriate, to the chief of the organization safeguarding the budget and salaries. It is also seen with paramedics and EMTs having the proper equipment and training in addition to ensuring crews have enough rest between shifts, so when a split-second decision occurs, the best one is selected.

“You see, if the conditions are wrong, we are forced to expend our own time and energy to protect ourselves from each other, and that inherently weakens the organization. When we feel safe inside the organization, we will naturally combine our talents and our strengths and work tirelessly to face the dangers outside and seize the opportunities.” 2

The absence of trust is uniquely a silent killer in the manner that employees revert to self-preservation and motivation for the organization dwindles.   

Sinek was able to embed with the Navy Seals and learned what trust meant at the highest level. “I work with the Navy Seals, and I asked them how do you pick the guys that go on SEAL Team Six because they’re the best of the best of the best. They drew a graph for me, and on one side, they wrote the word for performance, and on the other side, they wrote the word trust. The way they define the terms is the performance on the battlefield and performance (trust) off the battlefield. This is your skills; did you make your quarterly earnings. How we want to translate performance is traditional, this is how are you off the battlefield and what kind of person are you. The way they put it is, I may trust you with my life, but do I trust you with my money and my wife?”3

Sinek highlights one of the most important ideals of leadership… trust. The story paints a beautiful picture as to what is considered one of the highest performing teams in the world and how much emphasis they put into trust versus performance. EMS is notorious for hiring through nepotism, cronyism and seniority.

Appointing a family member or a friend might mean there is a stronger bond of trust, there also lies inherent distrust amongst current employees. Is the organization hiring the best candidate or just fulfilling a favor? Maintaining ultimate trust can still be accomplished, but through non-biased participants, during the hiring process, whereas the best candidate will prevail either way.

Sinek continues that nobody wants the low performer and low-trust person. The high performer and high trust is the absolute best candidate, but much harder to come by. Both are easily identifiable, but equally important is to recognize the high performer and the low-trust employees. While high performing and low-trust employees are meeting performance standards on paper, they are the most toxic people in the organization. These people are good at their jobs, but have begged, borrowed, stolen and climbed the promotional ladder at any cost; they lack the emotional quotient to be a leader while acting with selfish agendas.

Toxic leaders are the class of employees that will subvert the company’s mission ultimately destroying the organization from within. As referenced earlier in toxic leadership, catching and preventing this type of employee before they climb the ranks is of utmost importance. Changing their behavior once they have promoted will be almost impossible, and why would they change? Their response, affect and peer interaction has been endorsed time and time again through promotion.

Sinek states that the Seals would instead take a middle performer with high trust and possibly a low performer with high trust before the high performer and low trust employee.3 Traditionally, organizations to no fault of their own don’t have the metrics to value what trust is, so naturally, they evaluate performance. The high performer and low-trust employee rise through the ranks resulting in disproportionate thinking. Trust is an irreplaceable core value, and one of the highly sought-after character traits EMS leaders should be targeting.4 Identifying the most trusted and loyal employees is not hard to find, poll the employees, and they will be well-known. 

“We can take responsibility for the things we can control i.e., ourselves so we can choose to live our lives with an infinite mindset, and we can choose to create trusting teams even if they’re small just around us. I have a boss, I have one subordinate, and I have a couple of colleagues to the left and on the right. I commit to coming to work to ensure that they feel that I’m here to support them and help them rise to be there for them when they need it and make them feel like they’re part of something bigger than themselves.”4 By starting with trust, leaders can change the narrative from what is comfortable and traditional to exploit the weaknesses and flip the metrics.


Accessibility is fundamental to an organization. Transparency is defined as “having the property of transmitting light without appreciable scattering so that bodies lying beyond are seen clearly. Characterized by visibility or accessibility of information, especially concerning business practices.”5 Having the confidence to take the hard-long look in the mirror and take ownership when problems arise is what defines transparency. It’s easy to cast blame and look to others for being problematic.

As leaders, all the responsibility falls onto their shoulders and rarely any praise; similarly, transparent leaders understand others need more of the recognition to feel empowered and affirmed from their actions. It’s not easy being vulnerable all the time because constructive criticism will come and to learn how to respond with open arms is key. “The truth is that anyone can develop leadership skills, but it takes a special person to lead transparently.”6

EMS agencies are providing a service to the community and should be transparent because citizens deserve the best care possible. Improvement comes from avoiding complacency and to accomplish this one must be transparent in their own abilities. Transparency must start within an organization and start at the top. Leaders set the tone for culture, and openness must be one of the core values most sought after. Employees who embrace it allow oneself to be open to finding the nuggets (paramedic pearls, life lessons, teaching moments).

It’s unknown when they may appear, nevertheless allowing and being open to the opportunity for them to find you is paramount. Through these moments are when an organization is defined. The vulnerability that transparency provides allows everyone in the company to understand that being human and all that comes with that is indispensable. “When a leader takes responsibility for his own actions and mistakes, he not only sets a good example, he shows a healthy respect for the people on his team.”7

Paramedics must have the ability to feel empathy and sympathy; besides, no one is immune when it comes to the problematic situations that EMS providers face daily. Telling a parent their child is dead is not a conversation that comes from fabricated emotion. A supervisor telling an employee that improved performance is needed will only fall on deaf ears if the supervisor doesn’t also express the same mistakes that were committed when they started. Allowing oneself to be humbled frequently keeps perspective.

“Creating transparent leadership requires changing your mind-set as well as your behavior. It’s easy to be transparent about your strategy when the stakes are low. But how transparent are you when the stakes are high, views differ greatly, or you are heavily invested in your solution? The key is whether you are willing to work on changing your thinking, so you can lead your organization to better results and relationships.”8


The challenge any organization faces with communication is evident, but identifying it and working with it is paramount. Communication is defined as “a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.  Personal rapport.”9 Difficulties arise when two people are having a single conversation, much less an organization trying to convey their mission and values. The value of excellent communication cannot be echoed enough.

“It is not possible to have good human relations without communication. On the other hand, effective communication is required not only for human relations but for good and successful business. In practice there is no organization without communication or there are organizations with bad communication and it cannot be considered as successful organizations.”10

EMS faces challenges with communication at every level, but no more than the infamous “breakfast bar” talk when crews trade out. Conversations will occur about what calls they ran during their shift or the problems found on the ambulances. If this were the extent of the exchange, then few mistakes would arise. The challenge includes conversations about culture, management, other employees, difficult calls, and high-frequency utilizers (frequent fliers). The tone set by off-going crews can dramatically alter how the on-coming crew’s day will go.

Leaders need to understand that open communication amongst all employees will help alleviate the “rumor mill.” Leaders can also help address the negative biases associated with the job through demonstration. Assisting crews to realize that patient reports, night calls, intoxicated patients, and late calls are all a part of the job will minimize the effect they cause. When employees feel they aren’t being heard is when gossip and negativity ensues. Communication from management about how they plan to address these and what strategies are in place will reduce the burden for the crews. 

“People always are trying to find the meaning of actions, especially leaders’ behaviors. When you fail to be transparent (or communicate), you increase the chance that others will come up with their own theories about your intentions and motives – theories that often will differ from yours. Share your thinking and you influence others to see things from your perspective while reducing people’s need to invent stories about your actions.”8

For instance, allowing crews the ability to vent their frustrations without recourse will only enhance the flow of communication between employer and employee. Open-door policies are a common term management heads like to use, but unless leaders hold to their word, the trust, transparency, and, most importantly, the communication will be lost.

“Active listening is a person’s willingness and ability to hear and understand. At its core, active listening is a state of mind that involves paying full and careful attention to the other person, avoiding premature judgment, reflecting understanding, clarifying information, summarizing and sharing. By learning and committing to the skills and behaviors of active listening, leaders can become more effective listeners and, over time, improve their ability to lead.”11 Part of communication includes the ability not just to listen but to hear and understand the information. During critical events, EMS providers must utilize this skill because the information gathered may only be passed on once.

Whether it be events preceding the current situation or necessary medications a patient takes, crews must be able to gather as much critical information as possible to be able to make split-second decisions. Sometimes it only takes one piece of misinformation that will cause a provider to travel down a completely wrong treatment path. Paramedics are notorious for quick assumptions in part due to their previous interactions where similar patterns of recognition exist. Active listening affords the provider not to get too far ahead of themselves, but rather to slow down the thought process to allow for the entire picture to be absorbed. If running a call is the test providers face, then patients are the answer key. 

As providers, it is our responsibility to reveal the information and do this through physical exams, history taking and home medication knowledge. With active listening, the provider navigates through patient differentials based on the information received, not perceived.  “A sender may strive to deliver a message clearly. But the receiver’s ability to listen effectively is equally vital to successful communication. The average worker spends 55% of their workdays listening. Managers listen up to 70% each day. Unfortunately, listening doesn’t lead to understanding in every case.”12 Poor communication will only foster a more significant divide of the perceived reality.

One of the best communicators America has encountered was Dr. Martin Luther King.  Simon Sinek tells the story of the day Dr. King gave the famous “I Have a Dream” speech and why it was more about Dr. King being an incredible communicator than necessarily about the message.

“In the summer of 1963, 250,000 people showed up on the Mall in Washington to hear Dr. King speak. They sent out no invitations, and there was no website to check the date. How do you do that? Well, Dr. King wasn’t the only man in America who was a great orator. He wasn’t the only man in America who suffered in pre-civil rights America. In fact, some of his ideas were bad. But he had a gift. He didn’t go around telling people what needed to change in America. He went around and told people what he believed. ‘I believe, I believe, I believe,’ he told people. And people who believed what he believed took his cause, and they made it their own, and they told people. And some of those people created structures to get the word out to even more people.  And lo and behold, 250,000 people showed up on the right day at the right time to hear him speak.”13

Sinek goes on to say: “How many of them showed up for him? Zero. They showed up for themselves. It’s what they believed about America that got them to travel in a bus for eight hours to stand in the sun in Washington in the middle of August. It’s what they believed, and it wasn’t about black versus white: 25% of the audience was white.”13

Communication is a dynamic tool a leader can use to convey messages to employees and stakeholders alike. Sinek identifies an essential key to being an effective leader and an effective communicator. If leaders believe the words their sending and are thinking about how it will impact the receiver, people will follow. Using communication as a tool to help achieve an agencies’ why will allow leaders the capacity to write the narrative. 

Leadership in Action

When does leadership stop being a goal and start being policy? All too often, leaders set out with a plan to improve leadership, but fail to act. This section will provide a few examples of how to implement leadership into real-life applications. Changing the mindset of an organization is no small task, but leaders like Duke Blue Devils basketball coach Mike Krzyzewski truly understand. He described how to he got the most out of his players every year.

He states: “I don’t like the term buy-in because you are working or playing for. I want you to believe, so you own. Buy-in is for someone; belief is ownership in.”14

To create a culture of belief and ownership starts with setting a clear mission and giving employees a just cause to follow. “You have to be the leader you wish you had.”3 If enough people have like-minded goals and band together, eventually, this group will be promoted and will be in positions to make a global culture change.3 Exceptional people can perform well at any time, while specialized organizations perform well every time.

Discussed earlier on how employees can affect each other’s day by how they convey information furthermore describes how impactful each moment of leadership can be. This author created a philosophy called “Medic Team Six (MT6)” to help combat negative interactions amongst crews. MT6 is an idea that the six employees, who trade out at shift change during a full rotation of their schedules, strive to be more of a team and family than just coworkers. The name was derived from Seal Team Six and thinking about how the Navy Seals form an eternal bond.

If crews from other shifts applied the same mindset of the Navy Seals, a reduction in “shift wars” and animosity would occur. As a result, creating a positive interaction with the oncoming crew would elevate how their shift would start and set them up for success. Above all, team members would accomplish station duties and ambulance cleanliness not because of the fear of punishment, but because of the fear of letting each other down. Building trust amongst crews takes time to develop, but finding small victories can be executed immediately. For example, arriving early to work to ensure the off-going crew gets off on time speaks volume to care for each other.

When a crew has been up all-night running calls and the ambulance or the station is not as clean as it should be, reassuring the crew that “we got you” creates an unspoken trust. The more crews choose to think of situations on how they can help each other rather than thinking how someone can help them creates a pattern of trust. MT6 embodies the leadership pillars of taking care of each other to gain the trust of coworkers to create a safe environment for significant accomplishments to flourish. Finding the small victories each day will turn in to large victories every day.

Another philosophy created by this author refers to training and mindset through leadership. Paramedics and EMTs struggle at times with decision making and determining the proper course of treatments. If a patient breaks their ankle and is in severe pain, a paramedic can splint the ankle and get the patient to a position of comfort, reducing the pain slightly. At this junction, the paramedic needs to make a judgment call on whether to treat the patient’s pain with an analgesic or allow their EMT partner to manage the patient without pain management.

The patient will not die without a painkiller, but the patient will remain in a significant amount of pain throughout transport. To understand the decision-making process is perplexing, and each paramedic may utilize protocols or their personal metrics to make decisions. Decisions are sometimes made without the best intentions. i.e., paperwork, night calls, late calls or high-frequency utilizers. A mental tool was used to create a mindset that allowed choices to be made without distracting biases. The mindset is to visualize patients as family members, this enables the provider an opportunity to envision how they would like their loved ones treated. Treat all patients as if they were your own family members.

Receiving a phone call from a loved one about how they were treated from other medical providers is infuriating. Don’t allow your patients an opportunity to call someone else about our subpar care. Sometimes providers get caught up in the monotony of the job, and they lose perspective on why they chose this profession. As simple as it sounds, by doing this, it forces the provider to make prudent choices not because they have to, but because it’s the right thing to do.  The connection made between patients and providers becomes stronger without a negative biased approach.


“Half of what is taught in medical school is wrong, but nobody knows which half. –

 Lucy Hornstein, MD.”15 The same could be said about leadership as well. Many leadership fads have been developed over time and may have had their place, but as times and trends change, so does leadership. As leaders in EMS, it’s crucial to adapt to the new generations of employees and identifying the best ways to work for and with them. The story of the blind men and the elephant is a good story to remember as leaders to say not all things that appear to be true necessarily are.   

“Beyond Ghor, there was a city.  All its inhabitants were blind.  A king with his entourage arrived nearby; he brought his army and camped in the desert. He had a mighty elephant, which he used to increase the people’s awe. The populace became anxious to see the elephant, and some sightless from among this blind community ran like fools to find it. As they did not even know the form or shape of the elephant, they groped sightlessly, gathering information by touching some part of it. Each thought that he knew something, because he could feel a part.  The man whose hand had reached an ear… said: ‘It is a large, rough thing, wide and broad, like a rug.’ And the one who had felt the trunk said: ‘I have the real facts about it. It is like a straight and hollow pipe, awful and destructive.’

“The one who had felt its feet and legs said: ‘It is mighty and firm, like a pillar.’ Each had felt one part out of many. Each had perceived it wrongly. This ancient Sufi story was told to teach a simple lesson but one that we often ignore: The behavior of a system cannot be known just by knowing the elements of which the system is made.”16

The story of the elephant represents how leaders with a narrow view will unquestionably misinterpret the health of their organizations.  In contrast, leaders who focus on the system as a whole provide the vision to make progress and will undoubtedly lead successful organizations.  

Developing core values (Trust, Transparency, Communication) to represent the culture needed to have a robust and vibrant organization is especially crucial if EMS will learn from other’s mistakes and implement an environment where people are craving to be permanently. Change must come from the leaders within, and applying the tools provided will begin the process of changing the culture to a place where other industries look to for leadership examples. Targeting issues of employee retention, salary, culture, empowerment and moral injury cannot be done without understanding how first to be the leader everyone wishes they had.

Doing so starts with embracing the core values of trust, transparency, and communication, along with creating a team of like-minded individuals willing to take on this journey. Embracing this transformation and creating understanding will show there are no quick fixes. In turn, they are leading with valuable contributions to the longevity of EMS as a vivacious industry. Without it, the future will remain unknown and potentially catastrophic. Employees are the most significant commodity to the success of EMS.  As leaders, we must identify the ones who embrace the core values of the organization and empower them to reach heights higher than even they believe they could obtain. Lastly, combining the pillars of leadership with a leadership mindset will in turn bridge the gap to grow the industry into the next generation.  


  1. Trust. (2019). Merriam-Webster. Retrieved from https://www.merriam-webster.com/dictionary/trust.
  2. Sinek, S. (2014). Why Good Leaders Make You Feel Safe [Video]. Retrieved from https://www.ted.com/talks/simon_sinek_why_good_leaders_make_you_feel_safe/transcript#t-152763.
  3. Sinek, S. (2019). How do you measure success? [Video]. Retrieved from https://www.youtube.com/watch?v=nyqLJSclNb4&feature=youtu.be.
  4. Sinek, S. (2019). How you can change your company culture? [Video]. Retrieved from https://www.youtube.com/watch?v=vM8W48pH9Y8&feature=youtu.be.
  5. Transparent. (2019). Merriam-Webster. Retrieved from https://www.merriam-webster.com/dictionary/transparent.
  6. Baum, H. (2005). Transparent leadership. Leader To Leader, 2005(37), 41-47. doi: 10.1002/ltl.139
  7. Krzyzewski, M., & Phillips, D. (2010). Leading with the Heart: Coach K’s Successful Strategies for Basketball, Business, and Life. Grand Central Publishing.
  8. Schwarz, R. (2010). Transparent leadership. Government Executive, 42(4), 56. Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=https://search-proquest-com.ezproxy1.lib.asu.edu/docview/204316765?accountid=4485
  9. Communication. (2019). Merriam-Webster. Retrieved from https://www.merriam-webster.com/dictionary/communication.
  10. Spaho, K., M.A. (2010). ORGANIZATIONAL COMMUNICATION AS KEY FACTOR OF COMPANY SUCCESS. Paper presented at the 1372-1381,18. Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=https://search-proquest-com.ezproxy1.lib.asu.edu/docview/734617306?accountid=4485.
  11. Hoppe, M. H. (2007). Active listening: Improve your ability to listen and lead, first edition. Retrieved from https://ebookcentral-proquest-com.ezproxy1.lib.asu.edu.
  12. Organizational Behavior. (2017). Minneapolis, MN: University of Minnesota Libraries Publishing Edition.
  13. Sinek, S. (2009). How Great Leaders Inspire Action [Video]. Retrieved from: https://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action?language=en#t-462795.
  14. ESPN. (2018). Earn Everything [Video]. Retrieved from http://www.espn.com/watch/player?bucketId=13028&id=d37c17e2-3ba4-47af-84c7-825f4163354c.
  15. Grayson, K. (2013). Faith in EMS: My karma ran over your dogma. Retrieved 11 November 2019, from https://www.ems1.com/ems-advocacy/articles/faith-in-ems-my-karma-ran-over-your-dogma-G74qzqmOWFonDdNB/.
  16. Shah, I. (2014). The Blind Men and the Matter of the Elephant :: MediaCom. Retrieved 11 November 2019, from https://www.mediacom.com/en/think/magazine/systems-thinking/the-blind-men-and-the-matter-of-the-elephant.
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