Problem: Implementing EMS Supervision in a Dual-Role, Cross-Trained Fire Department
Over ten years ago, Loudoun County (Virginia) Fire and Rescue implemented a program to provide EMS supervision and leadership on incident scenes. Throughout its existence, these positions have been difficult to fill. They require a combination of an experienced paramedic, experienced incident manager, paramedic field preceptor, and well-respected department member. Not to mention, the initial required rank was battalion chief.
The role of these EMS battalion chiefs was to respond to incident scenes and provide on-scene EMS leadership, advice and supervision. This initial effort was not a widely herald success for several reasons. First, the EMS battalion chief produced role ambiguity with operations battalion chiefs. Since they carried the moniker “battalion chief,” they often came into conflict between supervising patient care and scene supervision. Second, the EMS battalion chief did not bring any additional skills than a standard department paramedic to an incident scene. This often created conflict concerning patient care decisions, especially with experienced firefighter/paramedics. Field personnel often did not garner strong respect for these positions for these reasons. This further impacted the ability to recruit strong “officer-paramedics” into the role of EMS supervision. Even after the reclassification of the “EMS battalion chiefs” to “EMS captains,” recruitment into the program continued to be difficult.
David Winter, a lieutenant with Fairfax County Fire and Rescue Department, wrote an Executive Fire Officer Paper in 2015 titled, “Why senior paramedics do not seek EMS supervisor positions?”1 Using surveys of paramedics, Winter identified “attractive and unattractive” characteristics of EMS Supervision positions.1 Then, he compared them to other agencies. Winter found the factors why senior paramedics did not want to become EMS Supervisors were:
- Inconsistencies with the division of EMS training, administration, and operations into three separate divisions.
- Overburdensome administrative loads in comparison to peers.
- Perception by field paramedics that the position did not add any additional resource/skill to an incident
- An organizational culture that views the positions with less respect than peers at the same rank.1
As senior leadership addressed the organizational structure and administrative load, the Loudoun County Fire and Rescue EMS Division worked to address the skill level and organizational culture of EMS captains. This would be accomplished through the implementation of a rigorous EMS supervisor school. This idea spawned from the implementation of a recruit school and officer candidate school. Both of these (in different ways) addressed knowledge and skill needs for new firefighters and new officers, respectively. We witnessed how a training school could improve the capability of personnel and the expectation of personnel already in the field.
Developing an EMS Supervisor School Program
An EMS supervisor school provides a benchmark training and on-boarding program. Coupled with stringent prerequisites, this program “raises the bar” above the care of the field paramedic. If your system has additional roles and skills for your EMS supervisors, they can be taught and honed in this training program. Obviously, the prerequisites and content are driven by your jurisdiction. Loudoun County is no different. As a dual-role, cross-trained fire and EMS agency, candidates were required to hold several pre-requisites to apply to become an EMS supervisor (Table 1).2
The initial content of the EMS supervisor school was a challenge. Budget constraints only allowed six days for the first school. As planning began, we were concerned there was not enough content to fill five, eight-hour days. We quickly learned that 48 hours was not enough time. The overall goal was to create a small number of highly trained personnel to fill future EMS supervisor positions. These personnel would need to be capable of performing rapid sequence intubation (RSI), guiding a battalion chief through a mass casualty operation (MCI), and overseeing paramedic preceptees, among many other responsibilities. The schedule quickly filled and (in some cases) exceeded eight hours. After candidate selection, the training cadre (current EMS supervisors) were ready to begin.
After many schedule overages, it was decided to increase the length of the school to accommodate all required material and additional skills that had been added from the first school. The second EMS supervisor was expanded to nine days and spread out over three weeks. This gave the candidates a chance to digest the material and hone skills before additional sessions.
Day 1 — The Role of the EMS Supervisor
The first day began with an introduction and a 50-question authorized paramedic protocol written test. As an EMS supervisor in Loudoun County, these providers are permitted to perform “AP” skills in the EMS protocols. An AP is an authorized paramedic by the operational medical director to perform.3 The AP protocol written test drilled down into the protocols about advanced airway management, RSI, complicated childbirth, contaminated patients, burns, treating weapons of mass destruction (WMD) injuries, and other AP skills and medications. The candidates were reminded that an EMS supervisor must have a strong knowledge of the protocols to garner trust from field personnel. This knowledge is also required in their work performing quality improvement efforts and precepting new ALS providers. The pretest was based on materials provided to them prior to the start of school and set strong expectations for the candidates to be successful and become authorized as EMS supervisors.
The next session was a round table discussion titled, “The Role of the EMS Supervisor.” Current EMS supervisors sat at the front of the classroom. The discussion was facilitated by one of the incumbent EMS supervisors. The purpose of the session is to motivate the students about the roles and responsibilities of the EMS supervisor. Overhead questions were asked, such as “What is the hardest part about being an EMS supervisor?” or “What do you do to interact positively with medic crews when you arrive on the scene?” (Table 2). Candidates were afforded the opportunity to ask questions at the end of this session.
“The Role of the EMS Supervisor” readily transitioned into the next session — “Daily Operations of the EMS Supervisor.” This covered the daily expectations of the EMS supervisor including daily work tasks, how to complete vehicle/equipment checks and handling daily operational items.
The afternoon included presentations on: Managing Elite and Understanding LifeNet. Both of these presentations were delivered by the quality assurance officer. They reviewed the EMS supervisor’s role managing the department’s ePCR Program (Elite). This included many routine administrative items from fire stations, such as password resets, unlocking reports and troubleshooting 12-lead EKG transmission. They also ensured everyone understood how our LifePak transmission network operated and how to access the system.
Day 2 — Advanced MCI Operations (Lecture/Practical)
The entire day was dedicated to MCI operations. The morning consisted of lecture designed to review the MCI manual; specifically to reinforce the roles of key positions (EMS branch, treatment, triage, etc.) and the specific responsibilities of EMS supervisors. While the EMS supervisor has specific roles, they also serve as the SME’s on these incidents and provide guidance to all personnel to ensure smooth operation and patient accountability.
The afternoon consisted of multiple simulated mass casualty incidents using casualties (i.e. stuffed animals with labeled injuries). With little direction from instructors, candidates filled the main roles of the MCI response (i.e. transportation, EMS branch, triage, etc.). Actual communications with the Regional Hospital Coordination Center were conducted. “Patients” were processed from the scene to simulated area hospitals and tracked electronically.
Day 3 — Infection Control, Managing Exposures, Managing Precepting and Mentoring and Addressing Quality Assurance Reviews
Loudoun County EMS supervisors serve as the department’s designated infection control officer (ICO). After reviewing the fundamentals of infection control, candidates learned the procedure to identify and manage a bloodborne exposure. Often, calls to the ICO are unfounded and come from a provider who does not have a true exposure. It is important that the EMS supervisor calmly address these false exposures with the EMS provider. If selected into the EMS supervisor program, candidates would complete a separate two-day course to become a designated infection control officer.
“Managing precepting and mentoring” was the second topic of the day. EMS supervisors are the designated mentors for new paramedics in the department. Experienced paramedics perform the day-to-day precepting, but EMS supervisors manage the overall field training experience (i.e. mentoring). This role places candidates in a position to recommend (or not recommend) new paramedics for release to independent practice. Candidates were provided a series of “problem precepting” scenarios and discussed the appropriate steps to manage the issue. Candidates also conducted role-playing counseling session with a preceptee and preceptors to address an issue between the two providers.
The morning ended with a lecture form the quality assurance officer regarding how to handle quality assurance reviews. They covered a myriad of topics including: current trends, how a review is generated, the EMS Supervisor’s role in the process and expectations when delivering a review.
The afternoon was dedicated to bloodborne pathogen (BBP) exposure and quality assurance practical exercises. Candidates played the role of EMS supervisors and had to appropriately mitigate the situation they were presented. There were two BBP exposure stations and two quality assurance review stations.
One BBP exposure simulation was a non-exposure where the member was extremely distraught. To be successful, the candidate had to educate the member that they weren’t in fact exposed and calm the provider from the situation. The second exposure simulation involved a true exposure in which they had to complete all applicable paperwork, ensure proper source testing was being complete and make appropriate notifications.
Each quality assurance review simulation involved scenarios that the incumbent supervisors had previously delivered. They involved scenarios with very stubborn providers who refused to concede they had done anything wrong and were very stubborn to admit their mistakes. These scenarios truly tested the candidate’s ability to communicate and educate difficult providers. To be successful they had to clearly educate the role players to their mistakes, get buy in, and provide guidance/training to avoid future mistakes.
Day 4 — Advanced Skills (Lecture/Practical)
Loudoun County EMS supervisors carry additional equipment that is specific to them, this includes: SAM junctional tourniquets, Control-Cric, McGrath video laryngoscope, ventilator and gastric tubes. Since we are the only entity in the county that carries these devices, it is the expectation that they have an intimate knowledge of the devices and their use. The morning provided a lecture on each device and its use. In addition to this equipment, EMS supervisors are also allowed to perform dual sequential defibrillation, which was also covered.
The afternoon was dedicated to practical scenarios where they could use the special equipment and procedures. They got to work with the equipment in simulation to gain proficiency. To practice with the control Cric, pig tracheas were obtained so they could practice multiple times with realistic conditions.
Day 5 — Special Situations for the EMS Supervisor
Day five began with a review session. This allowed the candidates to ask any questions they had and ensure they grasped the information they had been taught thus far. The review session also included a detailed quiz to gauge how well they were retaining the information.
This transitioned into their first lecture “Special Situations for the EMS Supervisor.” This was a very interactive lecture where unique situations that incumbent supervisors were presented and the candidates were asked how they would handle. Their choice, the decision that was made and the correct decision were all discussed. This situations were not typical day to day situations and most required critical thinking. Some of the cases presented included, caring for a distressed newborn who was delivered by a midwife in a residence, managing requests for interfacility transports, handling CPS/APS reports (Table 3).
The morning concluded with an overview of our Comp-X electronic locking system. The candidates were provided a lecture showing them how to access and operate the Comp-X program. This allowed them to activate new providers, reset pin codes and oversee any provider changes (upgrade/downgrade) that were to occur. They were also given an overview of our electronic document repository, its purpose and how to access it.
The afternoon kicked with a lecture from the Operational Medical Director (OMD) on how to handle termination of resuscitation (TOR) incidents. We recently began performing field TOR’s which has led to some interesting interactions with families and law enforcement (LE). The OMD covered how to handle these incidents, break bad news to the family members and how to best work with our LE partners.
Loudoun EMS supervisors are dispatched to all bariatric incidents. Their role on these incidents is to ensure appropriate patient care and safe movement of the patient. Since they are on each of these incidents, it is important that they understand how the equipment works. They were provided with lecture and hands on time with our most common bariatric equipment.
One of the other services the EMS supervisor offers is replenishment of medications to field units after a TOR is performed. They carry a compliment of medications to restock a unit after these incidents so they can rapidly return to service. This requires strict accountability and oversight of these medications. The candidates were educated on how these medications are stored, accounted for and requested after disbursement.
To conclude the day, they were provided an overview of how to handle system drug diversions.
Day 6 — Rapid Sequence Intubation
In Loudoun County, there are nearly two hundred paramedics who can perform intubation. With the varied call volume, many of these paramedics may only have one opportunity (every few months) to perform an intubation. Without regular opportunities to intubate, provider skills deteriorate. This is the reason that RSI in Loudoun County is an AP skill. It is limited to EMS supervisors who are the highest trained (and most closely monitored and mentored by the OMD). With only a small number of EMS supervisors, they are allotted more opportunities to perform RSIs. This reduces their skill degradation.
The entire sixth day of the school was dedicated to RSI. Experienced EMS supervisors taught this portion school. First, students received a detailed lecture of RSI medications, complications and procedures. Candidates were strongly encouraged to have a strong knowledge (i.e. memorization) of the RSI Protocol. After lecture, students completed several RSI skill stations led by flight paramedics, incumbent EMS supervisors and the OMD. This provided first-hand review by the OMD of each provider’s competence and confidence in performing an RSI.
Day 7 — OMD and EMS Chiefs Roundtable, Hospital Liaisons, Cardiac Arrest Technology Overview
With the first EMS supervisor school, the OMD and EMS chiefs roundtable occurred on the first day; however, due to schedule constraints this was the first available time slot available to have them all together to speak with the group. In this session, the OMD, the deputy chief of EMS, and the battalion chief of EMS presented their expectations of the EMS supervisor and their role in the Loudoun County EMS system. To facilitate this session, the OMD and EMS chiefs answered several questions to facilitate the discussion, including:
- How do you see the role of the EMS supervisor now and in the future?
- How does the EMS supervisor represent the OMD and Loudoun County Fire and Rescue Department?
- What are your expectations of an individual as an EMS supervisor?
At this point, the OMD empowered the candidates. The OMD pointed out each EMS supervisor represented him in the field. He expected them to make clinically sound patient care decision and be strong patient advocates. He also provided each candidate his personal contact information to contact him directly — whether on an emergency incident or non-emergency incident for direct OMD advice.
Working with hospitals and pharmacies provides the candidates an opportunity to meet our points of contact for our local hospitals. Hospital liaisons from the four in-county medical facilities introduced themselves to the EMS supervisor candidates. As the primary liaison with the hospitals, EMS supervisors regularly handle resupply issues, destination decision problems, changes in hospital capabilities and provider and hospital staff issues. By meeting the hospital and pharmacy liaisons, the candidates can begin to build relationships with hospital staff before issues developed.
In 2018, Loudoun County began implementing high performance CPR. With this transition, we introduced the use or code stat reviews, Full Code Pro to manage the arrest and performed termination of resuscitation (TORs) with unsuccessful efforts. The candidates were provided a review of high-performance CPR and their role on these incidents. They were encouraged not to take over the scene, but were given advice on how to encourage and mange personnel for successful incidents. They were given an overview of Code Stat, how to interpret the data, and given a few case studies as examples. They were also given a more detailed overview of the Full Code Pro program.
The afternoon portion of this day was dedicated to scenarios. These included a scenario managing a patient experiencing excited delirium that requires the candidate to use chemical restraint. A scenario involving a disorganized cardiac arrest in which the candidate needed to coach multiple providers and the code manager on proper technique and procedure. A smoke inhalation scenario that required administration of a cyano kit and RSI, and a scenario simulating them performing an RSI in a moving ambulance.
Day 8 — ISO-POD, Assisting at the Command Post, Command and Control of RTF Operations
Since the EMS supervisor is often confronted with anything and everything EMS, the HAZMAT Team reviewed the use of the ISO-POD. This is a positive pressure isolation device for the care and transportation of a contaminated patient. The EMS supervisor may be called upon to don PPE with HAZMAT technicians and provide care in this situation. Candidates were then provided simulation scenarios and appropriately managed a patient while in the ISO-POD.
The final two sessions of Day 7 focused on command and control. “Assisting at the Command Post” helped prepare candidates to assist a battalion chief on large incidents. The expectation of the EMS supervisor on large incidents is to report to the command post to serve as a command aide. As most candidates were lieutenants, they only had a peripheral knowledge of assisting at a command post. Candidates were taught how to use a command board, manage accountability tags and operate a radio channel at a command post. This readily progressed into the last topic of the day — “Command and Control of Rescue Task Force Operations.” After a review of the fundamentals of tactical emergency casualty care (TECC), candidates were immersed in the regional active threat manual titled, “Joint Action Guide for High Threat Environments.”4 Candidates focused on strategic items on these incidents beyond individual tactical patient care. Working with a battalion chief at the command post, an EMS supervisor may have to help establish unified command with law enforcement, integrate fire/EMS with law enforcement into Rescue Task Force Team (RTF) and Extraction Task Forces (ETF), and work with law enforcement to treat and extract casualties from the warm zone.
Day 9 – Final Testing
Final testing for the EMS supervisor school consisted of written and practical testing. The written test required an 80% score on a 100-question multiple choice test. The test content covered anything that was presented in the six-day course, such as the role of the EMS Supervisor, mentoring new ALS providers, working with the hospitals and pharmacies, appropriate management of special situations (hospice care, DNRs, childbirths involving midwives, custody with law enforcement), advanced skills (RSI, Control-Cric, SAM JT, and Orogastric tubes), and advanced knowledge of MCI operations.
Candidates were evaluated on four final practical scenarios.
- The first scenario consisted of a bariatric patient on the third floor of a simulated apartment building. Upon their arrival the patient is being cared for by a medic crew and requires RSI. The simulated apartment is full of rubbish and has a foul odor. The medic crew makes inappropriate comments about the patient and the conditions to which the candidate must cease and correct. The candidate then had to properly ramp the patient and perform RSI. An additional crew arrives with bariatric equipment to which they must also provide some pointers on its proper use. They then successfully extricate the patient out of the building. Critical points included maintaining a calm demeanor, preparing for success with patient ramping/head positioning and back-up airway preparation, tube verification, administration of appropriate drug dosages, maintenance of continuous sedation and securing the tube.
- The second scenario involved a BBP exposure in which the candidate must calm the provider to their needle stick injury. They must determine this was a true exposure, ensure appropriate testing is being completed at the simulated receiving hospital and correctly complete all appropriate documentation.
- The third scenario consisted of a pediatric patient that requires RSI. The candidate was confronted with a crew that is caring for a pediatric patient that is unconscious and hemodynamically unstable. They are inappropriately managing the PT’s airway and the patient is further deteriorating. The patient has been ill with a respiratory infection for multiple days and is now in septic shock. Critical points included maintaining a calm demeanor, preparing for success with head positioning and back-up airway preparation, tube verification, OG placement, administration of appropriate drug dosages including epi push pressors to maintain BP, maintenance of continuous sedation and securing the tube.
- The fourth scenario involved the candidate delivering a quality assurance review. This was a detailed review that required them to be very persistent to get buy in from the provider on their mistake. It then required them to re-educate the patient on appropriate management of patients experiencing allergic reactions including pathophysiology and pharmacology.
After EMS Supervisor School
On Feb. 11th, 2016, Loudoun County Fire and Rescue graduated eight lieutenant/paramedics from the department’s first six-day Emergency Medical Services (EMS) supervisor’s school.5 This was a considerable achievement considering the volume of material and practical stations conducted. Just because a candidate completed EMS supervisor school, that does not release them to fill-in or become a permanently assigned EMS supervisor. After EMS supervisor school, the instructor cadre reviewed each candidate’s performance. With their endorsement, the candidate could schedule the required 36 hours of ride-alongs with a permanent EMS supervisor. After these ride-alongs, the candidate was reviewed by the deputy chief of EMS, battalion chief of EMS, and OMD for endorsement as an EMS supervisor. This allowed the recently endorsed department member to begin covering shifts as an EMS supervisor.
On June 15th, 2018, Loudoun County Fire and Rescue completed the department’s second supervisor’s school. This school graduated three lieutenant/paramedics and one captain/paramedic from the department’s second Emergency Medical Services (EMS) Supervisor’s School. After EMS supervisor school, these candidates began the additional steps to become locally authorized as EMS supervisors. The department plans to conduct the third school in the summer of 2020.
Lessons Learned from the EMS Supervisor School
Several important lessons were learned from conducting the EMS supervisor school.
- The additional field skills and EMS supervisor school training elevated the organizational respect for the EMS supervisors. A genuine interest exists in the lower ranks to work toward becoming an EMS supervisor to perform more advanced skills, manage critical patients and develop the EMS system.
- EMS supervisor schools should be conducted annually or biannually. The EMS supervisor school provided an adequate pipeline for the next generation of EMS supervisors. With the regular promotion and expansion of the EMS supervisor program, the EMS supervisor school provides an important part of succession planning.
- It was quickly discovered six days was not enough time to cover all the topics. Nine days was allotted for the 2018 EMS supervisor school. This created adequate time to deliver all needed topics in appropriate eight-hour days. With the addition of new skills and equipment, the 2020 school is projected to be ten days. As learned with the second school, the candidates processed and retained the information better not running the school over multiple consecutive days.
- Adding additional practical days to the second school helped break up the monotony of lectures and allow the candidates to apply their knowledge. The scenarios they were given were challenging but not unrealistic. Many field providers were utilized to assist with these scenarios and thoroughly enjoy participating. This also gave those providers the opportunity to see how we trained and caused many of them to gain interest in the program.
- EMS simulation stations and facilitated discussion could serve as a strong format for EMS supervisor callback trainings. The EMS supervisor cadre conduct regular callback trainings to conduct skills maintenance. These challenging simulations allow advanced learning for these experienced providers as they are on a higher cognitive level.6 The facilitated discussions also allow stronger learning in this group.
- The committed format of a “school” allows adequate preparation for specialty positions in the department. In addition to EMS supervisor school, the department boasts a safety officer academy, apparatus operator school, staffing officer school, and officer development school (i.e. lieutenant academy). These programs allow committed training of these personnel for their specialty positions. Future “schools” could include a battalion chiefs’ school or technical rescue academy.
Authorship and Acknowledgements
The authors of this article all meet the criteria for authorship. Dr. Daniel J. Neal and Andrew Hopkins were responsible for developing this draft manuscript.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Loudoun County Fire and Rescue.
- Winter, David. “Why senior paramedics do not seek EMS supervisor positions?” Executive Fire Officer Program Applied Research Project. Emmitsburg, MD: National Fire Academy, 2015.
- Loudoun County Fire and Rescue. Information Bulletin 2015-038: “EMS Supervisor School.” December 23, 2015.
- Loudoun County Fire and Rescue. Non-Cardiac Emergencies Protocol 1-C. Advanced Airway: Rapid Sequence Intubation. June 2015.
- Law Enforcement and Fire and Rescue Departments of Northern Virginia. Joint Action Guide for High Threat Environments, First Edition. Issued October 2016.
- Loudoun County Fire and Rescue. Press Release: “Eight Paramedics Graduate Progressive EMS Supervisor School in Loudoun.” February 19, 2016.
- International Fire Service Training Association. Fire and Emergency Services Instructor, Eighth Edition. Stillwater, OK: Fire Protection Publications, 2012, p. 263.