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The Ambulance Driver's Perspective
by Kelly Grayson

EMS management: Moving responsibility upward

Many management systems that perceive a lack of discipline in their field crews are actually missing a lack of effective leadership

By Kelly Grayson

The beatings will continue until morale improves. -Anonymous Middle Manager


A few weeks ago, a Confessions of an EMS Newbie podcast listener asked my opinion of EMS agencies that adopt a rigid, quasi-military rank structure and chain of command.
My first instinct was to answer that such hierarchies are rather silly and a poor fit for EMS. But rather than spout an uninformed opinion based on secondhand knowledge, I did what any good instructor would do when a student stumps him with a question for which there is no easy answer — I consulted my sources.

I know a number of law enforcement and military officers who also serve as civilian EMTs, and I know a number of EMTs who served in the armed forces. To these men and women, I posed these questions: "Given your military experience, are quasi-military command hierarchies a good fit for EMS, and do such rank structures encourage or discourage personal initiative in the rank-and-file medics?"

Their answer was an emphatic and unequivocal, "It depends."

No, they weren't waffling. Cops and soldiers are nothing if not direct. Almost all of them thought the military style rank structure would be a good fit for EMS… if it is implemented fully.

That's a pretty big "if."

The problem with many of these systems is that they implement such rank structures because of a perceived lack of discipline in their field crews, when what is actually missing is a lack of effective leadership. What they wind up with is all of the drawbacks of the military rank structure and none of its benefits, because they lack the one element that makes such hierarchies work — responsibility upward.

As one former EMT and current law enforcement officer was told when he was commissioned as an Army lieutenant, "Rank hath its privileges, rank hath its responsibilities, and rank hath its obligations. The responsibilities and obligations always outnumber the privileges."

Too many supervisors forget that.

As one source put it, "Responsibility upward is what makes the rank system work. Without it, your troops may be obedient, but they'll never be motivated."

People are more easily led than driven. - David Harold Fink


Whether your agency adopts a laissez faire management style or a more rigid command hierarchy, neither one will succeed without effective leadership. One of the basic tenets of leadership is never order a subordinate to do something that you are not capable — and willing — to do yourself. If you aren't, believe me, your subordinates will know it.

More importantly, their performance will reflect it.

A leader is more than a supervisor. He's a coach, a mentor, a teacher, a disciplinarian, and an advocate for his subordinates. He sets clear goals, gives his subordinates the tools to accomplish those goals, and then he gets the heck out of the way. So much of leadership is simply making it easier for your subordinates to do the right thing than the wrong thing.

When those subordinates make mistakes — and they invariably will, because improvisation is the name of the game in EMS — the leader also reevaluates his mentoring, coaching, and teaching, and modifies his approach accordingly.

And if that approach was flawed, he practices responsibility upward by telling his superiors, "It's my fault, and my responsibility. I'll fix it."

Believe me, just as your subordinates know when you can't walk the walk, they'll also notice when you take the heat for their mistakes, and they'll bend over backwards to never put you in that position again. Their performance improves right along with their morale. They know you've got their backs, and as a result, they'll have yours.

They'll make you look good to your superiors, who in turn will look better to their superiors…

That's responsibility upward, folks.


A few weeks ago, my partner got lost on the way to a call. Through a confluence of factors, it took us a lot longer to reach the scene than it should have. Compounding the mistake, she relied on the proximity feature on our automatic vehicle locators to mark us at scene. It didn't, making an excessively long response time look even longer on paper. To make matters worse, she left the portable radio in the rig, and thus never noticed dispatch frantically trying to reach us.

And most of that was my fault.

Yes, she was driving. Yes, she was unfamiliar with the streets in her service area, and made a wrong turn. Yes, she continued on that wrong turn far longer than she should have, mistakenly relying on the turn-by-turn directions from our GPS navigator rather than the cross streets in the call notes. Yes, it was her responsibility to carry the portable radio.

But she was also a rookie, and still naïve enough to think that the technology always works like it should. There were half a dozen things I could have done to better familiarize her with the streets, none of which I did. And it's not like I didn't carry that portable radio quite a bit myself. She was still new enough that she looked to me for guidance on just about everything. Whatever the reason, on this call, that guidance was flawed and ambiguous.

I said as much to my supervisor as I signed the disciplinary form. "It's my fault, my responsibility. I'll fix it." There's no reason to spank the rookie and quell her initiative when the senior medic could have prevented the mistake.

That's a lesson I learned from some good supervisors early in my career, people who lead by practicing responsibility upward. I try to follow their example.

About the author

Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (, or email him at

The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Gary Walter Gary Walter Saturday, September 21, 2013 9:27:37 PM I'm not sure "discipline" was the best choice from if the agency was looking for improvement. Quite possibly this is a bigger issue than a a "comedy" of errors. Quite possibly, there are some agency-wide, nation-wide issues that should be improved.
Skip Kirkwood Skip Kirkwood Sunday, September 22, 2013 12:17:36 PM I think I see some personal bias in the framing of the question, Kelly. Use of a quasi-military rank structure does not equate with a rigid approach to life, a lack of staff input, or anything like that. In fact, the use of rank insignia is as often for the benefit of those outside the organization. WE all know who we are, and where we fit in our organizational food chain. The people we work with, outside of EMS, do not necessarily have that knowledge. We can all tell who the "top cop" on the scene is by reading the stripes or brass or whatever. Ditto for the top firefighter - brass, helmet color, turnout coat, etc. EMS? Not so clear. Funny story, happened to me once upon a time. An EMS agency where I was a chief officer had small, simple silver badges for EMTs and paramedics, and the same, small, simple gold badges for supervisors and higher. Shortly after adopting "EMS-unique" collar brass for shirts, I noticed an immediate change. Instead of the "Who are you?" look from the police officer on the perimeter, I got instead, "Come on in, sir, the command post is over there." THEY are used to reading collar brass on people they don't know, and responding accordingly. The Marine Corps is often thought of as having a most rigid command structure. Yet, if you work with them, you quickly learn that everyone, regardless of rank, is expected to speak up and contribute to the planning process, and point out flaws in what they see. This is so institutionalized that now, major USMC commands have been directed to set up "red cells" to challenge command thinking even further. So I guess that I don't think that the use of recognizable "rank" in EMS equates to any particular style of leadership. There may be more to it, but this is my thought for the day.
Jeff Birrer Jeff Birrer Sunday, September 22, 2013 6:43:53 PM agrred!
Rob Stabbe Rob Stabbe Sunday, September 22, 2013 8:25:51 PM Interesting article.
Warren Swanson Warren Swanson Monday, September 23, 2013 7:33:14 AM I think the rank structure in EMS is more for when we are on a call with other agencies they will be able to tell who the highest ranking person from EMS is.
Kelly Grayson Kelly Grayson Wednesday, September 25, 2013 4:14:00 AM Skip Kirkwood, there is a well known EMS agency that implemented in its training academy, a policy of requiring recruits to bark "Sir, yes, Sir!" when addressed by the training cadre, "drop down and give me twenty" and such nonsense. This wasn't just for green kids right out of EMT school or going through school, this was for *anybody* they hired, even medics with years of experience and significantly older than many of the cadre. After an incident that made the news, they backed off on much of that. Whether the incident had anything to do with it is anybody's guess. What I'm talking about is not so much the visible insignia of rank, or even what you call the supervisors (or command staff, if you prefer). I'm talking about the *way* they handle discipline and supervision. I'll go back and quote from the article: "The problem with many of these systems is that they implement such rank structures because of a perceived lack of discipline in their field crews, when what is actually missing is a lack of effective leadership. What they wind up with is all of the drawbacks of the military rank structure and none of its benefits, because they lack the one element that makes such hierarchies work — responsibility upward." They believe that a military approach is necessary to "whip the troops into shape," when they know little of the principles of effective leadership instilled in the actual military commanders. It simply doesn't work unless you take the approach such as you gave in your example about the Marine Corps. They have all of the outward dressings of the military command structure, and none of its innate strengths. It's still just micromanaging and punitive discipline dressed up in a uniform.

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