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How implementing command structure improves EMS response

EMS organizations can benefit from adopting the fire service model of a command structure as part of their response strategy


The PIC model ensures all crews are able to establish and follow a similar command structure.


By Brad Davison, alumnus, American Military University

Bringing calm to chaos – that’s what citizens expect when they dial 911. Yet, what often happens is that the chaos of critical emergency calls can quickly overwhelm and stress first responders. This is a less than ideal scenario, to say the least, but is surprisingly common.

The reason? Many emergency medical service (EMS) providers lack training and awareness about implementing an incident command structure. The fire service has worked for decades to develop and institutionalize a widely used incident command system (ICS) to bring organization to chaos during emergency response. However, EMS organizations have only recently recognized the value and need for such a command structure as part of their response strategy.

Mike Mondor, chief of EMS at the Maplewood (Minnesota) Fire Department, recognized that EMS providers were having difficulty applying fireground incident command practices to EMS calls. He noticed that critical EMS calls often became chaotic and disorganized when more than one provider acted in the role of team lead.

During a response, providers did not establish a formal command structure identifying a single commander, therefore causing further chaos at the scene. Due to a lack of organization and communication, providers’ stress levels spiked during critical calls, which contributed to tunnel vision, freelancing (action independent of command delegation), and ultimately less-than-optimal medical care quality. It became clear to Mondor that both providers and patients would benefit from the implementation of a formal EMS command structure.

Developing a command model for EMS

In 2012, the Maplewood Fire Department began to research various fire and EMS command models that were scalable and practical for all types of critical EMS calls. After researching various structures and combining their best features, they developed the paramedic or provider in command (PIC) model. The PIC model combined the scalability of ICS, the efficiency of a “pit crew” approach, and the structure of Blue Card.

In addition, since the department provided both fire and EMS services, they based the PIC model off the fireground command structure because many firefighters had already been trained on that structure. Doing so ensured that all crews were able to establish and follow a similar command structure, regardless of the nature of the call.

What is the PIC model?

The PIC model emphasizes one person in the command role, while giving the option to assign a later arriving senior medic or chief as an advisor. The objectives of the PIC are to focus on circulation, airway, breathing and family stabilization. The first-arriving unit initiates a working command to achieve these objectives and then assigns later-arriving providers specific roles, either as individuals or within groups to maintain those objectives (i.e., compression group, airway group, etc.).

Once four or more responders (law enforcement, fire, other EMS) arrive on scene, the PIC should be able to take a strategic role and remove themselves from any hands-on tasks. Mondor encourages his providers to position themselves by the patient’s feet, away from distracting screens and a crowded airway.

Along with assigning patient-care roles, the PIC is responsible for, and should delegate when possible, the monitoring, informing and comforting of the patient’s family. “The family will likely not remember whether you successfully performed a certain skill or not, but they will remember how you made them feel during the care of their loved one,” Mondor said.

Addressing skepticism during the adoption of a command structure

Like most changes in the emergency services world, shifting to the PIC model was slow and steady. Mondor recalls a noticeable pushback from his crews upon initial training and implementation of the PIC model. Some providers worried that there weren’t enough responders to justify having someone dedicated to the hands-off PIC and/or advisor roles. However, through training and real-world application, crews discovered that the PIC model could be implemented with as few as three to five responders (often including law enforcement and fire).

Training didn’t end in a classroom setting. According to Mondor, the Maplewood Fire Department leadership took an intentional and actively supportive role once crews had been trained on the PIC model. After initial training, staff were assisted and supervised when applying the command structure in the field. It was through this continued training, supervision and emphasis that crews were able to quickly adopt and embrace the new model.

As a result, once the model was fully implemented and fine-tuned, the department saw a significant improvement in the handling of critical cases. EMS providers are able to remain organized, clearly understand who is in charge, and stabilize a situation faster. Today, the PIC model continues to thrive at the Maplewood Fire Department, giving providers confidence that they are delivering organized, effective, and focused patient care.

About the author

Brad Davison is a firefighter/paramedic at the Maplewood Fire Department in Minnesota. In the fall of 2017, Brad completed his Master’s degree in Public Administration, with a concentration in Emergency Management from American Military University. He has been a contributing author to numerous Fire and EMS publications, and enjoys teaching whenever possible. To contact the author, please email To receive more articles like this in your inbox, please sign up for In Public Safety’s bi-monthly newsletter.

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