LEXINGTON, Ky. — At the 2025 American Ambulance Association Annual Conference, Royal Ambulance founder Steve Grau delivered a powerful reminder that leadership doesn’t start in a boardroom or budget meeting; it starts in the mirror.
In his session, “The conscious leader: Aligning mindset, energy and radical responsibility,” Grau challenged EMS leaders to reframe their understanding of leadership as an internal discipline grounded in mindset, emotional awareness and energy, not just metrics or management style.
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“Great leadership starts with self-leadership,” Grau told the packed room. “I realized that I was the biggest bottleneck in my own organization — and that everything starts and stops with me.”
Grau wasn’t speaking in metaphor. He recounted the early days of Royal Ambulance, founded in 2006, and the steep learning curve that came with growing from a small, two-ambulance BLS provider into a regionally recognized healthcare transport partner. At one point, facing lawsuits, financial stress and operational overwhelm, he had to confront an uncomfortable truth: he couldn’t blame anyone else. “I woke up and realized, I am doing this to myself.”
From reaction to response
The heart of the session centered around what Grau called “radical responsibility.” Rather than react to external circumstances, he encouraged leaders to ask one simple but transformational question: What can I do about this? “Blame is easy,” he said. “But it doesn’t solve anything. Leaders who take full responsibility create learning cultures instead of finger-pointing cultures.”
He also discussed the value of shifting from reaction to response — pausing, breathing and choosing how to engage with challenges. Grau led the room in a brief posture and breath exercise, prompting attendees to sit tall, breathe deeply and recalibrate their energy in real time.
“If we don’t manage our mindset and energy, our teams will absorb whatever we bring into the room,” he said. “You’ve seen it. A drained or distracted leader can deflate an entire shift.”
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Leadership is a practice — not a title
Grau didn’t shy away from vulnerability. He admitted to battling toxic self-talk during a difficult chapter in his company’s journey, and shared how he became the most frequent user of his own company’s EAP. That turning point helped him recognize that leadership is an ongoing practice, not a finished product.
“Leadership is spiritual,” he said, “not in the religious sense, but in the human sense. It’s the work of being aware of being aware. And that awareness affects how we lead, how we show up and how we inspire others.”
Throughout the session, Grau reinforced a key lesson: our thoughts drive our emotions, our emotions drive our actions and our actions drive our outcomes. To change results, we have to first shift what’s happening inside.
He also introduced the concept of living “above the line” or “below the line” — a tool from the Conscious Leadership Group. Above the line, leaders are curious, open and focused on learning. Below the line, they become reactive, closed and fixated on being right. Grau encouraged attendees to regularly ask themselves: Where am I right now?
From values to culture
Beyond self-awareness, Grau emphasized the importance of codifying and communicating values. “Our company values — drive, empathy, adaptability and engagement — aren’t just posters on the wall,” he said. “They came from hard-earned lessons and shape how we hire, lead and grow.”
He reminded the audience that culture is most tangibly measured by how it feels to walk into a station or office. “If you walk into a place and it feels heavy, that’s culture. If it feels energized and aligned, that’s culture, too. And that starts at the top.”
Grau left the room with several practical tools:
- Daily breathwork
- Gratitude practice
- Mindset resets
- What he called “priming” — preparing yourself each day to lead with clarity and intention
He encouraged leaders to “stand guard at the door of your mind,” eliminating distractions and managing mental noise that gets in the way of being present.
“EMS leaders don’t always get to control reimbursement rates or regulatory chaos,” he said. “But we do control how we show up — and that’s where real influence begins.”
Final thoughts on EMS leadership
Grau’s message was simple but urgent: you can’t lead others until you lead yourself. In a field where chaos and complexity are constant, presence, purpose and personal alignment are leadership tools just as essential as policies and processes.
“Tonight,” Grau told the room, “write down one thought pattern that pulls you below the line — and the breath that brings you back above it. That’s what you bring to work tomorrow.”
