March 7, 2019 | View as webpage


Attention to EMS reimbursement is reaching historic heights. After CMS announced the Emergency Triage, Treat and Transport Model, there has been widespread attention from healthcare and consumer media. Another sign of interest is the email I received from my county executive with the subject line, “ET3 and me?”, a clever play on the at-home-DNA testing kit. Email me the questions you are asking and receiving about ET3.

Thanks for forwarding last month’s Leadership Brief on safer ambulances! Please forward this leadership brief on EMS chaplains and EMS advocacy in the state capital. It’s easy to subscribe. Sign up here.


Greg Friese, MS, NRP
Editor-in-Chief, EMS1

In this issue:

By Russell Myers, D.Min., BCC

Professional chaplains are turning to original research to provide the foundations for clinical practice. Though measurement tools are not commonly associated with the work of the EMS chaplain, our work can be informed by the intentional use of research methods. The wellbeing initiative at Allina Health Emergency Medical Services is an example of how this can be done.

EMS chaplains support EMTs, paramedics and dispatchers

The role of the EMS chaplain is to support the paramedics, EMTs and dispatchers who serve our communities. EMS professionals serve in a job with a lot of emotional weight from:

  • Cumulative stress of caring for people in need
  • Stress that comes with a critical incident
  • A routine call suddenly becoming urgent
  • The sights, sounds and smells associated with an emergency call

A call that feels ordinary for one dispatcher can trigger unexpected memories and associations for another, becoming a critical incident.

EMS chaplains proactively build relationships

The professional chaplain’s approach to this position is one of proactive relationship building. We do that by riding with ambulance crews and sitting with dispatchers on a regular basis.

A guiding principle for me has been, "the time of a crisis is not the time for us to be shaking hands."

That is, we need to know each other, so that when the inevitable high-stress calls come, the dispatchers, paramedics and EMTs know who we are and why we are reaching out to them.

A reactive model of chaplaincy would resemble the employee assistance program, in which the provider is accessible on an on-call basis. Our proactive approach does not wait for the employee to ask; rather the chaplain reaches out to the employee to express concern and offer support.

Transparency is essential to the relationship; there is no hidden agenda. The "why" of this job is "because we care." Employees know I am contacting them because we all know this is a challenging field in which to work, and we, as an organization, care about the wellbeing of our people.

Who should an EMS chaplain serve?

EMS chaplain was a new position when I started in 2007. I wondered how I would determine who had experienced a difficult call, and how to prioritize them. Together with my colleague Al Kleinsasser, chaplain at a neighboring EMS agency, we asked the leaders of our organizations for guidance in determining which types of calls were most likely to cause distress, and used their top 10 list to develop standard operating procedures for when leaders should notify the EMS chaplain:

  1. Any event that results in a CISD, even if no one from our organization participates in the debriefing
  2. Death of a child
  3. Multiple casualty incidents
  4. Fatalities resulting from fires
  5. Two or more high-stress calls in the same shift
  6. Employee assaulted by a patient
  7. Traumatic work-related injury
  8. Line-of-duty death
  9. High-stress phone calls impacting dispatch staff
  10. Grotesque injuries or deaths such as decapitation, dismemberment or burned beyond recognition

Evidence for an EMS chaplain

This list was the beginning of the journey to create an evidence-based EMS chaplaincy practice and led to two IRB-approved studies. The first was a cross-sectional, validated survey of Allina dispatchers, EMTs and paramedics to evaluate professional burnout and an extensive list of potential risk factors.

As noted in the published paper, "Survey respondents indicated that they perceived CIs (Critical Incidents) involving children to be among the most difficult to experience and cope with. All seven of the pediatric incident types presented in the survey had very high average severity ratings, and accounted for seven of the top eight event types rated most difficult to cope with."

This is evidence, provided by our own clinicians, that pediatric calls are among the most difficult calls they get. This was not new. We know that calls involving children are challenging.

"Consistent with our findings and irrespective of methods or geography, studies universally report that calls involving children or persons personally or professionally known to the crew are among the most disturbing. Unique to the current study, however, was an examination of incident severity rating by parental status. We hypothesized that emergency responders with children might find pediatric CIs more distressing because of mental and emotional transference of the situation to children in their own lives, but our findings did not support any difference in perceived severity by parental status."

In other words, it doesn’t matter if the provider is a parent or not. Pediatric calls can be distressing to anyone. Informed by this evidence, I adapted my chaplaincy practice to place a high priority on follow-up contacts to all paramedics, EMTs and dispatchers who were involved in code three, lights-and-sirens, emergency transports of pediatric patients.

Our research team also conducted a follow-up focus group study to further delve into what specific elements of pediatric calls contribute to distress. The findings have been published in two peer-reviewed papers, to date.

The first, "Burnout and Exposure to Critical Incidents in a Cohort of Emergency Medical Services Workers from Minnesota" provides quantitative data on EMS providers’ exposure to critical incidents.

The second, "Emergency Medical Services Provider Perspectives on Pediatric Calls: A Qualitative Study" summarizes the qualitative information gleaned from the follow-up focus groups.

Future research

A next step in this process has been to identify and refine the referrals from supervisors and managers informing me of high-stress calls involving children, as well as referrals for follow-ups based on other criteria. Sometimes employees will contact me directly, on behalf of a coworker or to request support for themselves.

Another source of information about calls involving pediatric patients is the use of an automated notification program, set up through the communications center. Using keywords, the FirstWatch program generates email reports informing me of calls that meet the established criteria.

The initial notification gives basic information, such as the nature of the call, location and crew members. After the PCR is submitted, I receive that narrative as well. Within hours, usually before the end of the shift, I have sufficient information to begin reaching out to the dispatcher and crew members.

We have yet to do the work of measuring the impact of the chaplains’ care. In many ways, discovering the evidence on which to focus the EMS chaplain’s work has been the easy part. Measuring its effectiveness will be a greater challenge.

About the author

Russ Myers is the chaplain, Allina Health EMS, St. Paul, Minnesota and is board certified by the Association of Professional Chaplains. He can be contacted at


With an average 1,500 ambulance crashes per year resulting in injury, it’s time to recognize patient transport as a high-frequency, high-risk activity deserving a safety overhaul in EMS.

Improvements in transit safety begins by focusing on safety and ergonomic features when purchasing ambulances, and by limiting the time providers spend on the road.

By Kevin Underhill, EMS Chief

On Feb. 19, North Carolina EMS professionals discussed current issues affecting emergency medical services with members of the General Assembly at the first annual EMS North Carolina Legislative Day. The program, co-sponsored by the North Carolina Association of EMS Administrators and EMS Management and Consultants, brought attention to EMS as a profession and showed a unified approach of making EMS more effective at the federal, state and local levels of government.

Why leaders need to explain EMS to legislators

Although EMS is the distribution point of healthcare in communities across the country, the issues and needs of EMS are often linked to other healthcare policies. The issues affecting EMS today are more complex than ever before and our state representatives must hear and understand the value of EMS. These issues span:

  • Homeland security
  • Emergency management
  • Local governance
  • Medicaid
  • Medicare
  • Acute illness, trauma and chronic disease

Attendees were encouraged to schedule a 10- to 15-minute appointment with their representatives and staff members to share the current issues facing EMS in North Carolina.

How we prepared for an EMS legislative action day

EMS directors, paramedics and EMTs met on Feb. 18, the day before our legislature meetings. During this meeting, NC EMS Advocacy Liaison and former NC Chief EMS Officer Regina Godette-Crawford provided an overview of the next day’s events at the NC Capitol. Each attendee was provided a packet with a full itinerary, talking points, general assembly directory parking maps and other important information for the day.

After the meeting, attendees had the opportunity to network and make plans for the next day to ensure our message was shared with as many members of the House and Senate as possible.

What leaders discussed with NC lawmakers

Our key talking points for NC EMS Legislative Day focused on four critical issues:

  1. Reimbursement for services
  2. Opioid epidemic
  3. Community paramedicine
  4. Drug shortages

EMS reimbursement

Most of the EMS providers in North Carolina are local government based and rely heavily on a fee-for-service to fund these essential functions. The "waiver application" or "Section 1115 Demonstration" must continue to provide NC Medicaid Cost Report Settlements that provide over $35M annually to government-based EMS agencies across the state.

Although these are federally-funded dollars, they are administered through the state repository and must continue to be written into the state Medicaid plan for distribution. Current funding is based on the cost of service specifically related to response, assessment, treatment and transportation of patients, but does not capture the actual costs of availability and delivery of services.

Strain of the opioid epidemic

Opioids are putting a strain on healthcare and hitting every EMS system in the state. North Carolina has experienced over an 800 percent increase in opioid drug deaths from 1999 to 2017, largely driven by a growth of illicit heroin use.

The EMS response to the emergency is not enough. We need to have alternatives of care for patients with substance abuse disorders. This includes harm reduction strategies, acute inpatient detox, as well as rapid response teams. RRTs are a cross-functional team set up to respond post reversal to opioids, with a law enforcement officer and treatment advocate. We also need our law enforcement partners to adopt the HOPE initiative, much like the Nashville (NC) Police Department.

Funding for community paramedicine

Innovative community paramedicine programs are being provided across the state with no additional funding by Medicare or Medicaid. These programs are geared toward decreasing hospitalization and hospital readmission of citizens with mental health and substance abuse issues. The programs target at-risk individuals by providing services in the patient's home, reducing the need for costly hospital services, and providing transportation to alternative locations to provide more economical and efficient healthcare services to these individuals. Consider funding these types of services to include coverage and incentives for in-home care alternative destinations and telemedicine services.

Medication shortages

EMS agencies face daily shortages of critical medications. Without sufficient reserves of critical medications for daily activities, it would be difficult to respond to a major incident. The EMS industry is seeking support to ensure that the ongoing critical drug shortages don't impede the state's ability to respond to disasters and public health emergencies.

North Carolina EMS Legislative Day

The morning of EMS Legislative Day, nearly 70 EMS directors, paramedics and EMTS from 36 different EMS agencies met at Legislative Cafeteria to network with other EMS professionals and some of the State’s representatives over breakfast. After breakfast, EMS leaders met with legislators and staff members to share the collective message of how with legislative support EMS can help address the healthcare concerns.

The first annual NC EMS Legislative Day was a great opportunity for EMS staff to begin discussions with legislators from around the state about issues facing EMS today and in the future. A special thanks to the North Carolina Association of EMS Administrators and EMS Managing and Consulting for making this opportunity to advance EMS in NC.

About the author

Kevin Underhill is the EMS Chief for Durham County EMS in Durham, North Carolina. He can be contacted at


3 and out …

3. ET3 and you. Find the initial announcement of the Emergency Triage, Treatment and Transport reimbursement model and analysis from Dr. David Tan, president, NAEMSP; and Matt Zavadsky, president, NAEMT, on EMS1.

2. Educate the public on EMS. How long is your list of the things you wish the general public knew about EMS? Art Hsieh shares his top 8

1. Special coverage from EMS Today. Read our full coverage from EMS Today 2019, including these two popular articles on medical ethics and recruiting and retaining EMS providers.

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