I must start with exciting news. Our MEDS (Modernizing EMS Delivery and Sustainability) Bill has been introduced as H.R. 3443. This bill was described in detail in the April 2025 newsletter and calls for 1) a MedPAC study of the value of EMS medical direction, 2) a CMMI study to prevent shortages of essential EMS medications by paying for these medications and also paying for blood products, and 3) an approach to clarify hospital responsibilities for patients on arrival by EMS to eliminate excessive “wall time” before patient handoff. I urge each of you to reach out to your U.S. representative and ask that they join in supporting the future of EMS care by cosponsoring H.R. 3443.
Now to my newsletter topic for this month – the crucial role of the EMS medical director in ensuring patient safety and EMS clinician safety. My academic career has primarily focused on EMS safety, initially on reducing the hazards associated with unnecessary lights and siren use, and subsequently, over the past 30 years, on various aspects of EMS patient and practitioner safety.
Medical directors perform numerous functions within EMS agencies and systems. While we often emphasize our role in ensuring the quality of care provided within our agencies, we are also integral members of the safety team. A culture of safety originates at the top, and the EMS medical director plays an important role in safeguarding both patients and EMS clinicians.
When we think of safety in EMS, we all know of the dangers of unnecessary lights and siren use, and our recent NAEMSP position statement and other initiatives have led to a tipping point with many EMS agencies actively working to reduce this risk. The efforts of NAEMSP and others were recently highlighted in one of Malcolm Gladwell’s Revisionist History podcasts. We still have too many EMS clinicians, patients and members of the public harmed by crashes related to lights and siren responses or transports, but we are making progress.
In addition to efforts to reduce injuries and deaths of EMS clinicians through operational policies and a culture of safety, we also know that EMS medical directors are crucial to ensuring safety for our patients through training, protocols, patient monitoring, and support for safe technology. Treatments given in the field should heal more than they harm, and medications delivered in the field should be given with safeguards that are similar to those used in the hospital.
We are all familiar with the critical importance of universal capnography when confirming placement of an advanced airway, the added safety of giving continuously infused medications through an electronic pump, diligent monitoring of patients who receive a sedating medication, and best practices for storing and carrying medications to avoid errors – but is your system overlooking the training and education that your newest practitioners are receiving in their initial certification courses?
Are your local EMS education institutes specifically teaching safe practices and planting the seed for a culture of safety in their curricula?
If you are an EMS medical director at an education institute, I challenge you to evaluate whether the instructors are teaching and reinforcing safe practices to new recruits. Cutting corners during training and education can irreparably damage the culture of safety in new recruits. Recently, I became aware of two concerning stories from training institutes within my state.
One institute proudly advertised a capstone paramedic event on social media. Near the end of their course, paramedic students were required to stay awake for 24 hours, intermittently providing multiple high-level simulations with challenging cognitive, physical, and psychomotor cases. Their stated goal was to train students to function under sleep-deprived stress. I believe it would be more beneficial to teach evidence-based lessons on the impact of fatigue on performance and the national guidelines for mitigating fatigue. What measures were taken at the end of the session to ensure that students were not driving home so exhausted that they were functioning as if intoxicated?
Another story involved a recent EMT graduate who enthusiastically described a CPR training exercise from his program. Students performed manual CPR at a mock scene, moved and loaded the patient into an ambulance while continuing CPR, and maintained CPR in the back of the ambulance as it drove through the city from the education facility to the local hospital. The young student viewed this as a highlight of his course, unaware of the unnecessary risk of injury if the vehicle crashed while he was unrestrained or if he fell off balance during the exercise. He received no education about why this skill is seldom clinically necessary and that optimal high-quality CPR “where they lie” until ROSC is achieved offers better survival prospects for most patients.
These examples illustrate blatant unsafe practices, but how many education institutes teach skills in ways that reinforce muscle memory of bad habits—permitting intubation training on tables instead of the floor, allowing placement of advanced airways in hemisected mannequins without stressing steps that confirm correct placement of the airway, teaching the use of patient movement devices without emphasizing manufacturer standards for securing the patient, and so on.
I challenge all of you to examine how safety is taught in initial EMS certification courses and reinforced during credentialing and continuing education courses. Educating EMS clinicians about safe practices during initial certification training may be an effective way to initiate a strong safety culture in the future.
While there remains ample opportunity for improvement, I am encouraged that we seem to have reached a tipping point in attention to safety in vehicle and scene operations, medication use, appropriate technology incorporation, and overall safety culture. However, much work lies ahead before we can eliminate practitioner injuries and deaths and prevent patient harm due to avoidable misadventures by EMS clinicians.
“Let’s be safe out there! —for our patients, our EMS clinicians, and the public.”