The rate at which the world is changing is dramatic. People, governments and maps are changing almost overnight. There have been several changes in EMS over the years, and decade by decade the profession has improved. Yet the job's basics remain the same as they were 10 or 20 years ago. It is about getting patients to the hospital, providing care and compassion, and occasionally providing a technical intervention that buys a person precious time.

The very essence of leadership requires a chief officer to have vision. To lead an organization into the future the leader must be able to inspire people to follow that vision. An organization that does not see the future and begin preparing for it now will be fighting for its livelihood. The well-prepared and forecasted EMS organization will emerge with more opportunities and security in its ability to serve its communities.

The future is going to require EMS to be more accountable; several issues will surround this concept. In a world of surveillance, cell phone video and the Internet, the public will see more of the good and bad of what EMS and the fire service does. This will require a more significant role for public-information officers in fire and EMS. Fire EMS chiefs will need to become more adept at handling and cultivating media relationships. Michael Moore's film Sicko will remind Americans that fire-based EMS is frequently the best bet for honest, reliable and efficient care. It is this type of media that will again place our profession on a pedestal, making us more accountable to live up to our hero status.

Physicians and the medical community involved with regulation and reimbursement will require more accountable practices in billing, performance and the practice of medicine. The pre-hospital world will be required to put in place procedures, policies and practices that will be subject to the scrutiny of evidence-based medicine and require a return on investment. Expect challenges to ALS engines, response-time standards, intubations and many of the practices currently used by EMS. Fire departments will resurrect the fire surgeon and become integral players, if not the initiators, of medical research. EMS will hold a distinct advantage as unbiased evaluators and produce research that is not tainted by drug companies or profits.

City and country managers will start to ask for real cost for EMS services. With the implementation of the national EMS database, patients will be able to be tracked from the time EMS sees them to the time they are discharged. This will identify the true cost for certain injuries. The EMS database or records-management system will link to trauma center records-management systems, police department accident statistics, and onboard crash statistics transmitted by systems like OnStar. This will facilitate the funding streams like federal and state grants, HMOS and insurance companies putting more money into injury prevention targeted at specific diseases.

The natural progression of computer-aided dispatch will be to track EMS incidents and apply technology to achieve most efficient response. Fire and EMS agencies of the future will use Geographic Information Systems and real-time data to make decisions. gis mapping of call volume statistics will guide decisions on deployment, staffing and resource use. Systems like Firstwatch will enable managers and EMS chiefs to get real-time data on operations. For example, an EMS manager will know exactly when a sentinel event happens within the organization, like a pediatric drowning, and be able to respond to assess prevention strategies or lessons learned. Technology and data management will make resource acquisition a more precise science in EMS.

Decisions on human resources will continue to be the biggest issue for EMS managers during the next 10 years. Deployment decisions will become hard choices. While the concept of an ALS engine may be debated, the need for four-person engine companies will become the standard. The benefits of having enough staff for a strong command presents will become more apparent. As the National Incident Management System becomes more functional in daily EMS operations, the role of the incident command on even the most routine of EMS calls will be brought to into focus.

Many of the operations performed by the fire department will be more efficient, safe and cost effective with a standard crew compliment. As vehicle accidents now encapsulate most victims of a wreck, the evolution required to extricate and apply proper cervical spin protection needs four people. Cardiac arrest, the movement of bariatric patients, and applying a backboard are a few daily events that require a standard crew. Make no mistake, Americans will continue to get bigger and require more resources to move them.

The use of overtime also will artificially inflate paramedics' salaries and create rich and poor departments. Much like society's ever-widening gap between the wealthy and the poor, the middle class paramedic and firefighter will move horizontally between departments going to the highest bidder or to better-paying departments. The days of a well-trained and skilled paramedic having to work for three different agencies will disappear.

EMS will be asked to do more with less. Fire department and public safety salaries and pensions will continue to be the most expensive aspect of government budgets. When politicians are faced with raising taxes or cutting budgets, increases in equipment and personnel will be harder to come by. Tax increases voted on by the public will be more difficult to sell. The trend in constant staffing and the use of overtime in departments will continue leaving communities without the extra cushion of firefighters and paramedics for natural and man-made disasters or multi-alarm fires. This will force EMS agencies to rely more on their neighbors for daily help or multi-patient or multi-alarm incidents.

There will be fewer and fewer people coming to the door with a desire to do EMS. The EMS profession needs to work very hard to recruit new people into the work force. The number of people wanting to enter the medical profession is less than the number of those exiting fire-based EMS careers and those who will need EMS care. The younger generations are choosing other professions that do not involve taking care of someone or the emotion that goes into witnessing human suffering.

One hopeful source of new employees will be those returning from the military. Dedicated, well-trained and experienced pools of emergency service workers are awaiting our call. The future will see departments reinstitute the use of veteran's points to reward military service. Many of the new emigrants to the United States come from cultures where the idea of taking care of the elderly will be an honor instead of a burden, and those new immigrants will save the health care system.

There may be fewer engines and more ambulances deployed in systems where fire-based EMS is the main provider. As engineering practices reduce fires and the baby boomers impact the health care system, look for officials to staff peak-load units in the fire service or convert engine companies to ambulance or rescue companies. Fire departments will be required to use alternative staffing and delivery models to meet the community's needs without breaking the bank. As access becomes an issue in crowded urban areas, expect to see motorcycles, bicycles and alternative response vehicles used in more scenarios.

Americans will continue to look to the fire department as their health care safety net. Like the resourceful people we are, we will look to find alternative ways to deliver medicine under a public health model. This may include moving more nurses and physician assistants into the field of pre-hospital care. This also may require the fire-based EMS transport units to deliver people to alternative care centers like mental health facilities, clinics or hospice. More often, EMS will look for ways to provide care in the home and coordinate the resources necessary for families to stay home and care for their loved ones.

The use of nontraditional roles or the addition of civilians not involved in direct fireground or EMS operations will come into play in most fire-based EMS services. This will include everything from gis technicians, audio-visual specialist, training professionals and pubic-information specialist. Consider the amount of training being done over the Internet or distributive education platforms. Many departments may look to hire a technician to conduct this training in-house. Because many of the support roles needed in EMS require a person to move from shift work to a 40-hour work week, chiefs' positions will increasingly come from outside the organization. Often these may be people taking a second career or postponing retirement from another department.

So far, ambulance design has had only modest change. However, anticipate ambulance design changes based on science collected from crash tests and physics experiments. There will be more technology using gps and video to transmit or collect data in the ambulance on the ambulance drivers and the actions of other drivers around them. A stronger emphasis will be placed on the ergonomics of an ambulance and how to protect our work force from occupational injuries. Expect to see an NFPA standard on ambulance design. As the big three auto makers are overtaken by foreign manufacturers, look for a trend in fleets of foreign ambulance chassis with a variety of different fuels.

A single federal EMS agency may still evolve out of the Department of Transportation. Although a federal EMS agency may enhance coordination, look for more unfunded mandates, tougher regulation and, changes in the standard of practice and curriculums. Changes in these curriculums will force EMS chiefs to send more staff to college for paramedic training, change deployment of paramedics for better use or bring paramedic training in-house.

Fire-based EMS will be asked to supplement federal responsibilities similar to the National Guard as the Federal Emergency Management Agency and other response agencies are downsized due to the lack of equipment and personnel. Fire departments will need to better understand how to navigate the federal reimbursement schedules for deployments in natural or man-made disasters. This need to play a larger role will facilitate standardization of training and certifications.

The future is full of uncertainty and EMS will continue to be challenged by changes that are being driven by money and not altruistic motives. Fire-based EMS will continue to be the right response and be the most accountable to the public. It will be important to continue to ensure that the public never sees a change in the commitment, quality and enthusiasm fire-based EMS has traditionally given. That is something that should never change.

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Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.