ems supervisors are often lumped in with battalion chiefs, but the similarities are superficial and the differences are real.

The fact that ems supervisors share the uniform and vehicle of battalion chiefs doesn't mean that they share the same tasks. In fact, their position can be even more difficult, because they serve two masters: the fire department and the hospital.

In short, ems supervisors are senior medical providers who function as first-line supervisors or middle managers within two chains of command. However, there are unique management and supervisory skills needed for success as an ems supervisor. Unlike bcs, ems supervisors don't have standardized training curricula, skills or job performance expectations.

For fire chiefs to fully understand the role of their ems supervisors, we need to look closely at out-of-hospital ems delivery. Once we identify the critical job skills that are unique to this position, as well as those bc responsibilities that conflict with it, we'll have gone a long way toward recognizing that ems supervisors are more than super paramedics or junior battalion chiefs.

Command responsibilities The first step in understanding the role of ems supervisors is to remember their added responsibilties outside the department. These additional roles primarily mean two things for the fire chief:

1) ems command staff need time to maintain their paramedic skills, and

2) A well-commanded ems event looks different from a well-commanded room-and-contents fire.

ems practitioners must be able to perform to their level of certifcation, whether it be emt-Basic, emt-Intermediate or nremt-p. All of these levels require continued training and testing to maintain certification. For example, nremt-ps must obtain 72 hours of continuing education and pass a comprehensive knowledge and skills test every two years.

This need to maintain paramedic proficiency affects what happens on the street, especially for ems supervisors who provide hands-on assistance during life-threatening situations. From a traditional fire department perspective, this looks like improper command behavior. For example, they will intubate, defibrillate and administer medications. They may even ride with the patient or drive the ambulance to the hospital.

In some systems, the ems supervisor is the only person on the street with advanced airway training. He or she may need to be a hands-on commander if the patient is critical and needs to be paralyzed before intubation. Trained hands providing vital care is a hallmark of clinical command.

Now, can you imagine battalion commanders taking charge of the pump panel during a greater-alarm fire? That's not part of their role as managers. ems supervisors, on the other hand, are charged with overseeing paramedic performance for the operating medical director, who is the ultimate quality controller for als providers.

In life-threatening situations, which make up about 10% of all 911 calls, the ems supervisor is expected to be the omd's eyes, ears and hands, because the ems supervisor is the senior clinical provider at the scene. This is a serious responsibility, as the omd can revoke a paramedic's ability to function within the agency. Most state regulations don't provide due process or civil service protection to the paramedic.

Different events, different roles There are four types of ems events, and ems supervisors play a different role in each. Sometimes they're observers, sometimes they treat patients. They may need to oversee treatment while commanding a larger incident, or they may defer to a bc assigned to the scene.

1) Routine single-patient event. This ems event is like a fire suppression "silent" or local alarm. The patient is not dying and the crews know the routine. They do not require command staff. ems supervisors may observe these events as the eyes and ears of the omd.

2) Life-threatening single-patient event. Typical examples include cardiac arrest, shooting, struck pedestrian, drowning, entrapment, technical rescue and medivac. In terms of response and command, this ems event is like a room-and-contents fire. More units respond, but the activity level is within the capability of the fire and medical crews. Command coordinates activities, which means close medical oversight by ems supervisors, with early and frequent updates to medical control.

3) Multiple-patient event. This is usually a traffic crash, about one in six of which will have trapped patients. This event is like an all-hands structure fire and may require a special, second or greater alarm. Command must establish incident management sectors for triage, medical control, transport, extrication and safety, as well as coordinate multiple units from many agencies. In these events, the ems supervisor takes the Medical Control sector, coordinating and communicating with the hospitals.

Fire chiefs should consider dispatching both a battalion chief and an ems supervisor to these accidents, because it's difficult for ems supervisors to both command the event and serve as the omd's eyes and ears. While researching this article, I looked at 17 traffic crashes with four or more patients occurring between September 1997 and September 1999 in Fairfax County, Va. All events had an ems supervisor dispatched within the first five minutes. Eventually, all of the events had a battalion chief.

There was a noticeable difference in incident management when the bc arrived within the first five minutes. When the battalion chief arrived early, there were shorter at-scene times for transport units; quicker coordination with other agencies, such as the medivac helicopter, police or the accident reconstruction unit; and faster event stabilization. With no patient oversight responsibilities, the bc was free to concentrate on coordinating the incident.

4) Catastrophic multiple-patient event. This greater-alarm event, which includes subway train crashes, plane crashes, building collapses and natural disasters, may need all of your command resources. Deployment of ems supervisors is in accordance with your disaster plan.

Coordination and conflict Let's compare a typical fire with its ems equivalent. When a building is burning, the fire department deals with the structure, contents and built-in fire protection features. The first-arriving officer talks with people from the building to determine any life safety or hazardous situations. Once the water starts, there's little interaction between the incident commander and the building representative until the fire is under control.

This routine exists in stark contrast to the average medical event, which almost always involves a host of people. Each event means interaction with a patient, the patient's family or other companions, and hospital medical staff. Many events include decision-making discussions with law enforcement, allied health professionals, social workers, and health insurance or managed-care representatives.

Today's medical economics have significantly increased the people skills needed by ems staff. A decade ago, an ambulance run would be a quick transport to the nearest hospital. Today, the managed health-care web of regulations, restrictions and business miscalculations ensnares emts and paramedics, who have had to become active patient advocates. In situations like this, ems supervisors mitigate the issues that make it difficult to get the right patient to the right facility.

For example, northern Virginia hospitals saw a tremendous amount of overcrowding during the 1998-99 flu season. Patients who should have been in an icu or ccu bed spent days in the emergency department. As a result, there were many confrontations between nurses and paramedics over transport decisions. Both groups were overloaded with seriously sick patients, and neither had enough resources.

ems supervisors were a vital factor in maintaining a working relationship between the paramedics and the hospital staff. Of course, reducing conflict between agencies while delivering high-level service under hostile conditions is not part of the national emt-Paramedic or Fire Officer curricula.

The ems supervisors who made an extra effort were able to improve performance from both sides of the conflict. The supervisors who didn't were plagued by days-old hospital staff-paramedic complaints that were difficult to resolve. Every hour of delay increased the exaggeration and inaccuracy of the complaint - from both sides.

Immediate response by an ems supervisor seemed to lower the tension in the emergency departments between the paramedics and hospital staff. Everyone knew that an ems supervisor would show up within hours of a spat. Sometimes the supervisor was able to facilitate a face-to-face defusing.

While these efforts didn't solve the problem of inadequate hospital resources, it allowed both groups to re-focus on providing the best care for the patient by helping to place names with faces, and by educating each side about the other's responsibilities.

The biggest help was putting names with faces. When the conflicts started, the other party was identified as "the surly paramedic with a mustache" or "the red-headed nurse with the attitude." That created a problem, considering that there were more than 500 paramedics, 2,600 emts and hundreds of physicians, nurses and allied health professionals. Issues that went unresolved from a lack of identification would accumulate and fester.

Educating both sides on the overload situation was also a big help. Many of the early complaints focused on what the other agency should be doing. At the task level, neither side had enough knowledge on how the other worked, so there were many misconceptions and untrue assertions.

Some ems supervisors collaborated with emergency department unit managers to provide accurate information to all of the task-level players. The best suggestions to prepare for the 1999-2000 flu season came from these task-level collaborations.

Out-of-hospital conflicts In addition to smoothing over friction in the ed, ems supervisors can also minimize the number of complaints that go to elected officials and the media. Fairfax County surveyed other metro-sized fire departments that provide ambulance transportation. Departments with ems supervisors on the street had up to 75% fewer formal citizen complaints. A formal citizen complaint in this survey was defined as a written complaint sent to a medical director, fire chief, elected official, local bureaucrat or newspaper editor.

Formal complaint rates are lower because a street ems supervisor can immediately respond to a complaint or concern. Providing immediate, face-to-face response to a complaint is a vivid demonstration of the department's concern. This is a powerful tool in ems supervision, because many of the complaints are resolved after a single face-to-face meeting.

About 80% of the out-of-hospital complaints in the Fairfax survey were a perception by the patient or a relative that the paramedic or firefighter "did not care about me." Because the overwhelming majority of formal complaints arise from such perceptions, these complaints require immediate attention.

The second group of complaints (about 10%) were made because the patient or another party didn't understand how the ems system works. In other words, what happened was very different from they expected, often because of multi-tiered response. For example, a physician was shocked to see a pumper show up at the clinic when he called to have an ambulance transport a heart attack patient to the hospital.

Some of these perception complaints are determined to be unfounded. Others result from circumstances beyond the control of fire department staff. Many of these complaints come from single misunderstandings or lapses of professional conduct. A few of these complaints may point to a pattern of individual or organizational behavior that needs immediate attention.

The third and final group just needs to ventilate about the stress, problems and confusion created by a medical emergency. Most of these begin as a "didn't care" complaint.

ems supervisors also have an important role in customer service. For instance, say that mom has a kidney stone attack while driving a vanload of kids. While she's being taken to the hospital, the ems supervisor can take the kids home in her van and leave them with a neighbor, then drop the van off at the hospital so mom has a way home. This is also a medical issue, because mom was refusing to go to the hospital until she was assured that her kids would be taken care of.

The ems supervisor can also drive a spouse and/or neighbors to the hospital, which is also safer, because it avoids them tailgating the ambulance all the way to the hospital. In our haste to be heroes, we can't abandon the next most important person at the incident.

Finally, supervisors need to document every encounter, at least in part so they can discover trends and patterns before a situation becomes critical. It's interesting to note that the complaints which didn't get an immediate meeting required three to four times as much paperwork and time to resolve.

The training implications Fire department promotional examinations do not test a candidate's ability to operate effectively in a complex, multiple-agency service. Some assessment centers can only evaluate a candidate's ability to handle a supervisor-subordinate or supervisor-citizen conflict. No examination assesses the candidate's ability to succeed in an overloaded, heavily regulated health-care system.

ems supervisors are on the front line as the fire department's representatives to hospitals, state regulators and the medical community. Successful ems supervisors demonstrate an above-average skill in multiple-agency conflict resolution, including the use of tact, diplomacy and effective communication skills.

ems supervisors need to know the federal and state regulations that affect field care. Some of these regulations mandate what is supposed to happen at the paramedic-patient-hospital interface. The best example is the federal Emergency Medical Treatment and Active Labor Act regulations, which ensure that every patient who enters an emergency department gets a medical evaluation. The anti-dumping regulations benefit those without access to reimbursed medical care.

A challenge for the northern Virginia ems supervisors was determining what regulations affected local operations. The emtala regulations cover patients without health insurance, yet most of the patients transported in northern Virginia have insurance. Maryland and District of Columbia ems providers coordinate and approve emergency department diversions. In Virginia, each hospital is an independent entity with no legislative requirements to coordinate diversions. This difference was the source of much frustration.

Medical care is a people-based activity. Successful ems supervisors are on a first-name basis with the emergency department unit managers, physicians and nurses. In some communities, they're also on a first-name basis with social workers, police supervisors and adult/child protective service caseworkers. In other communities, ems supervisors are on a first-name basis with the nursing home and assisted-care unit managers.

Out-of-hospital medical care will continue to grow in complexity, and fire department ems supervisors will need more skills and resources to be effective middle managers. This may mean that the roles, responsibilities and daily duties of an ems supervisor in 2010 will be even more different from the battalion chief's. We need to develop the curricula to provide those unique training, skills and job expectations today.