There has been limited organizational research applied to EMS, especially in the area of job satisfaction. In the midst of a general shortage of health care workers, effective recruitment and retention of a qualified and satisfied work force is a critical issue. The purpose of this study was to examine the factors and elements in the structure or “design” of the work of emergency medical technicians (EMTs) and paramedics that can create conditions for high levels of work motivation, satisfaction, and performance.

A modified Job Diagnostic Survey was administered to a cross section of 102 paid and volunteer EMS personnel in Pennsylvania. The relationships between measured job characteristics, experienced psychological states, and job longevity on overall job satisfaction was examined.

Significant positive relationships (p<.05) exist between a number of the job characteristic variables (such as task significance, autonomy, and job feedback) and job satisfaction. Job longevity did not have a significant relationship to job satisfaction. Volunteer EMS personnel experienced higher levels of job satisfaction than did paid providers.

The results indicate that the EMT and paramedic perform complex jobs that have high levels of the characteristics that cause internal work motivation. Methods to increase the amount of these core job characteristics to improve overall job satisfaction are discussed.

Many authorities in EMS have cited the lack of data concerning the efficacy of medications administered by prehospital providers. This paper reports the results of a prospective assessment of the efficacy and safety of certain medications used by emergency medical technician-paramedics (EMT-Ps) in a three-tiered response system. Data were collected for six months using forms that were completed by the EMT-P at the conclusion of an incident. Medication efficacy was measured for: bretylium tosylate, 14 patients/3 conversions to a sustaining rhythm (21 %); diazepam, 20 patients/17 stopped seizing or converted to focal motor seizure (85 %); dopamine hydrochloride, 14 patients/9 experiencing increase of blood pressure (64%); furosemide, 49 patients/28 instances of decreased respiratory distress (57%); and terbutaline sulfate, 46 patients/34 instances of decreased respiratory distress (74%). Serious side effects were rare and well managed by the EMT-Ps. These data indicate that these medications are effective and safe when used in the prehospital environment. Analysis of more data from different delivery profiles is necessary prior to drawing appropriate scientific conclusions. Data collected should include patient follow-up through hospital discharge.

Prehospital advanced life support (ALS) is provided by non-physicians under the supervision and the responsibility of a physician—the Emergency Medical Service Medical Director (EMSMD). In order to assess the time required of the EMSMD as well as the technical support provided and the medico-legal risks involved, a survey was distributed to physicians in attendance at the Annual Scientific Assemblies of the National Association of EMS Physicians in August 1986 and June 1987. The survey also was mailed to all EMSMDs in Michigan.

Of the 66 EMS medical director respondents, 69% were compensated, 62% were provided with malpractice coverage, and 22% had been involved in legal actions. Clerical support was provided for 89%, office space for 58%, and 60% had access to a computerized record database system. The average time consumed per week was 17±13 hours.

Differences were detected in the amount of support provided between services with an excess of 10,000 ALS responses per year and those with less than 10,000. The larger services more frequently provided office space and equipment (p<.02), malpractice coverage (p<.01), and access to a records database (p<.03) than did the smaller services. The EMSMDs for the larger services also were involved more frequently in legal actions (p<.03).

Legal actions involved 14 of the EMSMDs: paramedic malpractice (6); system failures (3); dispatch errors (2); inappropriate receiving facility (2); and paramedic licensure, equipment failure, union grievance, withdrawal of medical control, and trauma center designation (1 each). Four of the 14 involved had not been provided with malpractice coverage.

Medical direction of a prehospital EMS system requires a significant time commitment, incurs medico-legal risks, and in most communities receives clerical and data retrieval support, and the EMSMDs are compensated.

The purpose of this study was to measure the contributions of a physician crew member in a helicopter emergency medical service (HEMS) and to develop a method to utilize physician services more efficiently. A two-part study utilizing two independent sets of measurements of physician necessity was conducted. A post-flight questionnaire and the success rate for endotracheal intubation were used as measurement tools.

With the passage of time, the fight nurses perceived the physician crew member' contribution to clinical judgment decreased from 21% to 1% of the flights and that the physician's contribution of technical skills (intubation) declined from 11% to 3%. The contribution to clinical decisions seemed more important on interhospital transports than on scene responses. The technical skills (judged by the tracheal intubation success rates) of a physician seemed more cogent on responses to the scene. When in the capacity of a second crew member with an experienced flight nurse, the endotracheal intubation success rate increased from 71% to 90%. Therefore, it seems that physician services could be restricted primarily to scene response flights. This limited utilization of flight physicians should make these physicians available for other duties.

The prehospital care provider has been limited in his or her initial assessment of patients due to having available only a limited number of simple diagnostic tests. There has not been an accurate field test available to rule out significant ethanol intoxication. We designed a prospective trial for the prehospital setting to test the utility of a rapid, semi-quantitative, saliva alcohol reagent strip for patients with an altered level of consciousness. We found that these strips were useful in ruling out significant ethanol intoxication as a cause of an altered level of consciousness with a sensitivity of 85.7% and a specificity of 94.4%, but were not useful in accurately predicting the blood alcohol level. We conclude that these reagent strips are useful in the prehospital setting to provide information about patients with an altered level of consciousness.

The expansion of hospices and recognition of living wills have made it necessary for emergency care providers to re-evaluate the appropriateness of universal application of cardiopulmonary resuscitation (CPR) in the field. The prehospital care community is coming to realize that CPR is beneficial only in certain specific situations. Some believe that when CPR is not likely to be beneficial, it should be withheld. Withholding CPR seems to be a simple matter of law and science, but a number of factors complicate the issue, especially in the prehospital setting: What are the definitive signs of irreversible, sudden death? When is the application of CPR futile? What are the responsibilities of the prehospital emergency care provider who announce someone dead? What is the lay public's perception of stopping or withholding CPR? Withholding CPR in this environment is a complicated social and emotional issue as well as a scientific and legal one.

Initiation of cardiopulmonary resuscitation when the death is the result of an end-stage, irreversible, and imminently terminal illness against the patient's prior request is immoral and indefensible. Medical providers should withhold treatments that are futile, and individuals have the right to refuse this invasive therapy.

The use of Do-Not-Resuscitate (DNR) orders has become a standard of medical care in health care institutions and should be incorporated into the prehospital medical care system. The American College of Emergency Physicians (ACEP) supports their use, and the National Association of Emergency Medical Services Physicians (NAEMSP) has developed a consensus paper endorsing the use of prehospital DNR orders. The Joint Commision on the Accreditation of Hospitals (JCAH) recommends the use of DNR orders and the American Heart Association (AHA), in Standards and Guidelines for Advanced Cardiac Life Support, recognizes their validity. It is time for EMS systems to develop and implement policies and procedures, with adequate safeguards, to allow the withholding of CPR in specific circumstances. The claim that DNR orders cannot be honored in the prehospital setting is a self-fulfilling prophecy. If an emergency medical services (EMS) system lacks strong medical leadership or believes that a prehospital DNR system cannot work–a communitywide DNR program never will come into existence. Dying patients will continue to suffer the indignity and burden of unnecessary and futile treatments that serve no benefit to the patient and only serve to alienate and anger the family members.

Prehospital health-care providers regularly are called upon to assist terminally ill patients in residential or institutional, non-hospital settings such as nursing homes or hospices. Among the most crucial issues regarding such patients is whether they should be resuscitated. With alarming frequency, EMS providers are encountering vigorous and sometimes violent refusals of examination, treatment, and/or transportation from the terminally ill patient, members of the patient's family, or third persons ostensibly acting on the patient's behalf. Today, the prehospital emergency health-care provider repeatedly is faced with the legal and ethical questions that surround the issue of resuscitation and advanced life support.