Tag Archives: emergency medical services

Human Resources & Challenges in Health Care

The function of human resources is not without its challenges and difficulties. No matter the industry or organization, acquiring and managing a pool of employees can be overwhelming (Thompson, 2012). Human resources managers in health care organizations seem to face more challenges than most. From nursing and physician shortages to attracting innovative and contemporary researchers, health care organizations seem to search within thinning pools of prospective employees, yet still demand the best and brightest (Keenan, 2003; Lewis, 2010; Thompson, 2012).

One of the most challenging issues to health care over the last few decades has been a significant nationwide nursing shortage (Keenan, 2003; Lewis, 2010). Thompson (2012) outlines both a declining skilled workforce and an increasing population contributing to the problem. Both Keenan (2003) and Lewis (2010) cite the aging babyboomer population adding to the increased need for nurses through 2020 and beyond. Novel human resources strategies can result in an augmented workforce designed to meet the continually growing impact these forces have on health care organizations, specifically those with emergency departments.

One novel strategy includes consideration of other highly-skilled clinicians that do not traditionally work in hospitals. As Oglesby (2007) considers the possibility, paramedics are, by far, one of the best examples. By introducing paramedics into the emergency department, a hospital can redistribute the nurses to clinical areas more suited towards their training, decrease the patient-to-nurse ratios (thereby increasing patient safety and maximizing outcomes), and tap into a new pool of prospective employees that are well-suited to rise to the stressful demands of the emergency department (Keenan, 2003; Swain, Hoyle, & Long, 2010). Additionally, organizations employing paramedics can augment both their emergency department operations and home health care operations by sending paramedics to certain patients to mitigate their complaints and minimize the number of inappropriate patient transports to the emergency department (Swain, Hoyle, & Long, 2010). This alone would decrease emergency department overcrowding and maximize revenue and efficiency in the delivery of care. Additionally, turn-over rates should be significantly lower with a more productive work environment where stress is managed, outcomes are met, and patients are care for more effectively.

In conclusion, intelligent and novel planning of the workforce can, itself, lead to increases in recruitment and retention; however, efforts still need to focus on each individually in order to attract, maintain, and develop a first-class workforce (Thompson, 2012).


Keenan, P. (2003). The nursing workforce shortage: causes, consequences, proposed solutions (Issue brief #619). The Commonwealth Fund. Retrieved from http://mobile.commonwealthfund.org/

Lewis, L. (2010). Oregon takes the lead in addressing the nursing shortage: A collaborative effort to recruit and educate nurses. American Journal of Nursing, 110(3), 51-54. doi:10.1097/01.NAJ.0000368955.26377.e1

Oglesby, R. (2007). Recruitment and retention benefits of EMT—Paramedic utilization during ED nursing shortages. Journal of Emergency Nursing, 33(1), 21-25. doi:10.1016/j.jen.2006.10.009

Swain, A. H., Hoyle, S. R., & Long, A. W. (2010). The changing face of prehospital care in New Zealand: the role of extended care paramedics. Journal of the New Zealand Medical Association, 123(1309), 11-14. Retrieved from http://journal.nzma.org.nz/

Thompson, J. M. (2012). The strategic management of human resources. In S. B. Buckbinder & N. H. Shanks, Introduction to Healthcare Management (Custom ed.; pp. 81-118). Sudbury, MA: Jones & Bartlett.

Prior Proper Planning …

… Prevents Poor Performance

I am in the midst of planning an ad hoc merger of a number of local emergency medical service agencies into a single regional provider to reduce overall costs while maximizing revenue, improve training and the delivery of care, and to streamline the operational processes that support our providers in the field. Unfortunately, I have found that there are many obstacles that need to be dealt with at every step before moving on to the next. My research has certainly opened my eyes to developing a useful approach to these problems.

Planning “[provides] the appropriate focus and direction for … organizations” (Zuckerman, 2006, p. 3). Without planning, organizations risk stagnation and obsolescence. For any organization to succeed (and continue to do so), the strategy needs to focus both on the contemporary traditional needs as well as those anticipated in the future, but this focus needs to be comprehensive. Bartling (1997) writes of 25 different pitfalls any health care organization might face when considering strategic planning. These 25 pitfalls are just some of the issues I hope to avoid.

One of the largest difficulties in planning for emergency medical systems, however, is the sense of ‘fiefdom’, or an assertion of organizational ownership — in a truly feudal sense. A fiefdom is a literal power trip. In this area, there are 10 towns with an average of two ambulances each, and each department’s administration will fight tooth and nail to keep the organization from outgrowing them. What is interesting about the area is that many of the members of one department work for at least two of the other departments, also. This is because the pay is so meager they have to work as many hours as possible, and there is no chance of working more than 32 hours at any one service in any given week. The pay is low as is the quality of care. This needs to change, but how do I create an amalgumated organization from the bits and pieces that I have to work with? Add to that my lack of formal authority in this process. My vision is to reduce the number of ambulances by staffing eight ambulances at all times and tactically positioning them around the region. This alone would create 48 well-paid jobs, using the same 40 people who currently job share across organizational lines.

In reviewing the available resources, I have learned that there is no particular process or flow-chart pathway to effective planning (Bartling, 1997; Begun & Kaissi, 2005; Zuckerman, 2006). Critical forward thinking is needed, instead. Some of the particular issues that Bartling (1997) discusses and I foresee might be particular to my planning process are: inadequate planning, short-sightedness, underestimating the complexity of the process, post-merger angst, analysis paralysis, and lack of evaluative criteria, to name a few. Politics plays a large role in many of these issues I mention.

Inadequate planning, short-sightedness, and a lack of evaluative criteria are closely related. I see in the present that the system does not work as well as it should (short-sightedness), and I want to develop a plan that can be implemented immediately (probably suffering inadequate planning). This would leave me with a fragmented system devoid of vision and, therefore, crippled from improving (lacking that evaluative criteria). These are pitfalls that I need to avoid. These issues would give rise to the others dooming my effort to failure and, possibly, leaving the system in even worse shape than it began.

Perhaps, my only chance of fulfilling this process is to first perform a limited situational assessment by identifying the mission, vision, and values of all of the stakeholders and show how a streamlined process can better fulfill their visions (Casciani, 2012). By gaining stakeholder support, I might better leverage my idea against those who fear change.


Bartling, A. (1997). 25 pitfalls of strategic planning. Healthcare Executive, 12(5), 20–23.

Begun, J. & Kaissi, A. (2005). An exploratory study of healthcare strategic planning in two metropolitan areas. Journal of Healthcare Management, 50(4), 264–274.

Casciani, S. J. (2012). Strategic planning. In S. B. Buckbinder & N. H. Shanks (Eds.), Introduction to healthcare management (Custom ed.; pp. 3-23). Sudbury, MA: Jones & Bartlett.

Zuckerman, A. (2006). Advancing the state of the art in healthcare strategic planning. Frontiers of Health Services Management, 23(2), 3–15.

Leadership: Determining the Best Approach

 The true value of leadership is empowerment, or the ability to promote those traits through the chain of command for subordinates to use to effectively make decisions that are in the spirit of the vision of the leader (Buchbinder, Shanks, & McConnell, 2012; Kirkpatrick & Locke, 1991; Wieck, Prydun, & Walsh, 2002). When leaders make decisions, the focus is not on the myopic view of the here and now but reflects the nature of ethics and vision promoting the endeavor (Kirkpatrick & Locke, 1991).

Buchbinder, Shanks, and McConnell (2012), discuss various strategies and attitudes employed to both lead and manage the health care workforce. Though each of the styles presented are effectively used in certain scenarios, many managers and ineffective leaders misuse these styles due to misplaced attitudes, trust, and motives. These styles are authoritarian, bureaucratic, participative, theory Z, laissez-faire, and situational. The authoritarian and bureaucratic styles are closely related as dictatorial and at risk for involving micromanagement; however, authoritarians tend to be motivated by their responsibilities, whereas bureaucrats tend to disregard their responsibilities. The participative and theory Z styles are more democratic and egalitarian describing the usefulness of a majority opinion or consensus before moving forward. Though these styles could result in indecision, they are best implemented when a leader has ultimate decision-making capabilities and relies on his or her subordinates for input. Laissez-faire leadership is typically characterized as the hands off approach. Laissez-faire leadership, when used correctly, relies on the specialized training or focused scope of the work of the subordinates and lends guidance only when necessary. Laissez-faire leadership, however, can provide refuge for a lazy manager. Situational leadership is the use of all or some of the styles described above depending on the specific circumstances of a given situation. For instance, providing guidance to a new employee might benefit from an authoritarian approach; however, deciding on the best approach to implementing a new process might benefit from a participative style of leadership.

In the emergency medical services, a move has been made over the last decade to separate from the authoritarian leadership of the fire service. In my opinion (due to the gross lack of research within both the fire and emergency medical services), the attitudes of the fire service leadership do not correspond well with the manner in which paramedics wish to be led. As paramedics are formally educated and expected to perform as skilled clinicians in the field, they tend to operate independently and view their supervisors more as a resource tool than as tactical or clinical decision-makers. Combination departments, or those that operate both fire and emergency medical services, would do well with developing situational leadership skills to guide both operations (Mujtaba & Sungkhawan, 2009). Though paramedics may utilize an authoritarian style of leadership during an emergency call (and, do well to follow such styles in these environments), during normal day-to-day operations, paramedics respond much better towards a laissez-faire, or indirect, style of leadership that allows for independent critical thinking (Buchbinder, Shanks, & McConnell, 2012; Freshman & Rubino, 2002). For example, during a call, I expect that when I direct my crew to perform a certain task that it is completed immediately; however, between calls when I might say that in a particular scenario a certain intervention is necessary, I expect some discussion to aid in the learning of my crews and to help develop and hone their critical thinking skills.

True leadership has its own rewards, primarily, empowering those who follow to synthesize the traits of their leaders and evolve into leaders, themselves. This, in addition to watching your own visions take root and flourish.


Buchbinder, S. B., Shanks, N. H., & McConnell, C. R. (2012). Introduction to healthcare management (Laureate Education, Inc., Custom ed.). Sudbury, MA: Jones and Bartlett.

Freshman, B. & Rubino, L. (2002). Emotional intelligence: a core competency for health care administrators. Health Care Manager, 20(4), 1-9. Retrieved from http://ezp.waldenulibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=12083173&site=ehost-live&scope=site

Kirkpatrick, S. A. & Locke, E. A. (1991). Leadership: Do traits matter? Academy of Management Executive, 5(2), 48-60. doi:10.5465/AME.1991.4274679

Mujtaba, B. G. & Sungkhawan, J. (2009). Situational leadership and diversity management coaching skills. Journal of Diversity Management, 4(1), 1-55. Retrieved from http://journals.cluteonline.com/

Wieck, K. L., Prydun, M., & Walsh, T. (2002). What the emerging workforce wants in its leaders. Journal of Nursing Scholarship, 34(3), 283-288. doi:10.1111/j.1547-5069.2002.00283.x

Self-Assessment: Finding My Niche

 Combining the business-sense with the altruistic nature of health care, a health care manager is truly unique in focus. Some of the virtues and qualities a health care manager must posses for a long and rewarding career include a high sense integrity and of one’s self, emotional intelligence, the ability to think critically and globally, and must be equitable and just to both colleagues and clients, customers, and patients (Buchbinder, Shanks, & McConnell, 2012; Buchbinder & Thompson, 2010a).

A qualitative self-administered inventory instrument, presented by Buchbinder and Thompson (2010b), provides some insight into the qualities and virtues useful and, perhaps at times, necessary to pursue a management career in health care. The instrument, designed in Likert fashion, presents quality statements with which the subject is to agree or disagree, whether strongly or not (Likert, 1932). Although this instrument is based on the authors’ opinion, albeit expert, and there is no scoring mechanism recommended aside from high is better than low, I performed the inventory as a self-assessment to help identify some of my strengths and weaknesses (Buchbinder & Thompson, 2010a). The scoring was performed by assigning values to the the statements: 5 for strongly agree, 4 for agree, 2 for disagree, and 1 for strongly disagree, and dividing the sum of the answers scored by the median neutral value of 3 (Garland, 1991; Likert, 1932).

My score using the instrument was 153 out of 180 (85.00%). According to Buchbinder and Thompson (2010a), I possess more skills than not for a management career in health care. The lack of import placed on time management and project management seem to be two of my weaknesses, according to the instrument; although without further scrutiny, it is hard to tell if these particular items may actually suggest otherwise (Buchbinder & Thompson, 2010b; Clason & Dormody, 1994). The instrument helped to identify my critical thinking skills and my communication skills as strengths that would be useful in a health care management career (Buchbinder & Thompson, 2010b). It also showed that I have a strong ethical focus on integrity and equity.

Qualitative self-assessment instruments, such as the one developed by Buchbinder and Thompson (2010b), allow the subject insight as to the appropriateness of something like a career choice or lifestyle. Being honest with one’s self in using these self-assessment tools will also help to inform the subject of characteristics in need of cultivation.


Buchbinder, S. B., Shanks, N. H., & McConnell, C. R. (2012). Introduction to healthcare management (Laureate Education, Inc., Custom ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. & Thompson, J. M. (2010a). Career opportunities in health care management: Perspectives in the field. Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. & Thompson, J. M. (2010b). Healthcare management talent quotient quiz. Career opportunities in health care management: Perspectives in the field (pp. 5-7). Sudbury, MA: Jones and Bartlett.

Clason, D. L. & Dormody, T. J. (1994). Analyzing data measured by individual Likert-type items. Journal of Agricultural Education, 35(4), 31-35. doi:10.5032/jae.1994.04031

Garland, R. (1991). The mid-point on a rating scale: Is it desirable? Marketing Bulletin, 2, 66-70. Retrieved from http://marketing-bulletin.massey.ac.nz/V2/MB_V2_N3_Garland.pdf

Likert, R. (1932). A technique for the measurement of attitudes. Archives of Psychology, 22(140), 1–55.

The Need for Multi-Agency Coordination

Terrorists, whether foreign or domestic, typically choose targets that have value in societies or philosophies that they oppose (LaFree, Yang, & Crenshaw, 2009). For instance, according to the Federal Bureau of Investigation (n.d.), al Qaeda, under the leadership of Usama bin Laden, had their sights on the World Trade Center, a symbol of global capitalism, for many years. Another example, involving domestic terrorism, is the bombing of the Alfred P. Murrah Federal Building in Oklahoma City by Timothy McVeigh, Terry Nichols, and Michael Fortier. This target was chosen as a representation of the federal government, which McVeigh and Nichols despised, citing the incident involving federal agents in Waco, Texas, two years earlier.

Considering local community events that might be of significant interest to terrorists as potential targets, the Bristol Fourth of July Parade comes to mind. The parade is a major component of the oldest celebration of our nation’s independence and is attended by over 200,000 people each year (Fox Providence, 2011). The parade is symbolic and casualties could number in the thousands, depending on the tactics and strategies used.

There is limited egress from the Town of Bristol (see figure 1). Hope Street and Metacom Avenue are the only two roads that provide a route in and out of the town. Both lead to the Town of Warren to the north, and Hope Street converges with Metacom Avenue just before exiting the town by way of the two-lane Mount Hope Bridge to the south. Both roads are heavily trafficked during the parade inhibiting both evacuation and emergency response.

In the event that a significant terrorist act was to occur at this parade, the initial law enforcement response would be limited to those officers already on site. These officers, operating under the auspices of the Bristol Police Department would be primarily Bristol police officers with a small contingent of off-duty officers from neighboring jurisdictions. There is usually a small contingent of Rhode Island State Police troopers present. These officers would be on their own for a length of time, some of them probably affected by the attack.

Secondary responders would include both Rhode Island and Massachusetts State Police, along with mutual aid officers from approximately 10 to 15 neighboring communities; however, as people flee the initial attack, a secondary attack could create further confusion and increase the likelihood of severe traffic jams at all three evacuation points further inhibiting a timely response. Once the degree and scope of the incident is ascertained and the access difficulties are identified, it would make sense for a contingent of law enforcement to board helicopters and boats out of Providence and cross Narragansett Bay. Once on land, these officers (most likely consisting of U.S. Coast Guard, Providence Police, U.S. Border Patrol, and other federal law enforcement entities housed in Providence, RI) would rely on alternative means (walking, bicycles, ATVs, et al.) to reach the scene.

Colt State Park, to the southwest, would make a viable forward area command, allowing access for all types of vehicles, including single-engine fixed-wing aircraft. There is also an added benefit of a strong sea breeze to help direct any plume away from this forward area command post.

I have to consider that the law enforcement entities, along with the local emergency management authorities, have a working disaster plan in place for the Bristol Fourth of July parade; however, the plan must detail the fact that all resources would be overcome due to the scope and severity of such an incident; therefore, contingencies, such as stand-by assets, must be established and ready to respond by alternative means in the event that a catastrophic event were to occur, whether criminal or accidental in nature.


Federal Bureau of Investigation. (n.d.). Famous cases & criminals. Retrieved from http://www.fbi.gov/about-us/history/famous-cases/

Fox Providence. (2011, July 5). Inbox: Fourth of July festivities. Retrieved from http://www.foxprovidence.com/dpp/rhode_show/inbox-fourth-of-july-festivities

LaFree, G., Yang, S., & Crenshaw, M. (2009). Trajectories of terrorism: Attack patterns of foreign groups that have targeted the United States, 1970-2004. Criminology & Public Policy, 8(3), 445-473. doi:10.1111/j.1745-9133.2009.00570.x

Rhode Island Emergency Management Agency. (2008). State of Rhode Island hurricane evacuation routes: Town of Bristol [Map]. Retrieved from http://www.riema.ri.gov/preparedness/evacuation/Hevac_Bristol.pdf

Figure 1.

Bristol RI Evacuation Route
“State of Rhode Island hurricane evacuation routes: Town of Bristol” (Rhode Island Emergency Management Agency, 2008).

Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.


Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Critical Incident Response Plans

The possibility of a large-scale event threatening the health and safety of a large number of residents in Connecticut is sizable. Emergency response plans (ERPs) need to be in place to address concerns including epidemic/pandemic disease, the intentional or accidental release of a hazardous material, contamination of the food and/or water supply, and other incidents that might threaten the 3.4 million residents and could result in mass casualties. For this reason, the State of Connecticut Department of Public Health (DPH; 2005) has developed an ERP to guide the department in the event of a catastrophic threat the lives and safety of the residents of Connecticut. Additionally, the State of Connecticut has developed a State Response Framework, much like the National Response Framework, in order to allow for a modulation of an incident from a local level to a state or federal level (State of Connecticut, Department of Homeland Security, 2010; U.S. Department of Homeland Security, 2008). The ability of an incident response to grow and shrink as an incident dictates follows the natural progression of incidents starting and ending locally, whether involving state or local responses at any time during the response (Walsh et al., 2012).

The ERP (DPH, 2005) that guides the DPH allows for representation in the state EOC while forming a modular incident management team (IMT) to staff the DPH emergency command center. The DPH IMT is designed not only to support the state EOC when activated, but also supports the various local incident commands as a public health and medical service resource. In keeping with the modular aspects of the incident command philosophies and the state and national response framework, the DPS ERP becomes a valuable resource for both initiating a response to a significant threat to the public health and safety and allows for an expert resource when other incidents of magnitude, but not necessarily public health in nature, require or benefit from the availability of public health experts.

One criticism I do have, however, is that the plan (DPH, 2005) does not address the provision of emergency medical services (EMS). For some time, there has been much confusion as to where EMS falls in the realm of emergency service functions. EMS, for many jurisdictions, is a function of the fire department and may fall under the direction of ESF #4, firefighting, especially as many EMTs and paramedics are cross-trained to fight fire. However, ambulances are not firefighting apparatus. As ambulances do transport the ill and injured, perhaps EMS falls to ESF #1, transportation. This is unlikely, though, as the primary need is not the transportation provided but the care rendered. Public health and medical services, ESF #8, seems to me to be the logical category for EMS to fall under, but EMS has an expanded role that also fits ESFs #9, #10 & #13 (search & rescue, oil & hazmat response, and public safety & security, respectively), as well as the aforementioned ESFs #1 and 4. This lack of initial categorization may allow flexibility in the deployment of EMS personnel and equipment, but it could also lead to ineffective deployment strategies resulting in a shortage of EMS in one area and overutilization in another.


State of Connecticut, Department of Homeland Security. (2010, October). State response framework. Retrieved from http://www.ct.gov/demhs/lib/demhs/telecommunications/ct_state_response_framework_v1_oct_10.pdf

State of Connecticut, Department of Public Health. (2005, September). Public health emergency response plan: Emergency Support Function #8 Public health and medical services. Retrieved from http://www.ct.gov/ctfluwatch/lib/ctfluwatch/pherp.pdf

U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Emergency Operations Center Leadership

The emergency operations center (EOC) is a decentralized and secure place for senior management officials to maintain operational awareness when confronted with a large scale events or disasters (Walsh et al., 2012). Although these events or disasters may dictate the use of local incident commands at various emergencies throughout an area, the EOC allows an incident management team to direct the overall response effort while maintaining complete situational awareness. This allows for increased interoperability and the availability of resources and a centralized planning and intelligence effort (Walsh et al., 2012). During a multi-state event, a joint field office (JFO) might serve as the primary EOC to support other EOCs that have been activated.

Within the EOC, there are a number of leaders and managers responsible for ensuring an effective response strategy for the emergency that is being faced. One of these leaders is the Area Command Logistics Section Chief (or, “Log Chief”). The Log Chief is responsible for procuring and otherwise acquiring the facilities and personnel to support the response initiative. This includes “resources from off-incident locations […] providing facilities, transportation, supplies, equipment maintenance and fuel, food services, communications and information technology support, and emergency responder medical services, including innoculations” (Walsh et al., 2012, p. 60).

In response to an impending an ice storm in Austin, Texas, in 2003, the city’s EOC was activated 24 hours in advance of the storm. One of the crucial area command members activated was the Log Chief. The Log Chief ensured that redundant communications facilities were available as power outages were interferring with some established communications equipment. The Log Chief also ensured that there was food available for delivery to each small-scale incident as it developed. This was important as the available resources were deployed, there was a lack of available manpower during shift change, so feeding hungry crews was a priority. The Log Chief, on this incident, had many other important functions, but as a responder working in these adverse conditions, it was most important for me to be fed and have solid communications in the event I was to be one of the motorists sliding off the road.


Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Motivation: A Career that I Enjoy

I am lucky to work in a career that I absolutely enjoy. As a paramedic in the emergency medical services (EMS), I am called upon to help those in my community in the worst of circumstances to help them when they feel helpless. There are drawbacks, however. Many people rely on EMS for problems that even they do not view as emergent, and others just plainly abuse the system. Still, I enjoy being the one called upon to help. My primary motivations are my sense of community, my ability to reduce suffering, and my ability to raise the standard of care within the system. Maslow (1943) includes some of the earliest accepted work on motivational theory, and more contemporary work is based on the acceptance, rejection or modification of his theories, so I will focus on Maslow to begin. My needs, according to Maslow, are not as important to motivation. Need fulfillment will not motivate me to perform; however, a lack of fulfillment may prevent me from performing. This is especially true for Maslow’s lower-order needs. Maslow discusses how emergency situations can “obscure the ‘higher’ motivations [and create] a lopsided view of human capacities and human nature” (p. 375), and while my career is focused on responding to emergencies, this may hold true for me. While Maslow’s theory is not wholly accepted motivational schema (Robbins & Judge, 2010), EMS managers, and other public safety managers, would do well to understand this exception to motivational theory.

Many EMS managers, it seems, subscribe to McGregor’s (1957/2000) theory X without understanding the ramifications or the competing theory Y. There is a deep-seated belief that the workforce is lazy and will do anything possible to undermine the operation. This results in micromanagement tactics that seem to promote an unwillingness to promote the goals of the employer. McGregor highlights this and cautions that it a result of poor management technique, not a cause that is easily rectified by the chosen technique.

Other theories, such as goal-setting, equity theory, and expectancy theory, as described in Robbins and Judge (2010), are all lacking in one particular constant: there is no constant in human behavior. There are a number of ways that a single motivational factor might influence a particular person on any particular day. For any theory to always be true in every situation, it would cease to be a theory and become a law. This being said, as managers, we need to measure the importance of certain tasks and focus our efforts on communicating this importance to the workforce. It is the manner of this communication that will tend to fail or succeed, based on both the needs of the manager and the needs of the employee at the moment the message is passed.


Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

McGregor, D. (2000). The Human Side of Enterprise (Reprinted from Adventure in thought and action: Proceedings of the fifth anniversary convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, 1957, April 9. Cambridge, MA: MIT School of Industrial Management). Reflections, 2(1), 6-14. doi:10.1162/152417300569962

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Using Intelligence in ePCR Database Design

The intelligence of a database design begins with the intelligent approach in which the developer focuses on the particular need the database is to fulfill. It is especially important to constrain, or specialize, a database used in health care, else the database can quickly grow beyond the bounds of efficiency. Efficiency can be found directly from table design, and it can be further achieved with business rules and logic. Designing a database for storing patients’ medical records also has some risk of increasing the likelihood of medical errors and statistical incongruities if done improperly; therefore, a qualified database administrator should be consulted (Campbell, 2004; McGlynn, Damberg, Kerr, & Brook, 1998). However, a preliminary needs assessment can be accomplished by asking a few simple questions: Who? What? Where? Why?

Who needs to use the database? For whom is the data useful? By identifying the scope, or domain, of each database user, the developer can gain a sense of which data points are important (McGlynn et al., 1998; Thede, 2002). For instance, in health care, a purely diagnostic database should efficiently offer comparative differential diagnoses to aid a physician in caring for patients; however, a database of this type will not offer much to the administrative arm of the practice. By understanding the relationship between physician diagnosis and billing, relational techniques can serve to ensure greater accuracy in billing procedures.

What data needs to be stored and retrieved? By listing the specific data to be stored, the developer has an opportunity to optimize the storage methods by creating an efficient and normal relational table foundation (Kent, 1983; Sen, 2009). A patient care reporting database, for instance, must be able to store patient identifying information, or demographics. Depending on the specific needs of the practice, demographic data can usually be stored in a single table. Other relational tables could be used to store references between the patient demographic record and pertinent medical information, thereby minimizing duplication (Thede, 2002).

From where does the data need to be accessed? Does this database require authentication for use on a local area network or a complex security policy for wide area network access (Campbell, 2004; McGlynn et al., 1998)? More importantly, however, is portability of the data. If the data is going to be replicated in a large composite database, the data needs to meet the specifications of the repository. This is often achieved by the publication of a template, or a clear set of directives on how data is to be formatted before transmitting data to the repository. An example of this is the Medicare electronic records requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. By accounting for common templates in the design phase, the developer can avoid having to parse data prior to transmitting the data over the network.

Why are we storing the data? Today, it is very common to store data if merely for purposes of recording an interaction, such as a patient contact. However, it is important to understand how the data will be used in the future. Will the data need to be immediately accessible, such as in emergency or critical care areas, or could the data be compiled and batch processed during times of off-peak network load, such as in billing or logistics. Could paper reporting fulfill the immediate need better? If so, should the data on the paper report be entered in a database later? Regarding transcription, it is important to be knowledgeable about the available technology for creating scanned images, portable electronic documents, and the use of optical character recognition in order to properly prepare for the storage of each.

By answering the who, what, where, and why of the database needs assessment, we ultimately answer the question of how to design and implement the database. As an example, in order to design an ambulance run form, we must take into consideration demographics, the history of present illness (or, the reason for the ambulance request), past and pertinent medical history, including, but not limited to: medications, past medical problems and surgeries, and allergies to medications and environment. It is also important to store the assessment, care, and outcome, as well as the disposition of the incident and the destination facility. Additionally, medical standards, such as diagnostic codes, medications, protocols, and algorithms, could be stored in reference tables for preventing redundancy within the data model (Kent, 1983; McGlynn et al., 1988; Sen, 2009, Thede, 2002). Ambulances are mobile; therefore, network access is an important consideration when designing an electronic ambulance patient care reporting database. For this type of database schema, I would recommend using a small, efficient database locally with a mechanism in place to replicate the data to the larger repository when the network is accessible.

Another challenge in creating a database is learning how not to store information. Information is made of of data, but only data should be stored (Collins, 2009). Programming logic can be used to synthesize data into information and, further, into knowledge. Many database designers mistakenly store information, or even knowledge, quickly inflating the size of the database and decreasing its efficiency and normalcy (Kent, 1983; Sen, 2009).

In conclusion, developing an electronic patient care reporting database for a physician practice has some inherent risk if done poorly; however, a knowledgeable member of the office team can highlight the project requirements by performing the needs analysis.


Campbell, R. J. (2004). Database design: What HIM professionals need to know. Perspectives in Health Information Management, 1(6), 1-15. Retrieved from http://www.ncbi.nlm.nih.gov/

Collins, K. (2009). Managing information technology. Exploring Business (pp. 122-130). Retrieved from http://www.web-books.com/

Health Insurance Portability and Accountability Act (HIPAA) of 1996, P.L.104-191. (1996).

Kent, W. (1983). A simple guide to five normal forms in relational database theory. Communications of the ACM, 26(2), 120-125. Retrieved from http://www.bkent.net/Doc/ simple5.htm

McGlynn, E. A., Damberg, C. L., Kerr, E. A., & Brook, R. H. (1998). Health information systems: design issues and analytical applications. Retrieved from http://www.rand.org/pubs/monograph_reports/2007/MR967.pdf

Sen, A. (2009, May 7). Facts and fallacies about first normal form. Retrieved from http://www.simple-talk.com/sql/learn-sql-server/facts-and-fallacies-about-first-normal-form/

Thede, L. Q. (2002). Understanding databases. In S. P. Englebardt & R. Nelson, Health care informatics: an interdisciplinary approach (pp. 55-80). St. Louis, MO: Mosby.