This research aims to report the components and culture of an effective collegiate EMS program in five different sections:
the history of the program being studied
EMT role and identity
the role continuum,
group cohesion, and
The author, a social scientist and Emergency Medical Technician (EMT), performed nine months of participant-observation research -- understanding a culture by fully participating in it -- at a small university on the West Coast. The program discussed herein treats roughly 200 students on campus each year.
State-licensed student-EMTs (hereafter referred to simply as 'EMTs') select roles along a continuum from 'student' to 'medical professional.' The medical condition of the patient is the largest contributing factor in role-selection for EMTs. If the patient has a non-serious injury, the interaction between EMTs and patient is very similar to that between peers. If the condition is serious, EMTs adopt the character of medical professionals. The theoretical implications of these findings indicate that emergency medical workers are likely to draw on their non-professional characters when appropriate to do so.
Focusing on interaction between EMTs, I discovered that group cohesion is the most important factor in running an effective program. When group familiarity is high, response time is quicker, EMTs display more teamwork, and fewer shifts are missed or cancelled. Program officers bolster group cohesion, and so larger programs (25-50 volunteers) are able to operate more smoothly.
Collegiate EMS programs are being created at a quickly increasing rate (more programs were engendered in the last 14 years than between 1950 and 1989). A case study will allow us to see which factors contribute to the effectiveness of a collegiate EMS program, and use the findings to improve similar programs. Using the lessons from this research, effective new collegiate programs can be created, and existing medical, safety, and community-based programs can be improved.
Effective collegiate programs reduce student medical costs, help alleviate strain on prehospital emergency workers and local fire departments, allow volunteers to gain medical and organizational experience, and, with quicker on-campus response times than off-campus emergency crews, can save lives.
A History of Sunshine University Emergency Medical Services (SUEMS)
This research takes place at Sunshine University, a West-Coast private school with an undergraduate population of 5,000, in close proximity to a Fire Department. In 1997, the Fire Department made over 120 emergency calls to the campus. The next year, four students approached a staff FNP/PA willing to volunteer their training to alleviate the stress put on county emergency services. The state-licensed EMTs volunteered to go on-call during all hours that the Student Health Center was closed. The FNP/PA agreed to act as Medical Advisor for the student-run program, and recalls "I had four people who came to me willing to stay up nights and take on an amazing responsibility, so I said, as long as you're willing, I'm willing." SUEMS was born, and in 1999 the Fire Department made only 20 calls to the university. How did they do it?
SUEMS secured funding for equipment and operational costs from the Student Health Center, to be drawn from the Office of Student Life. Like 90% of collegiate EMS programs nationally, all EMTs were volunteers. EMTs went on-call between 5:00pm and 7:30am, committed to responding to any medical emergency on campus within two minutes. During these hours, the EMTs became the front line of defense for the university. The Medical Advisor acted as base-advisor throughout the night.
SUEMS started gaining momentum the first year, and has grown every year since. The Medical Advisor has earned the title of "Our Fearless Leader" by the EMTs for her willingness to defend the program's existence against critics and secure funding for the program's survival. Today, there are 30 EMTs, each required to fill at least two shifts per month. To meet growing popularity and an increasing applicant pool, SUEMS has recently begun contracting on-campus EMT classes. Veteran EMTs hold offices such as Program Director, Training Director, and Social Chair. These experienced EMTs help the program wield its increasing volunteer force, and receive organizational, in addition to medical, training.
This successful program is engineered to transform unfamiliar groups into cohesive teams, year after year, as veterans graduate and new rookies are brought on. This research dissects the structure of the program to answer the question: why does this program enjoy unparalleled success? The answer lies in understanding the role of the individual EMT, and the cohesiveness of the group as a whole. When these two issues are understood, readers from within collegiate EMS, volunteer ambulance, or other organizations can use proven policy to combat volunteer-based pitfalls such as high turnover and low motivation, and share in the success of this collegiate program.
EMT Role and Identity: 'Student' and 'Medical Professional'
Much of the 'EMT role' lies in acting, a concept reinforced by social conventions and occupational details (cf. Katz, 1998). The spatial location of an incident is termed "the scene" as soon as an emergency worker sets foot onto it. EMTs often treat patients in public settings, and thus perform many duties in front of an audience. During my fieldwork, one patient referred to my partner, the veteran making the decisions, as "the star of the show."
Renowned social theorist Charles H. Cooley coined the term "looking-glass self" to mean a self-image based on how we believe others see us. In a social setting, one party learns to identify itself as another perceives it. If circumstances call for one party to view another in a professional manner, the other party will see itself as professional. Likewise, if one party views another as social, the latter party will learn to view itself that way, and socialize. Thus, patients suffering from serious conditions view EMTs as medical professional present to assist them, and EMTs adopt this role accordingly. Patients with trivial injuries do not have this perspective, and the EMTs draw instead from their own primary roles, that of student or peer.
The American Nurses Association is joined by the field of medical anthropology in viewing disease as different from illness. To understand the role of the individual EMT, we must consider this larger healthcare dichotomy. Disease is scientific and medically oriented, while nursing is humanistic and illness oriented. EMS is a combination of medical and social skills, and thus falls in between: unlike a hospital, which has objective medical equipment and extensive technology, EMTs are taught to identify a problem according to the patient's exhibition of illness or pain, and thus operate both scientifically and humanely.
The Role Continuum: The Area In Between
Three factors point to a role continuum among student-EMTs. First, their ability to pick and choose their roles for each specific call (and not follow a pre-defined role) stems from the organizational and medical culture of the profession as described above. Second, EMS has evolved both out of a physician-oriented attack of the ailment and a nurse-oriented diagnosis of the patient. The roles of collegiate EMTs have developed through association along this continuum. As such, EMTs have learned to be both medical-detail oriented and socially operative. Finally, nearly 400 hours of ethnography was conducted for this research, and concluded that EMTs acted very differently from one call to the next depending on the situation.
EMT role selection is continuous, not discreet. That is, EMTs are not limited to 'student' or 'medical professional' roles, but may select a mix of the two appropriate for the situation. This role continuum was most apparent on alcohol-poisoning calls. On one such call, which took place directly after a hard-liquor drinking contest on the floor of a dormitory building, the student started A+O x 4 [alert and oriented; able to answer their name, location, time of day, and describe the incident]. At this time, two students walked through the middle of our scene, provoking a scoff from the veteran. Within a few minutes the student dropped to A+O x 0 [Unable to answer any questions], and was unresponsive to painful stimulus. Advanced Life Support (ALS) was en route, and we were trying to keep her alert. At this time, two more students tried to walk through our scene. The veteran shot them a furious look at barked, "Go another way!" As if his words had thrown the heavy atmosphere of the call at the students, they stopped dead in their tracks for a moment, and went back the way they came. This example shows both the necessity of an EMT to adapt his or her role, from social agent to medical professional, and the ability to do so as the situation changes.
Group Cohesion: The Miracle of Meetings
Program effectiveness goes hand in hand with group cohesion. The difference between four EMTs at the start of SUEMS and 30 EMTs today is clear. With a large cohort, group familiarity is reduced. Each volunteer is required to work fewer shifts, and thus feels more removed from the organization. This phenomenon is most salient for rookies than veterans: rookies perform less 'behind the scenes' work than veterans, and miss more shifts. In addition, consistent theft and destruction of EMS equipment and vehicles by maleficent students may lead EMTs to feel disenchanted about their affiliation within the organization, making group cohesion all the more important.
Both the ability to perform a call effectively and the ability to coordinate scene logistics, as well as the larger goal of fulfilling the mission of SUEMS, depend upon group familiarity. Unlike occupational EMS, student-EMTs rarely see each other between equipment checkout and scene rendezvous. Thus, weekly meetings, during which pertinent calls are reviewed and relevant news is discussed, serve as the primary bonding time for members of the organization. Meetings serve as a time for organizational culture to run rampant, reinforcing group identity and "group-think" through simultaneous verbal and non-verbal (symbolic) actions during a rare time when the entire organization is present in one room.
The most prominent verbal phenomenon during group meetings is joking, a common theme used in occupational EMS to assuage the more morose aspects of the work. Student-EMTs frequently interrupt others with puns or jokes during meetings, reinforcing their mutual status within the program and underscoring feelings of group familiarity and identity. During meetings, rookie EMTs are called upon to debrief the group on scenes they have participated in during the past week. This practice serves as group review for the call, verbal rehearsal for quick SOAP relay to an ALS team, and as a socializing factor between veterans, who feel comfortable talking during meetings, and rookies, who may need a push to do so.
Just as group meetings and joking constitute verbal contributions to the culture of the program, the use of organizational symbols constitutes non-verbal culture. Unlike verbal examples, symbols can reinforce "group-think" outside of meetings. Examples of organizational symbols include SUEMS attire, sashes for graduation, certificates of appreciation, written praise from university officials, plaques commemorating the most devoted volunteers, token gifts for all volunteers, and pictures of organizational heroes (such as the founders and the Medical Advisor) in the SUEMS office.
Food or candy is often present at the meetings, and occasions are often celebrated. These treats create a friendly atmosphere during which the meeting may double as a social forum. Such opportunities help foster social interaction between EMTs, which in turn increases their ability to work more effectively for the organization. As in many contexts the world over, food at EMS meetings represents a bonding relationship that goes beyond mere professionalism. Mutual gift giving strengthens the bond among EMTs and facilitates organization transformation of SUEMS from a volunteer medical program to a tightly-knit medical community (cf. Malinowski, 1961).
Lastly, group participation in academically affiliated and non-academically affiliated community events serves to publicize the image of the group, bolster the safety of the event, and help volunteers conceptualize and solidify their identities and roles as EMTs.
Organizational Effectiveness: The Child of Training and Group Cohesion
In a non-serious call, the opportunity is provided for a rookie EMT to become familiar with being "on-scene" and practicing medicine in public, and get used to working under the veteran. Non-serious calls build "group-think" skills that are necessary for smoothly navigating more serious calls. During a serious call, the rookie must know how to supplement the veteran's actions to assure the best possible outcome. If the veteran is authoritative, the rookie must follow suit to maintain an image of professionalism. Non-serious calls give rookies both hands-on and mind-on experience so they are ready to make their own decisions in urgent situations, when the veteran is too busy to direct them.
The finding that familiarity builds effectiveness holds true for the relationship between SUEMS and the Fire Department. Both services have hosted social events and worked hard to foster professional cooperation. This effort has contributed to years of smooth transitions and quick information when every second counted, culminating in the Fire Department presenting standardized PCR forms to SUEMS. The forms have practical and symbolic value. Standardized PCRs can save firefighters' time in not having to repeat patient assessments and questions, as well as showing a mutual trust between the two services.
Conclusion: Applying these Lessons to Other Programs
EMT roles are decided on a call-by-call basis depending on the atmosphere. Thus, the role of an emergency medical technician is not static, but in flux and easily adaptable. The most effective EMTs are those who can determine the role they, as actors, ought to play when walking onto a scene, and to adjust that role as the scene changes. Roles are constantly affected by outside factors. This was clearly visible during my research, where the role of an EMT often changed from one end of the spectrum to the other in a matter of minutes. This finding highlights the importance of training employees to be agents -- to realize the importance of role presentation during service and feel empowered to alter aspects of EMT-patient interaction to improve the situation.
The second key finding in my research is that group cohesion has a direct impact on organizational effectiveness. This finding should change the way we think about cohesiveness among EMTs, ambulance crews, emergency workers, firefighters, hospitals, gerontology clinics, etc. By raising group cohesion, occupations can take objective measures to help increase their effectiveness, as SUEMS did with the presence of social events and group attire.
Generally speaking, group cohesion is raised where interaction exists between equal parties, is consistent, and is encouraged by organizational authority (cf. Damico and Sparks 1986, Allport 1979). Programs can raise cohesion through group attire, social events (including food), and informal meetings that foster the free exchange of dialogue or ideas. Group attire not only brands the organizational name onto the wearers, but also organizational values -- an 'official' article of clothing makes the wearer a representatives of the organization. What paramedic doesn't feel pride at putting on a uniform? Group attire instills the same pride, without the immediate demand for service. This clothing is thus a reward to the wearer, like a medal to a veteran. Raising an individual's feeling of pride toward the organization will result in that individual buying into -- internalizing - the values of the organization. This individual has now become a dedicated worker; eager to represent the ideals he or she has bought into.
Increasing workers' motivation by reinforcing identification with the organization ('buy-in') can also raise cohesion. Organizational heroes -- pictures or stories of model workers -- prove to the current workforce that exemplary service will not only be appreciated, but honored and long remembered. This phenomenon is especially salient for the volunteer work force. Annual awards, even if largely symbolic, let volunteers know that the most devoted among them will be honored as such.
In the fall, the SUEMS program used cohesion as a tool to court new volunteers, and through social meetings, community events, group attire, and organizational heroes the program witnessed a mass 'buy-in' to the values of the organization, which resulted in better performance both on and behind the scenes. Other branches of the medical community can take similar measures to raise their own group-cohesion building practices and, ultimately, organizational effectiveness.
Note: People interested in creating new collegiate EMS programs should consult the National Collegiate EMS Foundation and plan to work with a successful existing program to duplicate the organizational model.
Allport, G. W. (1979). The Nature of Prejudice. Perseus Book Group.
Damico, S. B. and Sparks, C. (1986). Cross-Group Contact Opportunities: Impact on
Interpersonal Relationships in Desegregated Middle Schools.
Sociology of Education 59: 113-123.
Katz, P. (1999). The Scalpel's Edge: The Culture of Surgeons. Allyn and Bacon.
Malinowski, B. (1961). Argonauts of the Western Pacific. Dutton.
Michael Wiesner, EMT-I, is a Health Science Research Specialist with the Department of Veterans Affairs. Previously, he has worked as a volunteer EMT at a suburban university campus in California, where he spent a year studying the cultural organization of the EMS program. Contact him at MWiesner@gmail.com.