Showing papers in "Prehospital and Disaster Medicine in 1990"
25 citations
TL;DR: 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.
Abstract: 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.
17 citations
TL;DR: In this paper, the United Nations (UN) through the Office of the UN Disaster Relief Coordinator (UNDRO) can play a role in coordinating emergency operations in the wake of a large scale disaster.
Abstract: Sound disaster preparedness and a well-organized, local and material response will considerably reduce the necessity for calling on international assistance in the event of disaster. However, despite an excellent level of preparedness, some dramatic situations in the wake of a large-scale disaster always will make the mobilization of international resources absolutely essential.The international network for disaster relief is quite complex. Many governments have set up emergency relief teams to cope with disasters in their own countries and are able to assign these teams to international relief operations. This type of governmental assistance is provided under agreement with the other governments involved. The United Nations (UN), through the Office of the UN Disaster Relief Coordinator (UNDRO), can play a role in coordinating emergency operations.
16 citations
15 citations
TL;DR: 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 and a communitywide DNR program never will come into existence.
Abstract: 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.
15 citations
TL;DR: The data indicate that a concerning lack of attention to the most basic details of patient assessment is common and it is possible that failure to measure vital signs (VS) might even happen more frequently during routine patient encounters without an observer present.
Abstract: We prospectively evaluated the frequency with which advanced life support (ALS) personnel fail to attempt to measure blood pressure (BP) and/or pulse (P) during prehospital patient assessment. A single in-field observer rode on ALS rescue vehicles from 20 Emergency Medical Services (EMS) agencies throughout Arizona during a one-year study (1/89–12/89). Data were collected from urban, suburban, and rural systems. Statistical evaluation was performed by Chi Square analysis with p <0.05 considered significant.Among 227 patient encounters, BP and/or P measurements were omitted in 84 cases (37.0%). BP and/or P were omitted in 50.0% of children (age <18 years) compared to 26.5% of adults (p=0.023). Among patients who were transported to a hospital, 19.4% had BP omitted compared to 49.1% of those not transported (p=0.00003). Seven of 58 patients in whom TVs were attempted (12.1 %) had BP omitted compared to 54 of 169 patients without IV attempts (32.0%, p=0.0055). Blood Pressure was omitted in 21.9% of patients transported Code 3 and in 24.2% of patients with Glasgow Coma Scale ≤13. Omission of BP occurred more frequently in non-urban agencies (33.9%) than in urban ones (20.0%, p=0.027).In a statewide evaluation of prehospital patient assessment, failure to measure vital signs (VS) occurred on a frequent basis. Our data indicate that a concerning lack of attention to the most basic details of patient assessment is common. It is possible that failure to measure VS might even happen more frequently during routine patient encounters without an observer present. Medical control physicians must emphasize to EMS personnel the paramount importance of careful assessment to ensure optimal patient care.
14 citations
TL;DR: It is concluded that only a small proportion of MVCMR variation can be accounted for by the density of medical resources, and the reasons for this are unknown.
Abstract: An inverse correlation has been reported between motor vehicle crash mortality rate (MVCMR) and population density. The reasons for this are unknown, but variations in prehospital and hospital resources are a possible explanation.Hypothesis:Densities of prehospital and hospital resources correlate inversely with motor vehicle crash mortality rates.Methods:Data regarding population, area, number of motor vehicle deaths, and number and types of hospital and prehospital care resources for 1987, were obtained from the Michigan State Department of Public Health and transformed to create measures of resource per square mile by county. Correlation coefficients were computed between motor vehicle death rate and medical resource densities.Results:Small negative correlations were seen for all variables. Correlation coefficients ranged from -0.224 (EMTs per sq mi) to -0.167 (beds per sq mi). Only the coefficient for EMTs per square mile was statistically significant (p=0.043).Conclusion:Small negative correlations exist in Michigan counties between MVCMR and medical resources. We conclude that only a small proportion of MVCMR variation can be accounted for by the density of medical resources.
13 citations
TL;DR: The United Airlines flight 232 with 297 passengers and crew on board, experienced disintegration of the number 2 engine (in the tail section) while at 40-thousand feet above Alta, Iowa (Map 1).
Abstract: On July 19,1989, at 1515h, United Airlines flight 232 with 297 passengers and crew on board, experienced disintegration of the number 2 engine (in the tail section) while at 40-thousand feet above Alta, Iowa (Map 1). The DC-10, en route from Denver to Chicago, was diverted to Sioux City, Iowa's Gateway Airport. The disabled jet made a crash landing on an unused runway, burst apart, and caught fire upon impact. Due to the advanced warning of the potential crash, local crash-fire-rescue (CFR) units from the Air National Guard stationed at Gateway Airport, local and regional paramedic and fire units, an advanced life-support EMS helicopter service, and the two Sioux City hospitals were on alert and ready. Firefighters and Air National Guard personnel fought the fire and EMS personnel performed triage, provided emergency care in the field, and transported victims from the crash scene to local health care facilities in Sioux City. Injured victims in critical condition were transported first followed by those with lesser injuries. All were being treated within one hour and 45 minutes of the event. Of the 297 passengers and crew, 59 were admitted to local hospitals in critical condition, and 124 were treated for less severe injuries and later released.
13 citations
TL;DR: It is concluded that fiberoptic verification is a promising method of ETT position in air-medical and ED intubations.
Abstract: Verification of endotracheal tube (ETT) location in prehospital setting and the emergency department (ED) is a challenging task. Unrecognized esophageal intubations with potentially dangerous consequences may occur more frequently in these environments than in less hectic settings. To evaluate the capabilities of a portable, non-directable, fiberoptic bronchoscope (Visicath; Saratoga Medical, Saratoga, Calif., USA) to detect appropriate ETT placement, a prospective series of 22 intubated prehospital, air-medical, or ED patients underwent fiberoptic verification (FOV) of a newly placed ETT. Each patient was intubated under urgent circumstances. The time required for FOV, ETT location, the relative difficulty of intubation, and the changes in management as a result of FOV were recorded. A total of 24 FOVs were performed, twenty-one tracheal (88%), and two esophageal (8%) intubations were identified. Position could not be identified in one case (4%). FOV confirmed placement in 23 intubations (96%) in less than 25 seconds. Seven intubations (29%) were judged to be "difficult." FOV resulted in five minor changes in management (22%) and was the sole confirmation method for five intubations. We conclude that fiberoptic verification is a promising method of ETT position in air-medical and ED intubations.
12 citations
12 citations
TL;DR: In this paper, a series of mechanisms to alleviate overcrowding of hospital emergency departments by distributing critically ill patients among facilities with available resources is described, including a distribution system based on the availability of emergency department resources and critical care beds, as well as a mechanism for diversion of ambulances to hospitals in neighboring counties at times of extremely high utilization.
Abstract: This study describes a series of mechanisms to alleviate overcrowding of hospital emergency departments by distributing critically ill patients among facilities with available resources. The initial mechanism, which was based on the availability of critical care beds, was used successfully between 1982 and 1986, but had to be abandoned when several new factors caused the availability of emergency department resources to become the limiting factor. A second approach, based on the availability of critical care and emergency department resources, produced limited success over a one-year period. The system currently in use, implemented in 1989, includes a distribution system based on the availability of emergency department resources and critical care beds, as well as a mechanism for diversion of ambulances to hospitals in neighboring counties at times of extremely high utilization. This experience demonstrates that mechanisms for planning the distribution of emergency and critically ill patients have universal applicability.
TL;DR: In this paper, thirteen paramedics were retested on identically moulaged trauma scenarios and written examinations 14-16 months after their initial training in Basic Trauma Life Support (BTLS).
Abstract: The Basic Trauma Life Support (BTLS) course was developed to teach prehospital providers a rapid, prioritized approach to assess and manage the trauma victim. Little data currently are available relative to the retention of the cognitive and psychomotor skilk taught in the course. To examine this question, thirteen paramedics were retested on identically moulaged trauma scenarios and written examinations 14–16 months after initial training in BTLS. No advanced notification of the re-test was given. Written test scores decreased from an initial mean of 93.0±6.6 to a mean of 64.9±11.8 (p<0.001) 14–16 months later. Similarly, the trauma scenario test scores declined from 71.6±10.4 to 61.3±16.2 (p<0.05). The results suggest that there is significant loss of both didactic information and practical skills from the BTLS course 14–16 months after training. Frequent BTLS refresher training in the form of supplemental readings, lectures, and repeated exposures to trauma simulations is needed.
TL;DR: For example, the tower of Babel was a language disaster, and disaster itself has a language as discussed by the authors, and disaster often calls for multinational assistance, whether act of God or act of man, and many governments, agencies, professions, and individuals from different parts of the world, representing different languages, specialties, religions, and cultures, all imbued with one and the same spirit of providing succor to the helpless, converge on the stricken land to help the victims, who are themselves of different language and background.
Abstract: If the tower of Babel was a language disaster, disaster itself has a language. Whether act of God or act of man, disaster often calls for multinational assistance. The many governments, agencies, professions, and individuals from different parts of the world, representing different languages, specialties, religions, and cultures, yet all imbued with one and the same spirit of providing succor to the helpless, converge on the stricken land to help the victims, who are themselves of different language and background.
TL;DR: This intravenous configuration could enhance greatly the ability of paramedics to provide fluid resuscitation in the field setting and may prove to be an important adjunct to improving patient outcome from hypovolemic shock.
Abstract: The ability to deliver large volumes of intravenous (IV) fluids may be critical to the successful prehospital resuscitation of hypovolemic patients. We compared the time required to deliver one liter of crystalloid solution, using an administration set-up consisting of a 16-gauge (g), 1.25 inch, intravenous cannula, a pneumatic pressure bag, and either conventional intravenous tubing (3.2 mm internal diameter [ID]) or large bore (4.4 mm internal diameter [ID]) "shock" tubing. With the fluid bag positioned at 110cm (46 inches) above the level of the cannula, the mean elapsed time to deliver 1,000ml using the conventional tubing set-up was 6.0 minutes, while the same volume could be delivered in only 2.7 minutes with the shock tubing configuration. This time was reduced to 1.8 minutes when the intravenous cannula size was increased to 14g. By attaching a liter of fluid to each arm of the "Y" adapter of the shock tubing, virtually uninterrupted fluid flow may be maintained at this rate. We feel this intravenous configuration could enhance greatly the ability of paramedics to provide fluid resuscitation in the field setting. When such IVs are established en route to a receiving hospital, this technique may prove to be an important adjunct to improving patient outcome from hypovolemic shock.
TL;DR: The governmental sponsored development of a recommended minimum data set (MDS) for EMS forms performed in 1974 is reviewed, and areas of needed investigation regarding data set development and usage are discussed.
Abstract: Report forms are used by Emergency Medical Services (EMS) systems for documentation of services provided and for self-analysis of EMS functions. Although the EMS Systems Act of 1973 originally intended for the development and implementation of a uniform EMS report form, items recorded on EMS forms vary throughout the United States. We review the governmental sponsored development of a recommended minimum data set (MDS) for EMS forms performed in 1974, and discuss areas of needed investigation regarding data set development and usage. The concepts used to develop the recommended MDS provide a useful resource for review of the purpose and content of one's own EMS report form. However, future data set development and applications should use outcome measure guided data set selection, on-line validation of data item accuracy and recordability, psychometric analysis of the process of form completion, and incorporation of new data entry and storage technology.
TL;DR: In this article, the authors discuss the copying syndrome in the context of prehospital and disaster medicine, and present a policy that all claims must be substantiated by citation of appropriate research in order to gain entry into Prehospital and Disaster Medicine.
Abstract: On February 16, I convened a meeting of the vendors displaying their wares at EMS Today in Tucson, AZ, USA. With the beginning of the Journal in its current form, a policy of reviewing all proposed advertising for truth and accuracy was initiated. This policy requests that all claims be substantiated by citation of appropriate research in order to gain entry into Prehospital and Disaster Medicine. During a recent course, I became aware of the enormous costs associated with the development of products and the research necessary to prove their safety and efficacy. Those firms that do appropriate research on the products they develop must reinvest a substantial proportion of the profits gained back into the development and testing of future products, including those that do not pan out. A large share of the profits reaped are resown. What caught me off-guard was the expression of frustration from those participants who have toed-the-mark with adequate research in the development of products. Their frustration stems from the copying of their well-researched products by others who had benefitted from but had not borne the costs of product research and development (R&D). Many of the products which suffer from the \"copying syndrome\" have been associated with handsomely supported research conducted by many of us. What results is a series of products marketed by other manufacturers which incorporate or frankly copy the design which has been tested at great expense by the originator. Usually, these manufacturers intensely market the copy or near-copy in direct competition with those who have footed the bill for the R&D. Hence, they are able to intensively market the copy and sell it to us at a much lower price than can the originator. The copycats have forgone the costs of the research and development but reap the profits justly due to the originators. On the surface, this may seem reasonable—we get a product at a lower cost. Given our budget constraints, we are tempted to purchase the renegade. However, when projected to the long-run, in doing so, we attenuate the financial initiative to develop new products. By supporting those who copy, we discourage R&D and, in fact, remove the incentive of industry to fund our important research. Unfortunately, the patent laws of the United States do not provide adequate protection for firms that bring products through rigorous research and testing. In addition, pursuit of the copycats by legal action would add further to the cost. Those firms that conduct appropriate R&D are caught in a double bind—out-marketed by copycats whose overhead is lower and reluctant to add to the costs by pursuing the copycats with expensive litigation. Perhaps the formation of a trade association by those who provide us with the quality we demand will strengthen the call for new protections for their well-researched and manufactured products. I salute those who have accomplished the research which I demand. Hopefully, you will rethink your use of the copies. Although the purchase of the originals does not allow us to stretch our budgets, the long-term support of those who do the R&D will result in ongoing efforts to develop those products which help us to meet the needs of those for whom we provide the care. If we demand high standards, we should support those who try to meet them.
TL;DR: The authors, who served as anesthesiologists for 15 months at an International Committee of the Red Cross (ICRC) surgical field hospital in a Cambodian refugee camp, report their an epidural experience with 2,906 patients, which shows preferential use of regional anesthetic techniques.
Abstract: The authors, who served as anesthesiologists for 15 months at an International Committee of the Red Cross (ICRC) surgical field hospital in a Cambodian refugee camp, report their anesthesiologic experience with 2,906 patients. In spite of preferential use of regional anesthetic techniques, general anesthesia was required in 68% of the cases. Local infiltration anesthesia was applied in 21% of the cases, conduction anesthesia in 3%, and spinal anesthesia in 8%.
TL;DR: The authors performed a retrospective review of the charts of 252 adult, non-traumatic, prehospital cardiac arrest patients treated over a one-year period in order to assess the effectiveness of intravenous (IV) and endotracheal (ET) administration of epinephrine (0.5-1.0 mg) (EPI) in assisting restoration of a spontaneous pulse.
Abstract: We performed a retrospective review of the charts of 252 adult, non-traumatic, prehospital cardiac arrest patients treated over a one-year period in order to assess the effectiveness of intravenous (IV) and endotracheal (ET) administration of epinephrine (0.5–1.0 mg) (EPI) in assisting restoration of a spontaneous pulse. Patients initially receiving IV-EPI were more likely to develop a spontaneous pulse earlier than those receiving a similar dose ET (7.3% vs 0.9%; p<0.01. In those patients who received a second dose of EPI, six (2.9%) regained a spontaneous pulse; each had been treated previously with IV-EPI. None who required a third dose of EPI regained a spontaneous pulse. In total, only five (2%) patients survived to discharge. We conclude that, in our system, patients who receive the currently recommended dose of EPI to treat cardiac arrest have a poor prognosis, and that IV-EPI is associated with a higher incidence of return of a spontaneous pulse compared to those treated ET.
TL;DR: In this article, the authors conducted a survey of emergency medicine residency training directors regarding their curricula for EMS and found that there is a wide disparity among the offerings from all residency programs.
Abstract: The Society of Teachers of Emergency Medicine's, EMS Educators Committee performed a mail survey of emergency medicine residency training directors regarding their curricula for EMS. The Committee was interested in determining the quality and quantity of EMS training in emergency medicine residencies. Out of 66 programs, 48 responded (73%). The programs reported that they provide medical control for a mean of 4837 calls per year (range 0–20,000) and interact with a mean of eight EMS agencies. Ten programs (21%) do not offer any formal EMS administrative experience, while 42 (87%) programs require residents to participate in paramedic training, and 31 (65%) require participation in EMT training. Both the type and the amount of “in-field” experience reported by programs varied considerably, with some programs offering it only as an elective. Similarly, there was great diversity in the type and amount of experience with helicopter ambulances. In conclusion, there is wide disparity among the offerings from all residency programs. Each training program must evaluate its own EMS curricula and expand it to fill existing gaps. Specific topics to be covered are suggested.
TL;DR: The problem of protection and sheltering of hospitalized patients in wars and other national emergencies has been reviewed by many countries in recent years as mentioned in this paper, and there are wide differences in policies that range from full underground protection of hospitals as adopted by the Swiss, partially protected to almost fully protected facilities in hospitals in Israel, to no protection at all as in most other countries.
Abstract: The problem of protection and sheltering of hospitalized patients in wars and other national emergencies has been reviewed by many countries in recent years. Presently, there are wide differences in policies that range from full underground sheltering of hospitals as adopted by the Swiss, partially protected to almost fully protected facilities in hospitals as adopted by the Israelis, to no protection at all as in most other countries.
TL;DR: Inhalation of 50:50 nitrous oxide:oxygen mixture may improve tolerance to TCP in the conscious patient, according to a randomized, prospective study on healthy subjects.
Abstract: Transcutaneous cardiac pacing (TCP) is a promising prehospital intervention, but there are little data available regarding protocols to improve patient tolerance to TCP. A 50:50 nitrous oxide:oxygen analgesic mixture also is a commonly employed prehospital intervention. In this randomized, prospective study, we compared the discomfort experienced by 18 healthy subjects when paced in two trials at the capture threshold: one following breathing of a 50:50 nitrous oxide:oxygen mixture; and the second only breathing room air. Discomfort was rated on an analog scale from 1 (minimal discomfort) to 10 (severe pain). Of the 18 subjects, 15 (83%) reported that nitrous oxide improved the tolerance to pacing at capture threshold. The median pain scores at capture threshold in the nitrous oxide and room air group were 3.8 and 5.0 respectively (P less than .05). Nine of the subjects tolerated TCP for the maximum allotted time of 30 seconds in each trial; six tolerated TCP for a longer time period in the nitrous oxide trial; three tolerated TCP longer in the room air trial. These data suggest that inhalation of 50:50 nitrous oxide:oxygen mixture may improve tolerance to TCP in the conscious patient.
TL;DR: The world population is becoming increasingly reliant upon nuclear fission for the generation of electric power, and nuclear energy production plant accidents have occurred when either the data were misinterpreted or systems misguided by human function.
Abstract: The world population is becoming increasingly reliant upon nuclear fission for the generation of electric power. In the wake of this activity, there have been two major accidents: Three Mile Island (TMI), near Harrisburg, Pennsylvania, United States, in 1979; and Chernobyl, near Kiev, Ukraine, Soviet Union, in 1986. It is noteworthy that both of these accidents were related to human error and not to malfunction of the emergency back-up systems. So far, nuclear energy production plant accidents have occurred when either the data were misinterpreted or systems misguided by human function.The major problem associated with a nuclear energy generating plant accident is the release of radiation. Even though the medical facilities may not be destroyed physically, they may be rendered useless because of contamination by radiation. Unfortunately, in the event of such an accidental release of radiation, all of the health-care facilities in the area will be contaminated. Therefore, all patients in hospitals and nursing homes will need to be evacuated to facilities outside of the contaminated area and not just relocated within the contaminated area.
TL;DR: The United States Air Force aeromedical evacuation policies and management structure is reviewed with attention directed toward additions and adaptations of this system needed to allow it to serve global disaster response.
Abstract: There are several unique aspects of aeromedical transportation that render it vital to the overall management of disaster emergencies. Valuable time can be saved in moving medical expertise, supplies, and equipment into the disaster area as well as in moving victims out of the hazardous area quickly and in large numbers. Chaotic ground traffic at and near the disaster scene as well as environmental obstacles en route often may be avoided. Large numbers of disaster victims can be cared for efficiently en route by proportionately fewer health care personnel than is possible using traditional land carriers due to the concentration of many patients in one aircraft. Patients with similar injuries (e.g., burns) can be routed to and concentrated in centralized institutions that specialize in the care of those specific injuries. The plans for execution of the foregoing should include the use of military troop-transport aircraft that may be converted easily for patient transport. Also, military personnel should be involved, as they are part of a highly organized structure that can be mobilized more easily and swiftly than can most civilian organizations. The United States Air Force aeromedical evacuation policies and management structure is reviewed with attention directed toward additions and adaptations of this system needed to allow it to serve global disaster response. Such a highly evolved system will require a governing body with global reach for purposes of coordination and management. The resources for such a system currently exist but such an organization has yet to be formed. Language: en
TL;DR: 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.
Abstract: 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.
TL;DR: A modified Job Diagnostic Survey was administered to a cross section of 102 paid and volunteer emergency medical technicians (EMTs) and paramedics in Pennsylvania and the results indicated that the EMT and paramedic perform complex jobs that have high levels of the characteristics that cause internal work motivation as mentioned in this paper.
Abstract: 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.