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Show Notes

Cold Open / Introductions

• Caleb fills in for Scott; Dr. Hill in his usual seat.
  
  

• Guests introduced as Cleveland EMS education/training leaders with multiple roles and responsibilities.
  
  

• Early context: Cleveland EMS runs 120,000+ calls/year with ~73,000 transports/year (as referenced by the host).
  
  

Segment 1 — “How I got here”: Career paths & the human side of EMS

Sharon’s path

• Inspired by an aunt who worked for Cleveland EMS and told “wild” stories.
  
  

• Wanted a career outside an office: hands-on work helping people.
  
  

• Started EMT at 18; hired by Cleveland EMS at 21; paramedic school through the City of Cleveland.
  
  

• Around 20 years with the service; promoted to sergeant in the last couple years.
  
  

Kim’s path

• Worked hospice as an aide for years, then wanted to shift from end-of-life care to “saving them.”
  
  

• Became EMT/paramedic; worked in ERs; joined Cleveland EMS and has stayed ~13 years.
  
  

• Hospice background helped significantly with family communication during arrests/terminations:
  
  

  • Explaining what’s happening in real time
    
    

  • Supporting families when resuscitation ends
    
    

Key teaching point

• EMS doesn’t get enough training on death notification and family support.
  
  

• The table agrees: advocacy includes the patient and the family, and EMS often has “more than one patient” in the room.
  
  

Segment 2 — Cleveland EMS structure: Third service, history, and growth

• Cleveland EMS is a third service (separate from fire), working closely with fire as first responders.
  
  

• Established 1975; recently celebrated 50 years.
  
  

• Documentary plug: “Pulse of the City” covers the origin story and evolution.
  
  

• Early days: police would transport sick/injured patients (or bodies) due to lack of dedicated EMS.
  
  

• EMS/emergency medicine highlighted as young compared to broader medicine.
  
  

Segment 3 — Operations at scale: Deployment, staffing, and call volume reality

Units and shifts

• 12-hour shifts.
  
  

• Typical deployment: ~25 ambulances days / ~21 nights (staffing dependent).
  
  

• Calls per unit per 12-hour shift: roughly 12–16, depending on severity and demand.
  
  

• Reality check: it’s not unheard of to have zero available ambulances—even overnight.
  
  

Crew configuration

• Two-person crews:
  
  

  • Paramedic/EMT or double paramedic.
    
    

• EMT hires generally must obtain paramedic within 3 years (with some grandfathered exceptions).
  
  

• Cleveland runs predominantly ALS workload.
  
  

Dynamic posting

• Cleveland uses DSD (Dynamic System Deployment) / dynamic stationing (“posting on corners”).
  
  

• Not popular, but operationally necessary for coverage.
  
  

Segment 4 — Relationship with Cleveland Fire: From friction to teamwork

• Fire is routinely dispatched as first response based on call acuity:
  
  

  • Alpha/Bravo: EMS only
    
    

  • Higher acuity (Charlie/Delta/Echo): fire is typically sent
    
    

• Most firefighters are EMTs; Cleveland Fire also has ALS engines staffed with paramedics (limited number).
  
  

• Co-location in firehouses improved relationships significantly:
  
  

  • Fire saw the true EMS workload
    
    

  • More conversations → better understanding of policy differences → better teamwork
    
    

• Fire assists with driving, manpower, and scene operations when needed.
  
  

Segment 5 — Training pipeline: Academy + FTO model

• Cleveland EMS operates its own academy.
  
  

• New hires complete a ~10-week program (described as recently updated):
  
  

  • Initial city onboarding at headquarters
    
    

  • Mixed classroom + ride time with FTOs
    
    

• Strong retention through academy; rarely lose candidates midstream.
  
  

• Focus areas:
  
  

  • Skill competency (meds, procedures, protocol application)
    
    

  • Scenarios requiring decision-making and leadership
    
    

  • Refreshing paramedics coming from other environments (e.g., ED-based medics)
    
    

Segment 6 — Retention, recruitment, and “the stepping-stone” reality

• Turnover trends (as shared):
  
  

  • 2023: 41 lost
    
    

  • 2024: 39 lost
    
    

  • 2025: 16 lost so far (~5%)
    
    

• Major driver of improvement: new union contract/raise.
  
  

• Recruitment surge: 200+ applicants, hiring class of 28.
  
  

• Acknowledged reality: Cleveland EMS is often a stepping-stone to fire jobs, but that may be changing.
  
  

• Notable observation from Dr. Hill: more medic students now say they don’t want fire, which is a shift.
  
  

Clinical Spotlight 1 — Prehospital Whole Blood (Ohio first)

Big news

• Cleveland EMS deployed prehospital whole blood in 2025.
  
  

• Claimed as first in Ohio for whole blood (others have component therapy).
  
  

Rollout timeline

• Deployed June 4, 2025 with one field captain (Southeast side) — chosen due to:
  
  

  • Distance from trauma centers
    
    

  • Higher rates of violent trauma
    
    

• Expanded to additional captains around Oct 23, 2025 (West/East added).
  
  

Utilization & outcomes (as shared)

• ~45 administrations since launch.
  
  

• Reported disposition: 32 discharged, 13 deceased (noted as impressive given shock criteria).
  
  

Eligibility criteria (trauma-focused)

• Must meet mechanism criteria + physiologic triggers:
  
  

  • HR > 110
    
    

  • SBP < 90
    
    

  • EtCO₂ < 25
    
    

  • Two of three required, OR SBP < 70 as standalone
    
    

• Clinical judgment caveat:
  
  

  • Beta-blockers considered (blunted tachycardia)
    
    

  • “Paint the picture” approach supported by medical direction
    
    

  • Med command available when readings are unreliable
    
    

Adjuncts and resuscitation strategy

• TXA + Calcium given with blood.
  
  

• Limit crystalloids; blood prioritized (and Cleveland carries normal saline, not LR).
  
  

• Emphasis on multiple access points; the blood line becomes the “busy line.”
  
  

Clinical Spotlight 2 — Ventilators + BiPAP capability

Rollout

• Ventilators deployed service-wide; reported first use Nov 17, 2025 (used within an hour of release).
  
  

• Adds BiPAP (previously CPAP-only with disposable devices).
  
  

Operational notes

• Keep legacy CPAP devices because CPAP is an EMT skill, while vent operation is not.
  
  

• Not used for pediatrics (peds remain on home/facility vent if appropriate caregiver present, or EMS bags).
  
  

Vent comfort principle

• If patient is stable on their home vent, consider transporting them on what they tolerate best.
  
  

• If switching vents, confirm tolerance before movement/transport.
  
  

“Back to basics” thread

• Repeated emphasis: great paramedics are great basics.
  
  

• BVM, positioning, tourniquets, capnography discipline — these save lives.
  
  

AccuVent / assisted BVM coaching

• Discussed use of a device that helps prevent overbagging by:
  
  

  • Guiding rate (countdown prompts)
    
    

  • Displaying tidal volume targets
    
    

• Reinforces lung-protective ventilation during high-stress calls.
  
  

Airway management: where Cleveland is now, where they want to go

• Not RSI-certified currently (guests express desire for expanded capabilities).
  
  

• Sedation approach referenced: ketamine (plus other meds available; conversation includes Ativan/fentanyl).
  
  

• Discussion highlights:
  
  

  • Modern airway tools (video laryngoscopy, bougie, supraglottics) reduce need for paralysis in many cases.
    
    

  • Bougie use: optional but evidence suggests routine use may improve first-pass success.
    
    

• Surgical airway:
  
  

  • Cleveland does not currently perform cricothyrotomy; guests want it if within scope.
    
    

Segment 7 — Urban vs rural EMS: what changes the game?

Urban realities

• Short transports can make it harder to justify advanced interventions (“you’re 10 minutes away” argument).
  
  

• Counterpoint: ED delays and earlier intervention opportunity may still justify expanded scope.
  
  

Rural realities

• Longer transport times, more reliance on advanced procedures and transport medicine.
  
  

• Helicopter utilization differs (more common in rural due to time/distance).
  
  

Patient population

• Urban setting offers constant exposure to diverse patient backgrounds and pathology → rapid experience gain.
  
  

STEMI / systems of care

• Cleveland transmits 12-leads and activates receiving centers.
  
  

• Discussed improving EMS credibility and the value of listening to prehospital clinicians.
  
  

• Dr. Hill shares a lesson learned: EMS called a stroke correctly before the ED recognized it — trust prehospital reports.
  
  

Segment 8 — Overdose burden and harm reduction efforts

• Overdose workload reportedly trending down (no stats given), but remains a major operational issue.
  
  

• Cleveland EMS initiatives:
  
  

  • Community outreach / resource linkage team (sergeants doing follow-up, assessments, and referrals)
    
    

  • Distribution of Project DAWN naloxone kits
    
    

  • Kits include fentanyl test strips (as referenced)
    
    

• Naloxone philosophy:
  
  

  • Goal is restoring respirations—not necessarily waking the patient fully.
    
    

• Community impact:
  
  

  • Strong acceptance of kits on calls (anecdotally “rarely refused”)
    
    

  • Large distribution volume at events (noted “thousands” of doses/kits)
    
    

Segment 9 — Big-system challenges: fleet, roads, downtime, training

System stressors

• Fleet wear and tear from constant operation, harsh winters, outdoor parking.
  
  

• Road conditions/potholes, snow operations, and recurring city events that block streets.
  
  

Downtime reality

• Little to no downtime; crews prioritize basic needs (food, hydration, bathroom).
  
  

• Training model:
  
  

  • Twice-yearly required HQ training blocks (8 hours/day, multiple days).
    
    

  • Field-based micro-training is harder compared with slower suburban/24-hour fire schedules.
    
    

Logistics

• Restocking through HQ supply room using OperativeIQ ordering workflow.
  
  

Segment 10 — QA/QI and dispatch operations

QI structure

• Dedicated department reviews charts with special focus areas (e.g., refusals, trauma, controlled substances, medical).
  
  

• Not all runs can be reviewed; select percentage plus mandatory review of certain categories (e.g., blood cases).
  
  

Dispatch

• City-based, separate from fire and police (all on same floor).
  
  

• Guests praise dispatch complexity and stress; one guest previously picked up dispatch overtime after a crash course.
  
  

Future vision: 3–5 years

Community paramedicine expansion

• Commissioner strongly supports building a robust community paramedicine/outreach program.
  
  

• Goal: reduce frequent callers by addressing root causes (med access, food insecurity, fall risk, social needs).
  
  

• Acknowledges barriers: reimbursement models still lag behind the clinical value.
  
  

Other future-facing ideas

• Mobile Stroke Unit already exists (in partnership with Cleveland Clinic).
  
  

• Ultrasound mentioned as a newly added scope competency and a possible next step.
  
  

• Continued investment in education, equipment, and clinical advancement emphasized.
  
  

Memorable quotes / “Big takeaways”

• “One call at a time.” (managing massive call volume)
  
  

• “Say they died.” (clear communication in death notification)
  
  

• “Treat your patient, not the monitor.” (whole blood decision-making)
  
  

• “I don’t need a paramedic on a critical call — I need a solid EMT.” (foundational skills matter)
  
  

• “We’re not ambulance drivers.” (clinical identity and professionalism)
  
  

Closing / Shout-outs

• Guests publicly recognize Cleveland EMS field crews: hardworking, high-performing, and deserving more recognition.
  
  

• Hosts encourage Cleveland EMS staff to join future live show Q&A.

From The Episode