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summaryIn this episode of A Duty to Act, host Jennifer Darling speaks with Mike Hilley, a retiring administrator and paramedic with over 30 years of experience in emergency medical services. Mike shares his journey from the Coast Guard to becoming a firefighter and paramedic, discussing the challenges and rewards of his career. He reflects on the evolution of EMS, the importance of community service, and the future of paramedicine in addressing modern healthcare challenges. This conversation explores the integration of community health into emergency medical services (EMS), the evolving career pathways for paramedics, and innovative approaches to address the opioid crisis through medication-assisted treatment. The discussion highlights the importance of building a behavioral health campus to provide comprehensive care and the significance of leadership in EMS.takeawaysMike Hilley has over 30 years of experience in EMS.His career began in the Coast Guard, where he was encouraged to serve his community.He transitioned from the Coast Guard to the fire department in Juneau, Alaska.Mike's early experiences included volunteering in hospitals and fire departments.He became a paramedic after completing a program in King County.Mike worked for nearly 28 years at the Redmond Fire Department before becoming EMS Director in Bellingham.He emphasizes the importance of data in improving EMS systems.Mike's education includes a master's degree in health sciences managing emergency services.He discusses the challenges EMS faces with modern issues like behavioral health and the opioid crisis.Mike hopes to influence the future of EMS through technology and community engagement. Community health integration is essential for effective EMS.Paramedics need diverse career pathways to maintain engagement.Innovative mobile health programs can address community needs.The opioid crisis requires urgent and multifaceted responses.Medication-assisted treatment is a critical tool in emergency care.Behavioral health resources are vital for comprehensive patient care.Leadership in EMS can drive positive change in communities.Grants and funding are crucial for developing health programs.Overcoming barriers to wellness is a community effort.Reflecting on a career in EMS highlights the importance of service.
Dr. Angie Loza-Gomez is double board certified in emergency medicine and emergency medical services. She is an attending physician at the Los Angeles General Medical Center and EMS Director in the Department of Emergency Medicine, as well as the Medical Director for several municipal EMS agencies in Los Angeles County. Dr. Gomez shares her extensive experience in emergency medicine and pre-hospital care, discussing the intricacies of balancing structured protocols with creative problem-solving in high-pressure scenarios. We explore the concept of just culture, the importance of robust communication, and the unique challenges faced by EMS personnel. Dr. Gomez also highlights the influences and lessons she has drawn from working with police and tactical EMS teams, and she challenges listeners to be mindful of their mission and clarity in communication.
Join us for an insightful special bonus episode of the Tennessee EMS Education Association Leadership Podcast as we sit down with Michael Dunavant, the esteemed EMS Director for Maury Regional Health EMS, a hospital-run EMS agency. Michael brings a wealth of knowledge and experience to the table, having led his team through one of the most challenging times in recent history—the destructive tornado that devastated southern Middle Tennessee. In this gripping interview, Michael shares his firsthand experiences managing a mass casualty incident amidst the chaos and destruction left by the tornado. He delves into the critical role of effective communication, not only with his dedicated staff but also with hospital administrators and external agencies. Michael provides a behind-the-scenes look at the strategies and tools used to maintain clear and efficient communication channels during such a high-pressure situation. Listeners will gain valuable insights into the importance of strong leadership and the power of teamwork in crisis management. Michael highlights how the support and dedication of those around us can make a significant difference in navigating emergencies. His reflections on the tornado response underscore the resilience and preparedness required to handle large-scale disasters. Whether you're an EMS professional, a healthcare leader, or simply interested in emergency management, this episode offers a profound look into the challenges and triumphs of leading a hospital-based EMS agency through unprecedented adversity. Tune in to learn from Michael Dunavant's experiences and take away practical lessons in leadership, communication, and the indispensable value of a solid support network. Don't miss this compelling episode of the Tennessee EMS Education Association Leadership Podcast. Subscribe and listen now!
Construction will close both directions of I-405 this weekend in Bellevue and Renton. One of the largest property developers in China is now insolvent. KNOW IT ALL: 1) EMS Director resigns in Maui. 2) Man arrested for Camp 'Unacceptable' fire was released. 3) Trump campaign ad targets the Biden family. 4) Bud Light heir wants to buy the company back. // Update on the war in Ukraine. CNN does a story on an escaped inmate and the guy walks right past their cameras. // Producer Greg's Friday film recommendations. Bryan tells a folksy anecdote about a conversation involving parental advice. See omnystudio.com/listener for privacy information.
Honolulu Emergency Medical Services Director Dr. Jim Ireland joined the Honolulu Star-Advertiser's “Spotlight Hawaii” livestream show today and answered viewer questions. This series shines a spotlight on issues affecting the Hawaiian Islands. #Hawaii #HINews #StarAdvertiser More from the Honolulu Star-Advertiser: Subscribe to our YouTube channel: https://808ne.ws/2Ww2WXN Website: https://staradvertiser.com Coronavirus coverage: https://staradvertiser.com/coronavirus Email newsletters: https://808ne.ws/newsletters Facebook: https://facebook.com/staradvertiser Twitter: https://twitter.com/staradvertiser Instagram: https://instagram.com/staradvertiser LinkedIn: https://linkedin.com/company/honolulu-star-advertiser
In the fall of 2022, an anonymous donor gave $20,000 to the Logan County Community Foundation, for the explicit benefit of the Logan County Fire Department and Logan County EMS. Learn how the leaders of these three organizations think about the volunteerism that underpins their success, and how they were brought closer together through the generosity of a donor who shares their commitment and passion for this Kansas community.Watch below or find us on your favorite podcast platform here: linktr.ee/seekingcontextSupport the show
The end of the year always brings a "slump" as we reflect on what we didn't get done this year, or maybe the hardships of the year, so I wanted to shed some positivity and optimism. I asked some people to share their "why" on why they love EMS/the healthcare industry! Thank you to: James Boomhower- NREMT-P, FP-C, C-NPT ; Darrell Buratti- NREMT-P, FF ; Morgan McCormick- NREMT-P ; Hunter Vidrine- NREMT-P and FTO ; Adinah Cobb- Pediatric ER RN ; and Ryan Moore- NREMT-P, EMS Director, TP-C, and Hazmat Technician.
This episode of the Inside EMS Podcast is sponsored by FirstNet, Built with AT&T. FirstNet uses the latest technology to keep your lines of communication and data open – to help you respond faster, smarter and safer. In this episode of Inside EMS, our cohosts, Chris Cebollero and Kelly Grayson, are joined by former EMS Director for the state of Utah, and current FirstNet Board Member, Paul Patrick. The discussion revolves around communication and making communication a stress-free resource. Patrick shares his knowledge on how communication can be hampered in MCI response, how we changed our communication practice during the pandemic and what we learned for the future of communication. He then shares some information about the history of FirstNet, how it came about and what it means for the first responder community.
Several tragic fires have already occurred in the Keweenaw this year. Todd VanDyke talks with Jon Stone, EMS Director at Michigan Tech, Instructor for the Michigan Firefighter Training Council, Emergency Preparedness Coordinator for Aspirus Health, and member of the Stanton Township Fire Department, about the simple ways to protect ourselves and our families from fire and carbon monoxide poisoning. Copper Country Today airs throughout Michigan's Keweenaw Peninsula Sunday mornings at 7:00 on WOLV 97.7 FM, 8:00 WCCY 99.3 FM and 1400 AM, and 9:00 on WHKB 102.3 FM. The program is sponsored by the Portage Health Foundation.
Justin Reed joins the podcast to share how he navigates the toughest challenges by turning them into opportunities for training and developing leaders. Justin is currently the Assistant Chief – EMS for Cy-Fair Fire Department. As the overall EMS Director, he is responsible for all activities involving the 140 full-time paid staff, 13 ambulances who respond to approximately 40,000 calls annually, covering a population of 640,000. Justin has over 15 years of progressively responsible experience delivering the highest quality of leadership, patient care, and customer service.During the podcast, learn how sharing your expertise and experience can lowering the anxiety of those you serve. Justin shares how remote learning during the pandemic helped break down silos and the importance of communicating with humility. Justin shares one of his biggest challenges around compassion fatigue and how doing early interventions and providing well-being resources continues to make an impact. ABOUT JUSTIN REED:Justin Reed is currently the Assistant Chief – EMS for Cy-Fair Fire Department. As the overall EMS Director, he is responsible for all activities involving the 140 full-time paid staff, 13 ambulances who respond to approximately 40,000 calls annually, covering a population of 640,000. Justin has over 15 years of progressively responsible experience delivering the highest quality of leadership, patient care, and customer service.Justin Reed is currently attending University of Pennsylvania's Master's of Health Care Innovation and is an honors graduate of Western Carolina University Emergency Medical Care program. He was recently recognized by the American Ambulance Association Top 40 Under 40 and is a Fellow of the American College of Paramedic Executives, 2020.Justin has volunteered with numerous organizations including a non-profit organization, MyLifeSpeaks, in Haiti providing prehospital care, education, and equipment. He serves in numerous committees including the National Association of EMS Managers, where he is the immediate former Chair of the Quality and Performance Improvement Committee. As a thought leader, Justin holds various certifications and has taught both domestically and internationally with a strong passion for behavioral economics, change management, and prehospital care in Haiti.Justin Reed, NRP, FACPEAssistant Chief – EMSCy-Fair Fire DepartmentJustin.Reed@cyfairfd.org
The situation at Sedgwick County EMS continues, Steve and Ted ask County Commission Chairman Pete Meitzner about the situation on Steve and Ted in the Morning. See omnystudio.com/listener for privacy information.
Dr. Diana Koelliker, Director of Emergency and Trauma Services at the Telluride Regional Medical Center and EMS Director, talks about the efficacy of the Johnson & Johnson vaccine, why distribution was put on pause, and what severe side effects have looked like. Greta Neumann provides Spanish interpretation.
Interview with Rick Callebs, Athens County EMS Director
The EMS Handoff crew is joined by Tim Nowak, AAS, BS, NRP, CCEMTP, SPO, MPO, CADS. Tim is the founder and CEO of Emergency Medical Solutions, LLC, an EMS training and consulting company that he developed in 2010. Through this venture, he is the editor-in-chief of EMS Director magazine, a webinar/app-based continuing education content developer, columnist and blog writer, product developer, instructor and speaker, podcast guest and host, and a social media influencer on LinkedIn.Tim is also the assistant chief of special operations with a county-wide EMS agency based in Florida, where he oversees the planning and logistics sections, special operations functions and community paramedicine programs for the agency.This podcast, the EMS Handoff crew is going to review Nowak's article, Training Day: 3 options for safely transporting your pediatric patient.1. Pediatric transports can be challenging!Safe versus Not Safe“Mom holding onto baby”2. Best practices for pediatric transport in the ambulanceThe “Working Group Best-Practice Recommendations for the Safe Transport of Children in Emergency Ground Ambulances” https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdfNHTSA 1999 “Dos and Don’ts of Transporting Children in an Ambulance” https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf3. What is acceptable?Start with their own car seatParents tend to keep up with their child’s growthWhat if it was in an accident?2012 NHTSA document https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdfNo visible damageWhere do you place them in the vehicle?4. Car Restraint SystemsInflatable car seatsIn-seat/ convertible restraint systemsCot-secured, adjustable strapsContour-padded restraint systemsRoll-out restraint systems5. Four-point shoulder/ chest restrainsPad the voidsUse four-point straps6. What is not acceptableNo one in the ambulance – parents, caregivers, medics or other passengers should be unrestrained during transport.Consider your options and plan ahead so you are prepared when faced with a pediatric patient.7. 4 Safety considerations for Pediatric TransportDo tightly secure all monitoring devices and other equipmentDo ensure available restraint systems are used by personnel and other occupants, including the patient.Do not have the child/infant held in the parent’s caregiver’s or EMS personnel’s arms or lap during transport.Do not allow emergency vehicles to be operated by persons who have not completed an approved driving course.“The next time you are completing your PCR, take a look at all of the transport options. Via stretcher leads the pack, but mom holding onto baby…. Well, it is not there for a reason…”
In this episode, Dr. Ben Walrath joins us to discuss the SMOG Shock/Hypotension guideline. The conversation focuses on hypovolemic shock, but also includes a discussion of other types of shock that sometimes get less attention in the tactical setting. Commander Walrath is a U.S. Navy emergency medicine physician and the EMS Director at Navy Medical Forces Pacific. He has made major contributions to military medical literature. Here's his Google Scholar citation list. Trevor mentions an episode of Heavy Lies the Helmet. This is a great episode, and you should definitely subscribe to the podcast. Max discusses Jamie Eastman's recent paper in the Air Medical Journal, Point-of-Care Laboratory Data Collection During Critical Care Transport. Jamie is a friend of our podcast, and we will be hearing more from him soon. The article is behind a paywall, but you can use your OpenAthens account from the MEDCoE/AMEDD Virtual Library (AVL) to log in and read it free. Read this piece from Next Generation Combat Medic for step-by-step instructions on how to get access to AVL. If you want to use this episode as part of your Table VIII medical training, use the following tasks per TC 8-800:081-833-0047, Initiate Treatment for Hypovolemic Shock 081-833-0034, Manage an Intravenous Infusion081-835-3000, Administer Blood081-835-3054, Administer Blood Products
Capnography is the measurement of the partial pressure of exhaled CO2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient. Our host Jordan Ourada is joined by Dr. Eric Hill who is a board certified Emergency Physician, EMS Director for 9 agencies around Colorado, a retired military physician with the Army, former paramedic firefighter and combat veteran to discuss advanced applications of capnography to monitor a range of different patients in the pre-hospital setting. Tune in to learn how to apply capnography to monitor your patients and detect serious conditions like sepsis and DKA and initiate time-sensitive interventions that reduce mortality in patients. Quick Educational Pearls: Normal range is between 35 - 45 mmHg Low capnography indicates they are blowing off CO2 High capnography indicates they are retaining CO2 Normal waveform morphology is box-like with gradual expiratory plateau after expiratory upstroke Monitor your patient’s status and interpret the capnography numbers, rate and waveforms accordingly Time Stamps 1:32 Capnography definition 6:36 Normal range 7:40 Reading capnography waveforms 12:36 Capnography monitoring in sedated/intubated patients 13:36 Intubation monitoring 18:03 VQ match vs mismatch 21:42 Asthmatic patients 24:30 Capnography cannula 26:24 Cardiac arrest uses 31:28 Acid-base physiology 37:28 Diabetic patients 40:15 COPD patients 41:42 CHF patients 45:18 Head injury patients 52:07 Sepsis detection and subsequent prehospital management 1:08:15 Closing thoughts on using capnography in the field REFERENCES Brandt, P. “Current Capnography Field Uses.” JEMS. 2010, Nov. DiCorpo,P.,etal.“CapnographyProvidesBiggerPhysiological Picture to Maximize Patient Care.” JEMS. 2015, Nov. Eckstein,M.,etal.“End-tidalCO2asapredictorofsurvivalinout-of- hospital cardiac arrest.” Prehosp Disaster Med. 2011 Jun;26(3):148-50 Kodali,B.“Physicsofcapnography.”2014 Poste,J.,etal.“Airmedicaltransportofseverelyhead-injured patients undergoing paramedic rapid sequence intubation.” Air Med J. 2004 Jul-Aug;23(4):36-40 Davis, D., et al. “Predictors of Intubation Success and Therapeutic Value of Paramedic Airway Management in a Large, Urban EMS System.” Prehospital Emergency Care. 2006: Vol. 10, Iss. 3. Grmec, S. “Comparison of three different methods to confirm endotracheal tube placement in emergency intubation.” Intensive Care Medicine. 2002; 28: 701-4. Silvestri, et al. “The Effectiveness of out of hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.” Ann Emerg Med. 2005; 45: 497- 503. Hartman, et al. “Systematic Review and Meta- Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.” Journal Intensive Care Med. 2015, Oct;30 (7) 426-35. Levine, et al. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” N England J Med. 1997, Jul 31; 337(5): 301-6. AHA 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Hunter CL, et al. “A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.” American Journal of Emergency Medicine. 2016 May; 34(5):813-819. Bou Chebi, R, et al. “Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department.” BMC Emerg Med. 2016 Jan 29; 16:7 Soleimanpour, H, et al. “Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department.” West J Emerg Med. 2013;14(6): 590-4. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.
| 22 | Med Legal for Medics (feat. EMS Director Craig Stanley, NRP)Join us as we sit down with the Director of South Kingstown EMS, from Kingstown Rhode Island, Craig Stanley. Craig has a long history of EMS experience as a provider, a station officer, field training officer and EMS educator, service director, and legal consultant. Craig has specialized in med-legal for decades, taking his education to the next level through formal business education, and classes offered by the National Fire Academy with the goal to better educate field providers on the legal liabilities they face on a day to day basis, how to protect themselves, and to motivate them to just do the right thing. Craig walks us through the logistics of our liability as paramedics, and provides data and recent figures of what he calls the top three "7 Figure Payouts." He explains the financial burden of legal representation for paramedics, and provides strong example of how we open ourselves up to liability, when to intervene for the sake of patient advocacy, and how to protect ourselves legally. Check back soon for updates, and be looking for |23| next week.For this and more:www.medicclasscitizen.com| "Subscribe" to receive email updates on the status of the store, and exciting things to come. Facebook: @medicclasscitizenInstagram: @medic_class_citizenTwitter: @medic_citizen
Robby Royal, 2014 Grand Champion of the popular television show BBQ Pitmasters, joins us on Episode 79 of the Tailgate Guys BBQ Show Podcast. Robby tells us about how the pandemic has thrown his Rescue Smokers team a curve and created even more challenging times than normal in his profession as EMS Director for Turner County Georgia Emergence Medical Services. He also discusses staying connected with the BBQ world via BBQ Champs Academy, an online teaching resource. Donald Cook of North Carolina’s Who Cares BBQ - the 11th-ranked KCBS team in the world, also joins us. Donald tells us about winning Grand Championships on back-to-back days earlier this month in Wythe, Virginia, and about his background in comp cooking. Thanks to our sponsors/marketing partners who make the fun possible: Blues Hog, The Butcher Shoppe, The BBQ Central Show, Royal Oak Charcoal, Code 3 Spices, Affordable Income Tax & Payroll, DDR Fabrication, Colaw RV and The BBQ League. Special thanks to Vietti Marketing Group and In the Garden of Eden for supporting our competition efforts. Have a great week! #SmokeEmIfYouGotEm
HE'S BACK!One of the original hosts of Camfire Hour, Andrew joins the Crew to catch up. As the EMS Director of Worden Fire, he shares with us his frontline knowledge of COVID-19. Just like the good old days in this episode.
In Episode 164, Pastor Corey and Tim interview Palouse EMS Director Annie Pillers about COVID-19, the EMS role and how Palouse residents can help their neighbors. You can find the Joint Fire Board/EMS Guidance at the link below: https://palousechurch.org/wp-content/uploads/2020/03/2020-03-19-JFB-COVID-19-Newsletter.pdf
In this week’s edition of The Richmond Register’s Weekly Chat Podcast, Taylor Six sits down with EMS Director, Carlos Coyle to talk about his job as director, change in the county, overdoses and his department’s accomplishments.
Welcome to QMC's 10Q30 EMS Leadership profile. This month, we are featuring the The Town of Derry New Hampshire. Tune in to hear Chuck Hemeon, Director of Town of Derry EMS as he responds to our ten questions in thirty minutes. You will find Chuck's responses to each of our questions interesting and in many cases, thought-provoking. This is a great 10Q so take a moment to join in and hear from one of New England's best. Your Host: Gary Harvat
Guest participant Debbie Sommer talks about her journey and experience as a Chief Fire Service and EMS Director at the Chicago Fire Department.
A brief breakdown of the EMS 3i initiative being presented through the EMS Director publication.
Episode 160 is Tim Nowak. Tim is the founder & CEO of Emergency Medical Solutions, an independent EMS training & consulting company that he developed in 2010. He began his EMS journey in 2002. His career formally began in Wisconsin as a full-time firefighter/paramedic with the state's 3rd largest department and has since transitioned into an educator & agency representative role for a hospital system in Colorado. He's also been involved in EMS training program development and course delivery throughout much of his career, including operating his own company. In addition to teaching, Tim has been a board member, is a contracted item writer, a columnist with EMS1.com, has his own podcast called EMS Insight, and is the Editor-in-Chief of the EMS Director, a printed publication dedicated to professional development in EMS. Tim is known for his thought provocating questions, opinions, and answers on LinkedIn regarding EMS. We talk about this subject, EMS education, consulting, EMS1.com and his entrepreneurial spirit.
Robert Avsec retired as a battalion chief after 26-years with the Chesterfield County (Va.) Fire and EMS Department. For the past 5 years, he’s worked as a freelance writer contributing to fire service publications online. During his career, Robert served in many roles from Company Officer (first-line supervisor of a fire company), EMS Director, Manager of Emergency Communications Center (911), and Chief of Training and Safety Division. His background with post-traumatic stress and firefighters is primarily confined to having an acute awareness of the subject which has moved him to use his “voice” to promote, amplify, and communicate information, primarily through his blog, Talking “Shop” 4 Fire and EMS, and articles that he has published on FireRescue1.com. Recently, Robert was invited to become an inaugural member of the Honorary Board of Advisors for Warrior Heart, a residential treatment facility outside of San Antonio, TX that serves members of the military and public safety agencies (fire, police, and EMS) in helping them to overcome drug and alcohol addiction and manage post-traumatic stress conditions.More info: http://www.fireemsleaderpro.org/2017/04/02/addiction-treatment-firefighters-ems-personnel/-- Find out more at http://rescuetherescuer.com-- Show sponsors:Recovery Innovators - In today’s busy world it is more important than ever to establish yourself as an expert. Gain the instant trust of your prospects and clients as a respected Addictions Authority: http://recoveryinnovators.comThe Addictions Academy - The Nation’s Leading Accredited Addiction Treatment Services, Recovery/Sober Coaching & Intervention Training Academy: https://theaddictionsacademy.com/
As the County Executive, Randy Porter essentially serves as the CEO and CFO of Putnam County. With his usual calm and steady demeanor, Randy talks to us about the daily responsibilities of his job, the things he sees on the horizon, and how serving as the EMS Director for 30 years prepared him for what he’s doing now. In this episode, Randy also shares about his faith, his family, and his values. It’s not often that we get to communicate with our elected officials on a personal level, but in this episode, we got to hear the core of our County Executive and why he feels privileged to serve our community in this capacity. Enjoy!
In today's episode, we are joined by EMS Director Darrell Clase & LPD Sergeant AJ Mellady. Spice and Heroin have become and increasing problem in recent years. Discussion revolves around what EMS and police personnel currently face on the issue.
Huntington, West Virginia made headlines this past Monday, August 15, 2016, after 26 people overdosed on heroin in the span of only 4 hours. Thankfully, there were no deaths and everyone who overdosed survived due to the quick response time of emergency services. Gordon Merry, EMS Director, acted quickly and diverted his resources in an effective manner. “Quite honestly, there should have been deaths in this,” Merry says, “Monday was one of the worst days we have had in dealing with a drug overdose incident.”
In this episode we discuss some exciting happenings at OhioHealth EMS. Amanda was joined by System Director Holly Herron and System Medical Director Dr. Robert Lowe. Besides discussing OhioHealth EMS, they also discuss the scholarship program developed in conjunction with Medcare Ambulance and the spring 2 day EMS conference. Thank you for listening. Stay Safe!!!
Chris and Kelly discuss what would happen if paramedics and EMTs were allowed to carry guns on duty. They also interview Ray Barishansky, Connecticut's EMS Director, on what the EMS leader of tomorrow looks like.