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PATI in EMS Leadership: Breaking Free from the “Chain of Pain”

After 20 years in EMS – from running calls to somehow ending up with a white shirt and too many meetings – I’ve learned one universal truth: micromanaging is about as useful as a screen door on a submarine. Yet here we are, in 2025, still routing every operational decision through seventeen layers of approval like we’re trying to launch nuclear codes instead of order more trauma shears.

The “Chain of Pain”: When ICS Becomes Excessive

Look, I love FEMA ICS as much as the next white shirt. Those 100, 200, 300, 400, 700, and 800 certificates look mighty pretty on my wall. But somewhere along the line, we started treating every call like it was a federal disaster. We’ve got crews trying to run a basic medical call, and suddenly they’re playing “ICS telephone” through five levels of command just to get an extra set of hands on scene.

Let me tell you a story that still makes me shake my head. Years ago, I’m working a serious trauma – one hand performing a finger thoracostomy, other hand starting blood products. We needed air medical, and we needed it now. So I did what any sensible medic would do: I keyed up and requested the helicopter directly through dispatch. You’d have thought I’d just declared myself Emperor of EMS based on the incident commander’s reaction.

There I was, trying to explain between managing my critical patient why it was more efficient to make a direct request than play 20 questions over the radio while juggling a finger thoracostomy and resuscitation. “But the chain of command!” they sputtered. Meanwhile, my patient’s getting the care they needed because I didn’t waste precious minutes giving a full dissertation on why we needed the resource that I was absolutely going to get anyway.

That’s the problem with becoming too rigid with our command structure – we sometimes forget what (and who) we’re here for.

Picture this: Your crew’s working a multi-patient accident. Under our traditional system, for every resource request they’d:

Radio command to request additional units
Command contacts dispatch to send the resources
Dispatch assigns the units
Command maintains system status awareness
Process repeats for each additional resource

Now, there’s nothing wrong with command wanting to maintain system awareness – that’s their job and it’s crucial for effective operations. But we’ve turned it into a game of telephone that delays resource deployment without adding value.

Breaking Free: PATI with System Awareness

When we implemented PATI (Push Authority to Information), we didn’t eliminate command’s awareness – we just streamlined the process. After all, no one’s saying command doesn’t need to know what’s happening in their system. But there’s a difference between keeping command informed and making them the bottleneck for every decision. Our crews now have:

Authority to request resources directly through dispatch
Dispatch simultaneously notifies command for system awareness
Command maintains overview without becoming a bottleneck
Clear triggers for when direct command involvement is needed
Streamlined communication that keeps everyone in the loop

Real example: Last week, one of our units was on scene of a motor vehicle accident with multiple patients. Under our PATI system:

Crew directly requested additional units through dispatch
Dispatch immediately assigned the closest appropriate resources
Command was automatically notified via radio traffic and CAD
Command maintained system status without delaying the response
Additional resources arrived minutes faster than under the old system

Total result? Resources got moving immediately while command maintained full situational awareness. No information was lost, but no time was wasted either. That’s what PATI is all about – maintaining necessary oversight while eliminating unnecessary delays.

What PATI Isn’t

Let’s be clear – PATI isn’t anarchy. It’s not “everyone does whatever they want.” It’s about creating clear boundaries where people can make decisions without playing “Mother May I” for every little thing.

Example of what it IS:

Crews can order supplies when they’re running low, not when they’re completely out
Station officers can adjust daily assignments based on skills and needs
Teams can coordinate directly with other agencies for joint training
Personnel can schedule their own community outreach events

Example of what it ISN’T:

Unlimited spending without oversight
Changing major policies without discussion
Bypassing safety protocols
Ignoring chain of command for major incidents

Real Talk: The Hard Part

Look, I’ll be honest – letting go is harder than a paramedic’s humor at 3 AM. The first time your crew orders something without running it by you, you’ll feel like a parent watching their teenager drive solo for the first time. But here’s the thing: if you’ve hired good people (and I know you have), they’ll usually make better decisions than you would have made from your desk anyway.

Managing Resistance: The Military Connection

“But we’re a paramilitary organization!” I hear this one a lot when introducing PATI. And yes, EMS and Fire services traditionally follow a military-style chain of command. Here’s the irony though – PATI isn’t some touchy-feely management theory. It’s actually adapted from the U.S. Navy SEALs and other elite military units.

Think about it: Who has a more rigid command structure than the military? Yet when the SEALs need to operate at their highest level, they use PATI. Why? Because they’ve learned that in dynamic, high-stakes situations, the person with boots on the ground often has the best situational awareness to make immediate decisions.

Some hard truths about resistance:

Middle Management Fears
- Loss of control isn’t loss of authority
- Their role becomes more strategic, not less important
- Good leaders develop leaders, not just followers
- Success is measured by how well their team operates without them
“That’s Not How We’ve Always Done It”
- Neither was advanced airway management once upon a time
- Elite military units evolved beyond rigid hierarchy for a reason
- Tradition is great for ceremonies, not for operational efficiency
- If SEALs can adapt their command structure, so can we
The Real Source of Resistance
- Often comes from insecurity, not actual operational concerns
- Fear of becoming “unnecessary” (spoiler: good leaders are never unnecessary)
- Worry about accountability (it actually improves under PATI)
- Concern about consistency (guidelines ensure this)

A Leader’s Guide to Implementation

Look, I get it. As leaders, we’re ultimately responsible for everything that happens on our watch. That’s probably why we’ve developed this habit of wanting to be involved in every decision. But here’s the thing: being responsible doesn’t mean we have to make every decision ourselves.

Some hard truths for my fellow leaders:

Your crews are already making critical decisions without you
- Every tube placement
- Every medication administration
- Every clinical intervention And guess what? They’re doing just fine.
Fear of failure isn’t a leadership strategy
- If you’re afraid to let go because “what if they mess up?” – remember they can only grow by having the opportunity to make decisions
- Create safety nets, not restrictions
- Be there to support, not to control
Your job has evolved
- From making decisions to developing decision-makers
- From controlling to coaching
- From directing to developing

The Final Word

Remember: Strong leadership doesn’t create followers; it creates more leaders. PATI isn’t just about improving efficiency – it’s about developing the next generation of EMS leaders who understand how to balance autonomy with accountability.

Here’s your hard truth for the day: If you’re spending your shift approving supply orders and playing telephone with resource requests, you’re not really leading – you’re just being an expensive radio relay. Your crews are already making life-or-death decisions about medication doses, treatment plans, and whether that gas station hot dog is really worth the risk. Trust me, they can handle ordering more 4x4s without a parliamentary procedure.

Think of PATI like a good partner on a busy night: it’s there to help you, not create more work. And just like that partner, the more you trust it, the better it works.

Now if you’ll excuse me, I need to go not micromanage some crews who are handling things just fine without me. Though I might peek at the CAD just one more time… old habits die hard, right?

I am a veteran humble paramedic and EMS leader who still occasionally catches himself wanting to approve band-aid orders, but is getting better at letting go. He’s also still trying to figure out who keeps ordering the extra-large gloves when everyone on the department has normal-sized hands.

References

Willink, J., & Babin, L. (2017). Extreme Ownership: How U.S. Navy SEALs Lead and Win. St. Martin’s Press.
- Foundational work on decentralized command in military operations
McChrystal, S., Collins, T., Silverman, D., & Fussell, C. (2015). Team of Teams: New Rules of Engagement for a Complex World. Portfolio.
- Explores how the U.S. military adapted its command structure for modern warfare
Hines, S., Luna, K., Lofthus, J., et al. (2008). Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Agency for Healthcare Research and Quality.
- Application of decentralized decision-making in healthcare settings
Federal Emergency Management Agency. (2017). National Incident Management System, 3rd Edition.
- Framework for understanding when to apply full ICS versus modified command structures
Bigley, G. A., & Roberts, K. H. (2001). The Incident Command System: High-Reliability Organizing for Complex and Volatile Task Environments. Academy of Management Journal, 44(6), 1281-1299.
- Research on adapting ICS for different operational environments
Weick, K. E., & Sutcliffe, K. M. (2015). Managing the Unexpected: Sustained Performance in a Complex World, 3rd Edition. Wiley.
- Discussion of high-reliability organizations and decision-making
U.S. Department of the Navy. (2018). Decentralized Command and Control: Empowering Front-Line Decision Making. Naval Doctrine Publication 6.
- Military doctrine on pushing authority to information
Institute of Medicine. (2007). Emergency Medical Services: At the Crossroads. The National Academies Press.
- Overview of EMS organizational structures and leadership challenges
Comfort, L. K. (2007). Crisis Management in Hindsight: Cognition, Communication, Coordination, and Control. Public Administration Review, 67, 189-197.
- Analysis of command structure effectiveness in emergency services
Gasaway, R. B. (2009). Fireground Command Decision Making: Understanding the Barriers to Situational Awareness. Fire Engineering Books.
- Examination of decision-making in emergency services command