EMS One-Stop

In this episode of EMS One-Stop, Rob Lawrence sits down with Dr. Maria Koeppel to explore a topic that has long existed in the shadows of EMS culture — alcohol use among providers.

| MORE: First responders and alcohol – how much is too much?

Drawing on NIH and FEMA supported research, Koeppel outlines how EMS clinicians may be engaging in higher-risk drinking behaviors than the general population, with patterns influenced by stress, exposure and workplace culture.

What emerges is not a story of individual weakness, but one of systemic pressure — where both major traumatic incidents and the accumulation of low-acuity, high-frequency calls contribute to a steady burden of stress that many providers attempt to manage off-duty.

The conversation moves beyond statistics into culture, leadership and generational change. Koeppel highlights how traditional “crew bonding” through alcohol — what one participant termed “hydraulic debriefing” — may be giving way to a new, more wellness-focused approach among younger clinicians.

At the same time, gaps in education, policy and peer support remain evident across EMS systems. For leaders, the message is clear: alcohol use is not a fringe issue, but a workforce health, safety and performance issue that requires thoughtful engagement, cultural awareness and proactive support structures.

Key quotes from Maria Koeppel

“Over 50% of firefighters surveyed had binge drank in the last 30 days — about twice the rate of the general population.”

“EMS providers tend to drink a little bit more frequently than the general population — and that’s tied directly to stress.”

“It’s not just the big trauma calls — it’s the micro-stressors that add up over time.”

“A third of clinicians in our sample engaged in high-risk drinking behaviors.”

“Younger clinicians are at higher risk — but that risk declines with age as coping mechanisms develop.”

“Paramedics are at higher risk than EMTs, likely due to increased responsibility and patient exposure.”

“Some described going out after shift as ‘hydraulic debriefing’ — using alcohol to process the day.”

“Gen Z is driving a more sober culture — they’re choosing connection without alcohol.”

“Leadership isn’t just policy — it’s culture, awareness and how you care for your people.”

“Alcohol and coping has to be part of the conversation if we care about workforce health and patient safety.”

Episode timeline

01:06 – Maria’s background: firefighter and researcher

02:24 – Overview of NIH/FEMA research and EMS focus

04:14 – Key findings: stress, frequency of drinking and EMS culture

05:08 – Micro-stressors vs. major trauma calls

06:54 – Risk factors: age, role, education, multiple jobs

10:11 – Culture and “hydraulic debriefing”

11:46 – Fire vs. private EMS cultural differences

14:38 – Generational shift: Gen Z and sober culture

19:24 – Alternative substances and coping trends

21:20 – Leadership roles: policy vs. culture

24:11 – Peer support gaps in EMS

26:41 – Workforce impact: sleep, stress, retention

27:14 – Education gap and need for EMS-specific training

29:11 – Conferences and future research dissemination

30:13 – Episode wrap-up

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In this episode of EMS One-Stop, Rob Lawrence travels to New York City to sit down with Lillian Bonsignore, the 37th Commissioner of the Fire Department of the City of New York (FDNY). A 30-plus year veteran who rose through the ranks of EMS — from EMT in the South Bronx to Chief of EMS and now Commissioner — Bonsignore brings a ground-up understanding of the largest fire-EMS system in the United States.

She reflects on stepping into the role as “walking onto a fast-moving train,” immediately confronted with major incidents, severe weather and system pressures, while simultaneously building her leadership team and setting direction for the future.

| MORE: ‘We have to right the ship’: FDNY commissioner doubles down on EMS pay parity

The conversation explores the unique structure of FDNY, where the Commissioner operates as the executive leader “almost like CEO of the company,” while operational command sits with the Chief of Department.

Bonsignore is clear-eyed about the scale and demands of the system: over 2.2 million runs annually, with 1.6 million EMS-related, reinforcing her long-held position that EMS must be treated as an essential service with appropriate funding and career pathways.

Drawing on her experience leading through the COVID-19 pandemic and responding on Sept. 11, 2001, she emphasizes resilience, communication and presence — being visible in stations, honest with staff and committed to supporting those who “leave their own families behind to go serve a stranger.”

Bonsignore also addresses criticism of her appointment directly and without hesitation, framing it as a misunderstanding of the Commissioner’s role and the realities of modern emergency response. She underscores that FDNY is both fire and EMS, and that her career — spanning 9/11 response, pandemic leadership and decades of frontline service — positions her to lead the entire enterprise.

Looking ahead, she speaks to the need for infrastructure investment, workforce stabilization, mental health support, and the thoughtful adoption of technologies such as AI and body-worn cameras. As FDNY approaches the 25th anniversary of 9/11 and the nation’s 250th year, her focus remains clear: support the workforce, strengthen the system, and prepare the department for the next generation of service.

Key quotes from Commissioner Bonsignore

“Walking into a position like this is like walking onto a fast-moving train.”

“I understand the ground level challenges that go on because I lived them.”

“The commissioner is the administrative level, almost like CEO of the company.”

“We’re responding to over 2.2 million runs a year … 1.6 million of those runs are EMS-related runs.”

“We have to stabilize our system … it’s time that EMS is finally treated as an essential service.”

“I will always tell you the truth. You may not like my truth, but I will give it to you.”

“The decision of a first responder is to leave their own families behind … to go serve a stranger.”

“They are literally your heroes … they will put their lives on the line for you.”

Episode timeline

01:10 – First 100 days as Commissioner — “fast-moving train”

02:30 – Career journey and EMS roots shaping leadership

04:30 – Workforce trust, credibility and lived experience

06:30 – Pay parity and EMS as an essential service

09:00 – Structure of FDNY — Commissioner vs. operational command

11:30 – Setting direction and stabilizing the organization

13:30 – Relationship with the Mayor and political leadership

17:30 – Addressing criticism and misconceptions

19:30 – Leading through COVID — scale, innovation, mutual aid

23:30 – Morale, resilience and leadership presence

26:30 – Recruitment and retention challenges

30:30 – AI and future innovation in EMS

32:30 – Behavioral health response and BeHeard program

36:30 – First responder mental health and support systems

38:30 – Violence against EMS and workforce protection

41:00 – Body-worn cameras and transparency

43:30 – 9/11 reflections and legacy

50:30 – Commemoration planning and future outlook

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This week on EMS One-Stop, Rob Lawrence sits down with Sarah McEntee, executive director of the Commission on Accreditation of Ambulance Services (CAAS), to unpack what accreditation really means for modern EMS systems.

Moving beyond the “sticker on the truck,” Sarah reframes CAAS as a living, breathing process — one that drives internal improvement, organizational alignment and long-term sustainability. From its origins within the American Ambulance Association in the 1990s, to the latest Version 4.0 standards, the conversation highlights how CAAS provides a unified, industry-driven framework that elevates agencies from compliant to high-performing.

Rob brings a practitioner’s perspective, reflecting on his own experience navigating multiple accreditation cycles, emphasizing how CAAS becomes a “guiding light” for governance, clinical care and operational excellence.

Together, they explore the structure of the standards, the application journey, and the cultural readiness required to succeed.

The key takeaway is clear: accreditation is not a project with an endpoint — it’s a continuous process that strengthens organizations from the inside out, identifying risks, improving systems, and ultimately delivering better care to patients and communities.

Episode timeline

01:30 – Origins of CAAS and need for unified standards

03:30 – Breakdown of CAAS standards (admin, clinical, operations)

06:30 – Deep dive into operational standards and structure

10:30 – Rob’s real-world experience with accreditation

12:30 – Accreditation as a process vs. project

16:00 – Value proposition: internal vs. external benefits

18:30 – Cost vs. value — and the risk of not being accredited

22:00 – Step-by-step accreditation journey (readiness → submission → review)

28:30 – Site visits and peer collaboration

31:30 – Resources, support and how to get started

34:30 – Final reflections and leadership call to action

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This edition of EMS One-Stop, recorded at the inaugural National EMS Management Association conference in Arlington, Virginia, pairs two complementary conversations about leadership and the future of EMS.

 

In the first half, General Robert Neller brings a military leader’s lens to universal leadership truths: lead yourself first, remember that everyone is watching, stay humble, listen better and understand that decisiveness matters. His message is simple and sharp. People want leaders who will set the example, make the call when it matters, and balance standards with empathy.

 

| MORE: EMS Leadership Institute — AI and the future of EMS

 

In the second half, NEMSMA President Dr. Hezedean Smith reflects on a successful launch for the conference and looks ahead to where EMS leadership must go next. He frames this association as a growing home for mentorship, shared learning and strategic thinking, while also pointing to the disruptive forces already reshaping the profession:

Artificial intelligence

Redesigned systems

Recruitment and retention pressures

The possibility of autonomous ambulance operations

Taken together, the episode is both a leadership masterclass and a forward look at an EMS profession that cannot afford to stand still.

Episode timeline

00:39 – Rob sets the scene from the inaugural NEMSMA conference in Northern Virginia.

00:51 – Rob introduces General Neller as the opening keynote speaker.

01:38 – General Neller explains his leadership “roadmap,” beginning with leading yourself first.

03:38 – Rob and General Neller discuss how leaders are always being watched.

06:04 – Advice for the newly promoted EMS lieutenant: growth takes time, ask for advice, study and learn.

08:11 – General Neller reflects on what he wishes he had known earlier in his career: be a better listener.

09:41 – The “don’t eat the cake” story becomes a lesson in humility and example-setting.

11:42 – General Neller discusses when leaders must consult and when they must simply decide.

13:22 – Final leadership theme from General Neller: empathy strengthens standards rather than weakening them.

17:04 – Rob returns with Dr. Hezedean Smith, President of NEMSMA.

17:18 – Dr. Smith describes the early success of the inaugural conference and strong turnout.

18:12 – Dr. Smith confirms planning is already underway for next year because the event has outgrown the venue.

19:25 – Discussion shifts to the future direction of EMS leadership and system design.

19:49 – Dr. Smith highlights AI, system redesign, and recruitment and retention as major themes.

20:47 – Dr. Smith talks about self-driving ambulances, solar-powered systems and rapid technological change.

21:38 – Dr. Smith emphasizes that technology must make providers’ work easier, not harder.

22:22 – Rob asks why people should join NEMSMA.

22:28 – Dr. Smith outlines mentorship, information sharing and rapid organizational growth.

23:13 – Dr. Smith closes by reaffirming NEMSMA’s role in the EMS leadership space.

23:46 – Rob signs off from what he calls an “amazing time” at the conference.

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In this edition of EMS One-Stop, Rob Lawrence is joined by Bob Davies and Hilary Gates to explore the mission behind Six Minutes to Live, a growing movement focused on improving survival from sudden cardiac arrest.

| MORE: ‘Six Minutes to Live': Mini-documentary spotlights cardiac arrest care crisis

The conversation begins with the stark reality that every minute without CPR and defibrillation reduces survival by 10%, and then widens into a larger discussion about injustice, geography and system performance.

Bob reflects on his landmark USA Today investigation into EMS disparities across the country, while Hilary explains why this issue remains deeply personal and why communities, not just medical systems, must be part of the solution.

The episode then turns from problem to action. Hilary and Bob describe how Six Minutes to Live is using storytelling, advocacy, community partnerships and public training to drive change, especially through bystander CPR education, school-based training and public access defibrillation.

From Santa Cruz to the Resuscitation Academy in Seattle, the emphasis is on making the simple feel possible: hands-only CPR, early defibrillation and empowering ordinary people to act. The result is more than a nonprofit or a campaign. As Rob notes, this is a movement.

Memorable quotes

“For every minute that a person's heart has stopped, their chance of survival decreases by 10%.” — Hilary Gates

“Life and death is defined by geography.” — Bob Davies

“There are vulnerable, voiceless people living on the margins who need a voice.” — Hilary Gates

“The main way that people save more lives is they care.” — Bob Davies

“Every podcast that Hillary and I are involved with is actually sponsored by R&D. Rip off and duplicate, show up, take our stuff, go and save lives with it.” — Rob Lawrence

Additional resources

Six Minutes to Live

Six Minutes to Live mini documentary

Episode timeline

01:34-02:14 – Rob Lawrence introduces the episode and welcomes Hilary Gates and Bob Davies.

02:21-03:21 – Hilary Gates shares her background as an educator turned paramedic and cofounder of Six Minutes to Live.

03:48-08:14 – Bob Davies recounts his experience as a paramedic and journalist, including his USA Today investigation into EMS performance disparities.

08:24-10:50 – Rob asks what has changed in 20 years; Bob discusses the enduring formula, new technology and the energy of younger clinicians.

11:08-13:02 – Hilary explains why Six Minutes to Live was founded and frames cardiac arrest survival as an issue of injustice and community responsibility.

13:13-17:08 – Rob asks what Six Minutes to Live is and how it fits among other advocacy organizations; Bob and Hilary describe its role as a connector and storyteller.

18:04-18:39 – Rob resets the conversation and asks what the organization is doing now.

18:50-20:47 – Hilary describes the Santa Cruz partnership, community CPR training and support from donors and local agencies.

21:12-23:47 – Bob highlights their upcoming workshop at the Resuscitation Academy in Seattle and the power of systems that care enough to measure and improve.

24:00-25:20 – Rob offers a transatlantic explainer connecting Eisenberg, Utstein and UK ambulance response standards.

25:24-28:41 – Hilary discusses community myths about CPR and AEDs, and the need to simplify action for laypeople.

28:48-31:02 – Bob outlines what is next: documentaries, deep listening, connecting voices and helping movements grow organically.

31:17-33:01 – Rob and Hilary talk about creating local champions, liability concerns and getting communities to act.

33:13-34:47 – Rob asks the closing question; Hilary urges EMS clinicians to become local champions for simple lifesaving actions.

35:22-37:20 – Bob closes with a call for EMS professionals to confront the “little secrets” they know and act on them.

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