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What happens when you call 9-1-1 and no one is available? Rural areas fighting to keep healthcare – Daily Montanan [1]

['Darrell Ehrlick', 'More From Author', '- August']

Date: 2022-08-14  

TOWNSEND, Montana — Most Montanans assume when they dial 9-1-1, there’ll be someone who answers on the other end. They’re equally sure if they’re calling because of a medical emergency, an ambulance and a paramedics are just moments away.

But ambulances and emergency medical technicians aren’t a guarantee – as much as people might suppose.

Nothing in state and federal law requires counties to have an ambulance or staff EMTs or paramedics. Low pay, long hours, COVID-19 and an aging emergency medical workforce have meant that rural counties in Montana and throughout the nation are faced with either subsidizing a service, or going without, which could means response times of more than an hour – a life-threatening amount of time for trauma, heart attack or stroke.

Many ambulance services and first-responders are money-losing endeavors. Reimbursement rates don’t cover the expense of an ambulance or the wear-and-tear on it, leaving some agencies literally holding bake sales to keep the service running.

Then, there’s the staffing issue: Some rural counties won’t get a single call in a day, meaning that ambulance services are forced to pay for staff that has stocked and restocked the ambulance, ready to roll with nowhere to go. Other days, multiple calls can mean a crushing amount of work.

And different levels of emergency medical technicians can also affect the quality of medical care in rural areas. For example, a basic EMT cannot administer the type of drugs or do the same life-saving procedures as a paramedic. However, paramedics are in high demand, and rapidly rising wages have meant fewer and fewer paramedics look to rural communities for employment.

That can create an entirely new set of problems for counties which have mostly relied on “volunteer” services where volunteers stay on-call, often toting around an emergency pager and radio wherever they go. Those volunteers are usually paid by the number of calls, but that often requires them to be close to home or the ambulance. And rural healthcare providers report fewer people are willing to dedicate so much time to a volunteer effort where you’re stuck in one place and must abstain from alcohol or have sleep interrupted.

Most paramedics and EMTs look for full-time employment. Finding work isn’t the problem, but because of the demand for service, coupled with the scarcity of emergency medical workers, even hired staff complain of long hours and multiple shifts just to cover “call.”

Cyrus Brandt, a paramedic at Broadwater Billings Clinic in Townsend, said there are times when he works every day in a week. He’s constantly on-call because other part-time workers need time off. There’s eight EMTs on his roster, and 124 shifts per month.

Many may assume that Broadwater County, nestled between Helena and Bozeman, wouldn’t be quite as taxing as many of Montana’s more distant counties. But a call can be anywhere in a nearly 100-mile radius.

“It can take 45 minutes to an hour on a good day without road construction,” Brandt said. “Thirty minutes is just not feasible for an ambulance.”

Jenny Clowes, the chief executive of the Broadwater Billings Clinic, said that if an ambulance is already on a call transporting a patient to Helena or Bozeman, that may mean other calls that come in will wait until a nearby ambulance can respond. But that can take minutes or even an hour.

It’s hard to achieve any kind of work-life balance, Brandt said. And the stress? It’s usually on every call.

“It’s very high stress because these people are having the worst days of their life and they expect and need the best quality care. That’s a lot of pressure,” Brandt said.

But it’s been a dream of his since high school to become a paramedic, and he loves the variety of work.

Brandt and other healthcare leaders worry about a possible inevitable wave of cases coming, the long tail of COVID-19. Many people put off health concerns and conditions to avoid healthcare settings during the pandemic. But that is making them worse off.

“The last couple of months, we’ve seen an uptick in strokes,” Brandt said.

When it comes to stroke, time is of the essence.

“We see everything you would in Helena or Bozeman, you just don’t see as much of it,” Brandt said. “And working in a smaller community, these are people you know and you live around, and that adds stress, too.”

Clowes praised Brandt and other employees and volunteers, who, despite some staffing shortages and dealing with the pandemic, still get to more than 90 percent of the calls in less than 10 minutes – a statistic that not many departments can match.

Yet, sometimes the system is inefficient. For example, if a paramedic is not on call, and the patient is in severe pain, they may have to stop at the hospital in Townsend first, so that a nurse or other professional can administer pain medication (emergency medical technicians are not certified to administer some drugs). That means a stop before moving on to Bozeman, Helena or to a hospital that can take the patient.

A dirty little policy secret

Montana isn’t unique in the challenges to recruit healthcare professionals. Nor is the Treasure State doing anything differently than other states.

A 2014 report from the National Highway Safety Board showed that only four states classified ambulance and emergency medical technicians as “essential services.”

While this sounds like a matter of bureaucratic labeling, the classification of essential services is a determination each state makes about what services the government is minimally obligated to provide. For example, most states consider fire and police protection as essential, and in most cases, that obligates states to fund them to some degree.

“It’s easy to say it should be essential, and it probably should be, but what are the parameters and what does ‘essential’ mean if you’re a city council member or a county commissioner?” said Drew Dawson.

Dawson was formerly a part of the state’s Department of Public Health and Human Services, and oversaw state EMS before moving onto the National Highway Traffic Safety Administration. He also has seen the problem as a city council member in Boulder.

“How do you judge essential? Is it arriving on your doorstep in five minutes?” Dawson said. “That’s pretty unrealistic for many areas of Montana.”

Since their inception, Montana, like most other states, has stopped short of classifying ambulance or emergency medical responders as “essential” because it would likely obligate state funding for a largely rural state with a vast amount of area to cover.

“It’s really expensive if you look at it from an entire state that needs coverage,” Clowes said. “But it doesn’t seem so expensive if you’re the one having a heart attack.”

Dawson has seen evolution of emergency medical responders and ambulance systems evolve.

“As the EMS systems began in the 1960s and early 1970s, there was not quite as much of a problem for volunteerism,” Dawson told the Daily Montanan.

The economy was different and families didn’t have as many activities or obligations.

“It was just different and people volunteered more readily,” Dawson said. “And fewer people are willing to get out of the bed in the middle of the night and be away from family. We also expect a different level of proficiency. We expect the folks that take care of us, whether we’ve had a car accident, we’re having a heart attack, stroke, diabetic reaction – we expect more than a ride to the hospital. We expect first-rate care. That’s required more knowledge and training, too.”

But that demand for more training has meant that volunteers or staff have had to carve out more time in an already tight time budget.

“Then you have to have adequate vehicles and equipment. That’s expensive,” Dawson said. “That a big commitment of the local community, and yet the public expects and commands that ambulances be ready and available.”

One of the other challenges for rural providers is – ironically – finding enough work. Smaller communities may have calls, but not as many as larger communities. This means that depending on nothing more than sheer chance, a well-trained volunteer medical technician may not see many calls.

“They get into it to go out on calls and help, but if they sit around, their skills can atrophy,” Dawson said.

Powder River County Commissioners have begun having the county take over the ambulance service in Broadus after a private company went out of business, reported Kaiser Health News.

Others, as in the case of Broadwater Billings Clinic, have taken over the ambulance service because it’s an essential community need, but a money-losing proposition. Instead, Clowes said the healthcare organization sees it as part of its job. After all, it doesn’t make much sense to have a place to care for sick patients like the clinic if they can’t get to the facility, Clowes told the Daily Montanan.

Even without paying for staffing, the equipment is expensive. Ambulances routinely cost between $150,000 and $200,000 and the insurance alone runs $1,000 per month.

However, most of the patients who need transporting to a hospital are covered by Medicare or Medicaid, both of which don’t cover the full cost of providing the service.

“The reimbursement isn’t enough and we never get the full amount,” Brandt said.

Clowes said that the reimbursement system is skewed. Some ambulance calls are not even billable. For example, a call for patient who has fallen and needs assistance but not transporting to the hospital is not a billable charge.

Out of the approximately 45 calls per month the Townsend-based service gets, Clowes estimates that only 30, or two-thirds are billable. Then, many are not reimbursed at the full amount it costs.

Clowes said another part of the puzzle when it comes to emergency medical services in rural areas is the problem of graying. Many of the emergency services were set up in the early to mid 1970s around Montana. That means the first generation of volunteers who have been staffing ambulance calls for decades is beginning to “age out.”

“There have been a few who say, ‘I can’t get up in the middle of the night and pick up a 300-pound person anymore,” Clowes said, “and in most rural communities you have this volunteer-paid model.”

For the extra couple of hundred dollars a month the EMTs earn by going on call, it just isn’t worth it, Clowes said.

“It’s just not enticing enough to carry a radio, and most have day jobs,” Clowes said. “We have to make it sustainable.”

Sustainability also looked a lot closer before the pandemic. Clowes said that paying $16 or $17 per hour may have enticed EMTs to places like Townsend. But with inflation and the rapidly increasing housing costs across Montana, even smaller towns have felt the pinch and increase of housing.

“Now, they’re going to need more like $24 hours just to get housing,” Clowes said. “Now, the question is: Can I have somewhere to sleep?”

There are trained people from area communities who are willing to join the crew, but need living quarters while they’re on shift, similar to that of firefighters.

“This is a daily concern,” Clowes said.

One day recently, there was a three-day period with no calls. The next day, there were five.

“How can I plan for that?” Clowes said. “How can we, as a state, support each other?”

Dawson agrees: The solution may be in finding a system where different professions are cross-trained, like firefighters with more advanced medical training.

“There is an EMS crisis on the horizon,” Dawson said. “And in rural areas there needs to be more coordination between rural ambulances and rural fire to provide staffing levels. But calling 911 and expecting someone to be immediately at your doorstep, that’s just not the case.

“Television has done a lot of good showing EMS, going back to the show ‘Emergency’ which helped popularize Emergency Medical Services and EMS became a thing many years ago. It created a push in the EMS and people began to expect EMS. That’s a good thing. That’s what got me involved, but it creates sometimes an unrealistic expectation that things that happen in Los Angeles County would happen everywhere. But that isn’t what can happen in Montana. I think Montana EMS providers have done a spectacular job stepping up to the plate, but we have to be cognizant of the resources and we don’t have infinite resources.”

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[1] Url: https://dailymontanan.com/2022/08/14/what-happens-when-you-call-9-1-1-and-no-one-is-available-rural-areas-fighting-to-keep-healthcare/

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