Shannon did a great job with this report! Another example of the crisis facing EMS across the U.S.
Rural communities have the greatest challenge, but urban communities are facing similar challenges…
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Your Ambulance Is on the Way. ETA: 65 Minutes.
Rural patients can wait an hour or more for emergency responders from strained services
By Shannon Najmabadi
November 16, 2023
https://www.wsj.com/us-news/your-ambulance-is-on-the-way-eta-65-minutes-0431facd
MERRIMAN, Neb.—Call 911 in this northwest Nebraska town, and the ambulance responding will likely be coming from South Dakota.
If that crew isn’t available, the ambulance might drive from Valentine, Neb., 60 miles and a different time zone away. Or from Gordon, where the all-volunteer staff includes employees of a grocery store, bank, veterinary office and farmer’s co-op.
“You’re looking at an hour or longer for a response,” said Rose Chappell, the last emergency medical technician in Merriman, which had to shut down its ambulance service.
This patchwork has become the norm in many parts of America, putting some people at greater risk of death or serious injury as rural residents are getting older and small hospitals are closing.
Buck Buckles, a rancher, said the Merriman ambulance service picked him up after he fell off a horse in 2015, at age 74, breaking a shoulder and seven ribs.
“If I had still been laying there waiting for an ambulance to come from Valentine, 75 miles away, or Hyannis, 70 miles away, I might have been dead,” he said.
At least 4.5 million people nationwide live in an ambulance desert, where they are farther than a 25-minute drive from an ambulance station, according to a 2023 study. In Nebraska, more than 80% of emergency medical providers are volunteers working in sparsely populated areas where there are too few calls to justify having full-time staff, according to a 2019 study.
“I think that the majority of the American people do not understand how different it is out there,” said Andy Gienapp, deputy executive director of the National Association of State EMS Officials.
Rural ambulance services have been strained by a largely unprofitable business model, the pressure of the pandemic and recent struggles to hire people willing to undertake extensive training and work a high-pressure job for free, emergency medical personnel say.
Most state and local governments aren’t required to fund ambulance services the way they do law-enforcement offices.
In Gordon, a town 30 miles west of Merriman, Neb., volunteers say they regularly leave their jobs midday or wake up in the middle of the night to respond to 911 calls.
More than 55 ambulance providers have closed since December 2021, according to a log of news reports compiled by the American Ambulance Association and the Academy of International Mobile Healthcare Integration.
As departments close their doors, there is no agency “required to step up and fill that gap,” said Micheal Dwyer, a volunteer firefighter and emergency medical technician with Arlington Fire and Rescue in Nebraska.
Merriman’s ambulance service is the first in Nebraska to close due to lack of a workforce, said Allan Urlis, spokesman for the state’s Department of Health and Human Services. The state, which is conducting an assessment of emergency medical services statewide, has offered grants to replace rural ambulances and reimburses some education and training costs.
Ambulance services are funded by a mix of patient bills, donations, taxes and fees. In some places, emergency medical services are provided by cross-trained firefighters, private companies or hospital employees.
Industry experts say patient bills alone can’t cover the cost of providing ambulance services in a rural area—where emergency medical officials might respond to 100 calls a year but still require hundreds of thousands of dollars to buy and fuel ambulances.
Medicare, a federal health insurance plan for seniors and some people with disabilities, and Medicaid, a joint state and federal program for those with low incomes, typically don’t reimburse the full amount charged for an ambulance ride, those experts say. Medicare typically doesn’t pay for an ambulance if the patient isn’t transported to a hospital.
“We don’t control the calls we get, and we don’t deny calls,” said Michael Christensen, chief executive officer of the hospital in Martin, S.D., 18 miles north of Merriman. Grandma might have a bruise after falling down the stairs, he said—a 911 call the ambulance likely wouldn’t be paid for if the woman is treated at the scene—or “Grandma might have something horribly wrong—she fell down, banged her head and has a closed head wound that will kill her in an hour.”
The pressure on ambulance services comes as many are seeing increased demand.
Christensen’s hospital owns an ambulance service that responds to 911 calls across 2,000 square miles, including parts of two Indian reservations, three economically distressed South Dakota counties and a swath of Nebraska. The ambulance’s nine volunteers—paid $2 an hour to be on call—now regularly treat people who call 911 for minor ailments.
“We get phone calls because people in our area don’t have cars,” said Judi Claussen, who works in the hospital’s radiology department and volunteers for the ambulance service with her husband, a city councilman, and her daughter, the hospital’s lab technician.
Merriman is surrounded by sand hills and ranches. Its population shrank from 128 residents in 2010 to 87 residents in 2020, according to the U.S. Census Bureau. The local school and a senior center have closed, the dance hall has a broken window, and a sign at the beauty salon on the town’s main street says it is open one day a week.
Chappell said she joined the town’s ambulance service in the early 2000s, when it had a crew of about 10 people. Over time, some of the Merriman ambulance volunteers grew old. Others moved away. Younger residents didn’t sign up. The ambulance service had little community involvement and ineffective management, a 2017 assessment found.
By 2017, the service was down to Chappell and one other emergency medical technician. He resigned. Chappell was uncomfortable with answering calls by herself. The ambulance went into storage. It hasn’t responded to 911 calls in more than five years.
Chappell and members of the Merriman ambulance board have written letters, placed radio ads and made calls soliciting volunteers. Some people said they would sign up—including two people over age 70—but none followed through with completing the 150 to 200 hours of required training. This year, the ambulance board agreed to disband. The board is trying to sell its ambulance.
Neighboring ambulance districts answer emergency calls in Merriman, but the distance and reality of having volunteer staff with separate day jobs can eat into crucial medical response time, local responders say.
“It might take an hour to get out to the patient and an hour back,” said Nancy Hicks-Arsenault, interim CEO of the hospital in Valentine, where the ambulance service has 28 volunteers and covers a county larger than the state of Connecticut.
“That golden hour of treatment is already exhausted,” Hicks-Arsenault said.
The current crisis stems in part from the industry’s decadeslong reliance on volunteers, whose free work subsidized the largest cost of running an ambulance service, said Gienapp, with the national emergency medical services association.
Fewer people are volunteering now, in part because rural populations are shrinking and remaining residents are older; adults 65 and older are the age demographic most likely to need ambulance services, studies show.
With fewer volunteers shouldering the work, small ambulance crews can flame out from the stress of being on call around the clock or from seeing community members in medical distress.
In Gordon, a town 30 miles west of Merriman, volunteers say they regularly leave their jobs midday or wake up in the middle of the night to respond to 911 calls.
“You’re running every call and we’re seeing a lot of really, really bad things,” said Alyssa DeHart, who volunteers with her husband Nick. “And then, we’re the only ones that are doing this.”
“There’s no one coming to help us.”
