In the first mild week of almost-spring, the EMS radio traffic in my county probably reflected that of many rural areas: Medical calls and lift assists for elderly and disabled people. A fall in the shower. Other falls. Transports from the local hospital to other medical facilities, and from assisted living to the hospital. Possible heart attack. Possible stroke. What sounded like a drug overdose. Lifeline calls. At least one PNB (pulseless non-breather). Febrile seizure in a child. A mutual aid response into an adjacent county whose ambulances were all on other calls. Motor vehicle accidents, including a motorcycle vs. deer collision.
In rural areas, even under the best conditions, response and transport times are longer than what’s considered normal in a city. We all have a stake in rural emergency medical services. As a potential future patient, you want to know the standard of care you can expect where you live. As a voter, you’re electing people who make vital decisions about pre-hospital care. As a taxpayer, you want to know what you’re getting for your money.
In first responders lingo, ABC stands for airway, breathing and circulation – a reminder to start with an assessment of those vital systems. To begin to understand the challenges facing rural EMS, we can use a similar assessment, CAB:
- (Standard of) Care
- Availability and
- Bucks
Standards of care vary from state to to state but here are some general descriptions. Emergency Medical Services (EMS) refers to delivery systems – agencies, organizations and practices. In Wisconsin, those tend to be locally controlled by a municipality or by an independent organization that contracts with one or more municipalities.
First responders who provide pre-hospital medical and trauma care, whether they are paid or volunteers, have different levels of training and licensing, including:
- EMRs. Emergency Medical Responders are trained to provide immediate lifesaving care until more highly qualified resources arrive. Licensed EMRs work under medical oversight, performing basic interventions with minimal equipment.
- EMTs. Emergency Medical Technicians provide more advanced interventions and care and transportation by ambulance to a medical facility. Additional advanced training allows some EMTs to administer fluids and medications.
- Paramedics have even more training that allows them to do more advanced interventions, including advanced cardiac life support and airway management.
Requirements vary from state to state, but in all states EMTs and paramedics must be licensed. Municipalities and organizations that operate or contract for EMS generally require background checks on personnel. In my area in 2023, EMT training was 180 hours. Paramedic certification involved 1,242 hours of classroom and clinical training. Both licenses require successful completion of written and psychomotor (“practical”) exams. Continuing education is required to keep these licenses. Practitioners may only perform the skills, use the equipment, and administer the medications specified by the state Department of Health Services in the scope of practice for the level to which the individual is licensed, certified or credentialed.
In Wisconsin, EMS agencies are bound to standards of care linked to the credentials of personnel delivering that care. For example, an EMT ambulance must be staffed with two licensed EMTs or one licensed EMT and one with an EMT training permit – whether those people are volunteers, paid, a combination, paid-on-call, non-profit or for-profit.
These and other considerations affect how EMS services are reimbursed by insurance. That’s if they are reimbursed, which may not happen if there’s no transport (say, for a lift assist). Due to the sheer number of people on Medicare and Medicaid, those payers set standards for EMS billing that include four core items:
- a flat rate for transport
- a modifier based on the standard of care the transport unit can deliver compared to base-level ambulance service (relative value units)
- a geographic modifier (important for rural services with longer transports) and
- a per-mile fee.
Availability. In 2018, my community lost its volunteer ambulance service – a private corporation contracted to provide EMS for two townships and a village. Despite recruitment efforts, the volunteer squad struggled to cover two 12-hour shifts in every 24-hour period with two volunteers credentialed at the advanced EMT level that best served the needs of our aging population and our distance to hospital. Reducing the level of service to Basic EMT was an option that seemed unlikely to solve the shortage of volunteers. Eventually – and not without controversy and hard feelings – the volunteer service was disbanded and the area is now served by contract with the paid city fire department in our county seat.
For the most part, that’s going well. We now get paramedic-level care from a department that’s staffed 24/7/365. The time it takes for them to arrive on scene out here is very close to how long it took volunteers from here to leave work or home, roll the ambulance, and arrive on scene. When roads are extra bad, our volunteer fire department which does not have EMRs may be called to assist with CPR until the ambulance crew arrives. Occasionally they call us for help on a lift assist.
But that agency, like many others in rural communities, has unfilled paid full-time and part-time positions. What’s causing turnover, and why are there not more applicants for those jobs? Those are questions we all should be asking.
And we need to be careful about making sure the answers we accept are based on real issues, not political convenience. In a recent interview with the local newspaper, the mayor said riots in Minneapolis and around the country after George Floyd died caused people to leave the profession “because of the abuse that they were receiving.” He said that created vacancies in larger cities, which attracted small-town emergency personnel to a “higher salary range.”
Ideological talking points are no substitute for evidence. For example, concerns about scene safety are nothing new. This is a core element in EMS training and practice because the hazards of working in EMS are significant. Those hazards include exposure to infectious diseases, lifting injuries, injuries in transit and on the ground at motor vehicle accident scenes. A study published in 2018 in Prehospital Disaster Medicine found U.S. EMS personnel are 22 times more likely to be injured due to workplace violence than other occupations. All these factors predate the events of 2020.
We also need to look at what emergency personnel say in exit interviews – things like limited opportunities for personal and professional advancement, challenging work/life balance, insurance benefits. We must insist on more than pat answers from those holding the pursestrings. But now that my rural area is served by contract with an agency governed by another municipality, I’m unable to vote for the people holding the pursestrings.
Money isn’t the only answer to the issue of availability in rural EMS. But it certainly is an important part. If we’re talking about George Floyd, though, who notices if it’s not just big cities paying more than your rural area, but also comparable communities? Who notices when no mention is made of stalled contract negotiations with the union to which those firefighter/EMTS and paramedics belong?
Last year in a meeting of the city’s Police And Fire Commission, the fire/EMS chief noted that public sector jobs are not as desirable as they used to be in the past. In 2011, legislation known as Act 10 was passed in Wisconsin. It impacted collective bargaining, compensation, retirement, health insurance, and sick leave for public sector employees. And we wonder why there are not more applicants for EMS jobs?
A 2013 applied research paper on the department’s problems in employee retention said the Number 1 reason for employees leaving at that time was instability caused by the threat of eliminating the city’s full-time paid fire and paramedic service. In the previous two years, city management had explored options that included privatizing the ambulance service and replacing paid fire personnel with volunteers. The investigation negatively impacted morale within the department and the ability for the department to recruit and retain personnel. Ten years down the road, this may no longer be the Number 1 problem. But the volume of medical calls continues to increase, and staffing is still a concern.
Bucks. In 2021, Wisconsin Policy Forum reported on an eight-year study of challenges to EMS, noting that: “It seems intuitive that local governments facing challenges with recruitment of both part-time and full-time responders will need to examine their pay structures and consider increasing rates of pay to attract greater numbers of applicants. Yet, that notion is problematic on two counts: 1) the ability to do so may produce budget increases that conflict with state-imposed property tax levy or expenditure restraint limits; and 2) the state EMS Association reports that even with higher rates of pay, staffing shortages are a problem at most departments.”
That 2013 applied research paper on employee retention in my area stated: “Due to Wisconsin Act 10 the state has imposed a revenue cap to keep property taxes lower. The revenue cap states that governments cannot raise the tax levy above the rate of assessed value for the community without a ballot initiative. With the revenue caps in place the city of Antigo has to look at other methods of paying for the services that the city provides to its citizens. For the fire department and most all other government agencies the choices have come down to: cutting costs, raising user fees, or raising general revenue.”
The latest national EMS trend survey reported this: “Labor shortages across all business sectors (including EMS) have continued since the pandemic. Retention has remained the No. 1 critical issue facing EMS for 4 straight years. In EMS, recruitment and retention efforts have been exacerbated by the inability of agencies to provide competitive compensation packages as compared to other healthcare and public safety positions. For the past 2 years, pay and benefits have been consistently identified by nearly 9 out of 10 respondents as an issue impacting retention.”
We won’t solve these problems overnight, but we also won’t make progress toward solutions until we put everything on the table. The buck stops with voters and taxpayers. We have to talk about this stuff if we hope to ensure our rural areas have emergency medical services. A CAB assessment is a good place to start.
But there’s also something else you can do: Try to make life a little easier for the EMS personnel who respond when you need them. Make sure your address is clearly visible day and night. Hide a key responders can use to get inside to help you. Know the signs of heart attack and stroke, and call for help sooner rather than later. Keep an up-to-date list of medical conditions and medications posted on your fridge. If you have an advance directive, wear the bracelet because otherwise if your family calls 911 EMS is legally obligated to resuscitate. If you have complex medical concerns, know in advance to which facilities your EMS responders can and cannot transport. While you may prefer to go immediately to a more distant hospital, taking an ambulance out of the community for a longer transport can mean a friend or neighbor or family member has to wait even longer for help to come to them.
Donna Kallner writes from Langlade County in rural northern Wisconsin.
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