Pandemic exacerbates ‘paramedic paradox’ in rural America

Even after finishing her shift, Sarah Lewin keeps a Ford Explorer equipped with medical equipment parked outside her house. She is one of four paramedics that span five counties in the vast and sprawling eastern Montana. She knows that a call that someone has had a heart attack, has been in a serious car accident, or needs intensive care and is more than 100 miles away nearest hospital can occur at any time.

“I had up to 100 overtime hours over a two-week period,” said Lewin, the battalion chief for the Miles City Fire and Rescue Department. “Other people have had more.”

Paramedics are often the most skilled medical providers in emergency response teams, and their presence can make the difference in saving lives in rural areas where health services are scarce. Paramedics are trained to administer specialized care in the field, such as placing a breathing tube into a blocked airway or decompressing a collapsed lung. Such procedures go beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a longstanding labor shortage has been exacerbated by turnover and quits linked to pandemic burnout.

The larger departments are trying to attract paramedics by raising salaries and offering hefty signing bonuses. But smaller teams in underserved counties across the United States don’t have the budgets to compete. Instead, some rural teams try to train existing emergency responders for these roles, with mixed results.

Miles City is one of the few rural communities in eastern Montana that has paramedic services, but the department does not have enough paramedics to provide that care 24/7. , which is why auxiliaries like Lewin take calls in their spare time. The team received a federal grant for four staff members to become paramedics, but they were only able to fill two positions. Some candidates refused the training because they could not reconcile the intensive program with their work. Others didn’t want the extra workload of being a paramedic.

“If you’re the only rescuer there, you end up taking more calls,” Lewin said.

What’s happening in Miles City is also happening nationwide. People who work in the field of emergency medical care have long had a name for this problem: the paramedic paradox.

“The patients who need paramedics the most are in rural areas,” says Dia Gainor, executive director of the National Association of Emergency Medical Services Managers. But paramedics tend to gravitate toward dense urban areas where response times are quicker, trips to hospitals shorter and healthcare systems more advanced.

“Nationally, if you throw a dart at the map, there is a good chance that any rural area will have problems with personnel, income, access to training and education,” Mr. Gainor said. ” The list is long. »

The Michigan Ambulance Services Association has called the shortage of paramedics and emergency medical technicians a “true emergency” and called on the state legislature to spend $20 million this year to cover the costs of recruitment and training of 1,000 new paramedics and emergency medical technicians.

Earlier this year, Colorado reactivated its crisis care standard for short-staffed emergency medical services teams who are dealing with increasing demand for ambulances during a spike in covid cases. The shortage is such a problem that in Denver, a medical center and a high school have teamed up to offer classes at a paramedic school to pique student interest.

In Montana, 691 licensed paramedics treat patients in emergency situations, said Jon Ebelt, spokesman for the Montana Department of Public Health and Human Services. More than half of them are in the five most populous counties in the state — Yellowstone, Gallatin, Missoula, Flathead and Cascade — together covering 11% of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties do not have a single licensed paramedic.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major issue is funding. Federal Medicaid and Medicare reimbursements for emergency care are often less than the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staff, and the most isolated places often survive on volunteers alone, without the funds to hire a highly trained paramedic.

If these rural groups find or train paramedics in-house, they are often poached by the big stations. “Paramedics get siphoned off because as soon as they have those skills, they’re marketable,” Gienapp said.

Gienapp wants more states to consider emergency care an essential service so that its existence is guaranteed and that taxpayers’ money contributes to it. So far, only a dozen states have done so.

But action at the state level doesn’t always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to provide at least a “minimum level” of ambulance service. But lawmakers have not earmarked money to accompany the law, leaving the additional cost – estimated at $41 per capita each year – to be borne by local governments.

Andy Smith, paramedic and executive director of Grand County Emergency Medical Services in Moab, Utah, said at least one city his team serves doesn’t contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said it’s a constant struggle to find and retain the personnel needed to cover that terrain.

Smith says her team is lucky — they have multiple paramedics, in part because the nearby national park is attracting interest and the ambulance service has helped employees pay for their paramedic certification. But even those perks haven’t attracted enough applicants, and he knows some of those who come will be drawn elsewhere. He recently saw that a paramedic job in nearby Colorado started at $70,000, a salary he says he can’t match.

“The public expects that, if something happens, we always have an ambulance available, to be there within minutes and to have the best trained people,” Smith said. “The reality is that’s not always the case when money is tight and it’s hard to find and retain people. »

Despite staffing and budget issues, state leaders often believe that emergency teams can fill gaps in basic health care in rural areas. Montana is among states trying to expand EMS work into non-emergency and preventative care, such as having medical technicians meet with patients in their homes to treat their wounds.

A private ambulance provider in Powder River County, Montana agreed to provide these community services in 2019. But the owner has since retired, and the business has closed. The county took over emergency services last year, and County Commissioner Lee Randall said the provision of basic health care was taking a back seat. The top priority is to hire a paramedic.

It is possible to improve the care that ambulance crews can provide without the help of paramedics. Montana EMS System Director Shari Graham said the state has created certifications for basic EMTs so they can provide certain higher levels of care, such as fitting an IV. The state has also reinforced training in rural communities so that volunteers can avoid traveling to follow it. But these measures still leave gaps in the field of advanced resuscitation.

“Realistically, you’re just not going to have paramedics in these rural areas where there’s no disposable income,” Graham said.

Back in Miles City, Lewin said his department could get an expansion to train additional paramedics next year. But she’s not sure she can fill the spots. She’s hired a few new EMTs, but they won’t be ready for paramedic certification by then.

“I don’t have anyone interested,” Ms. Lewin said. For now, she keeps her rescue truck in her driveway, ready to go.

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