In Colorado, Rural EMS Nears a Reckoning

The Denver Post

Fresh off a 24-hour shift, Clay Trevenen was finishing breakfast at a restaurant in Craig on Sunday morning when a text came in: Anyone available to help transport a patient to Glenwood Springs?

The 51-year-old slid the phone to his wife, with whom he'd promised to spend the day.

"She said, 'Are you gonna go?'" Trevenen said. "I said, 'If I don't, it's not going to happen.'"

So much for a day off.

In Moffat County, this is how people in rural areas often find their way to a hospital in an emergency, relying on emergency medical service (EMS) workers like Trevenen to pick up extra shifts. The EMS crew's funding is low because the reimbursement rates from Medicare and Medicaid patients are low, and there's not enough staff because there's not enough money.

The northwest Colorado county's EMS service may vanish altogether if voters don't step in, and EMS leaders warn that other rural departments in Colorado — and across the U.S. — could follow. Some have already shut down.

Unlike police and fire, EMS is not considered an essential service by the state, which is the norm in this country. And though the state is relatively flush with cash thanks to a growing economy and billions in federal stimulus, EMS funding has not been a priority for the legislature. This life-saving service is in many cases kept afloat by bake sales, potlucks and endless hours of unpaid labor.

"We're an essential service. The community expects it. We're 24/7," Ute Pass Regional Health Services District CEO Tim Dienst said. "It costs a lot of money to provide and nobody really wants to pay for it."

Boulder Mayor Sam Weaver, who spent 15 years with a volunteer mountain fire department that provides EMS west of town, said that without better funding there will be more cases where people call for an ambulance and no one shows up. People will die.

"It is that much of an emergency in certain areas. That's not overdramatizing," he said.

'God Help You if You Have a Heart Attack'

Moffat County is almost as large as Connecticut, but usually has only one ambulance crew working. If backup is needed, the group text chain pops and someone steps up — but it might take twice as long as is ideal, or more.

As the saying goes in the EMS world, time is brain and time is tissue; if you're suffering a stroke or cardiac arrest, every minute makes a difference.

Near Dinosaur by the Utah border, there are no ambulances. Paramedic Brooks Bingman recalled a recent patient near there who was having a heart attack. She'd like to get to that kind of call in 10 minutes, or at least within 20.

After 45, "I'm sweating," she said. It took 75 minutes.

Then there's the pay: An EMT in Craig could make more at Wendy's, said Bingman, who works a second job. Trevenen works three total.

"This is a field that kind of runs in your blood," said Shana Silver, director for Baca Grande Emergency Services in Crestone. "The people who do it love it."

But EMT work in her area pays less than $12 an hour, she said, and hers is one of those rural Colorado departments that covers a wide area with few resources. For that kind of pay, she said, "Why the hell would you come out here?... Where are we attracting them from? And why would they leave their other jobs?"

It's not good enough and should not go on this way, Silver and her peers say. But it can get worse.

There are some 200 different EMS agencies in Colorado and nearly as many different funding structures, said Scott Sholes, EMS chief for the Durango Fire Protection District and President of the Emergency Medical Services Association of Colorado.

Sholes said roughly half are based in fire departments, which can mean paid staff, volunteers or a combination. The other half are split among city- or county-provided services, health systems or private companies that contract in urban and suburban areas.

The economics get trickier the poorer and more remote an area is. It costs a lot to sustain an EMS department, but low call volume and low reimbursement rates essentially guarantee no profit.

"The fire department will come and put out that fire and spend as much time as it takes and investigate it, and that costs a huge amount of money per call," Sholes said. "People get that they need to pay for police, for their schools, for fire. There's confusion about who pays for the ambulance."

Memorial Regional Health, which houses Moffat County's EMS agency, lost $600,000 on the service last year. It's been that way for years and the losses are projected to grow in 2022.

The hospital says it can't sustain that, and in November, voters in the county are expected to decide on a property tax hike — about $35 annually for the average homeowner — to create a new countywide program with more consistent service in Maybell (which is volunteer-only right now) and Dinosaur.

Chief Financial Officer Sam Radke thinks that's a reasonable ask, but he's worried: "I've got people telling me it'll never pass. People in authority, who know Moffat County."

Tax hikes aren't popular in this conservative area.

"But neither is death of a family member," EMT Vicki Crawford said. "I'd pay $100 a year extra — I'd pay a thousand, a million, a year — if it was my family member."

Often nobody pays. And Memorial Regional Health says it can't keep propping up EMS with more profitable lines of service.

Radke said he's thought about whether it might be best to clear up any confusion about EMS funding by making totally, painfully clear with voters what might happen if they don't approve the tax hike.

"Could be 12 hours a day. The other 12 hours, god help you if you have a heart attack," said Radke, who arrived in Craig two years ago and has worked with 17 rural hospitals.

The hospital may have to consider eliminating EMS entirely, he said. He added the only one of those 17 places he's worked that had no consistent EMS service was in Liberia, one of the world's poorest counties.

A Day in the Life

As it stands, rural EMS is fueled largely by the passion of workers and volunteers, who keep their phones and pagers close and make financial, social and familial sacrifices to ensure every call gets answered.

"It gives you a lot of gratification, helping people. Even if it's just holding their hand," Crawford said Tuesday morning inside the Moffat County EMS headquarters.

She got into this work after crashing her car into a ravine and being rescued by an ambulance crew. She said she was inspired to repay them somehow. EMS folks often have personal stories like that.

At this crew's office, in the corner of the hospital upon a hill above Craig, there's an ambulance garage, a couple desks, two sleeping rooms and a speaker that blares new calls. On this day, around 11:15 a.m., a call fills the room: 44-year-old woman with a panic attack. She's just down the road in Craig.

Police are already there when Bingman and Trevenen arrive at 11:23. The patient is sitting on a bed in a crowded home within a duplex, shaking and sobbing: "I feel like I can't breathe," "I just need somebody to talk to" and "I don't want to lose my kids."

A few feet away, a 7-year-old with dyed-pink hair cries.

"Mommy's gonna be fine," the patient tells her daughter through heavy breaths.

Seven minutes later, she's loaded into the ambulance and the crew treats her, cognizant of her constellation of ailments: anxiety, obesity, hypertension. Bingman chats the woman up as she checks a monitor and handles various tubes. She's friendly, congratulating the patient on efforts to quit smoking, and asking lots of questions — Are you warm enough? Too warm? Had any falls lately?

The woman is doing much better on the ride back, and thanks Bingman for being a "godsend."

"I thought I was keeping it together," she said.

Bingman responded, "Sometimes we just don't, and that's OK."

The crew gets about five calls per day, and, medically speaking, most aren't critical. But they can be tough in other ways, said Trevenen, who tries not to remember previous calls for his own sanity.

"Some stick, most don't," he said as the crew gets back to the hospital at about noon. "The little girl on the call right there. That's going to make me upset."

It's a cliche, he and the crew said later, but a true one: You don't get into this work for the money.

'Did We Miss Out?'

There's plenty of recent evidence that the threats of lost service in Moffat should be taken seriously. Many agencies have cut back and just this month the EMS agency in Penrose in rural Fremont County shut down. "The community cannot assume that an ambulance will be available for a call," the department posted on Facebook.

Said Kim Schallenberger, an EMS honcho from that part of the state: "The volunteers are not there. They just don't exist anymore, and the public still expects a 911 response."

Real as the concern may be, EMS advocates have so far failed to make their case for more money to state policymakers.

In January, the EMS association asked Gov. Jared Polis for $40 million in emergency funds, which they did not receive. They sought a couple hundred thousand during the 2021-22 springtime budget-writing process, but again lost.

None of the $3.8 billion flowing into the state through the federal American Rescue Plan Act — a once-in-a-generation infusion, Polis called it — has been set aside for EMS.

This all despite the fact that one of the most powerful people in the legislature, Senate President Leroy Garcia, is a veteran paramedic who still sometimes goes out on ambulance runs in Pueblo.

He said the legislature mostly stays out of EMS funding because it is so complex and looks so different depending on population and geography.

"One of the reasons we have a hodgepodge is because ambulances and those services are not regulated by the state. It's county-driven," he said. "So when I first went to the legislature, my thought process was that we should merge these things. But the dynamic becomes battling county commissioners, and I never even drafted a bill."

EMS leaders say they need a new message.

"We have to do a better job," said David Patterson, regional CEO of the private company Falck, which provides EMS services in Aurora. "The biggest fear I have is, man, with us not having our stuff together, did we miss out?"

Patterson said his sector might do well to encourage lawmakers to think radically by funding a reimagination of EMS. Some communities, like Eagle County and a few on the Front Range, are trying to divert people from emergency rooms with methods like having paramedics do more preventive work where people live and transporting them to urgent care or specialist offices.

"In terms of the bread and butter — someone calls for an emergency and we take them to the ER — the basic format has been the same since the '70s," he said. "How great is it if we can get someone with a specific need to a more focused resource?"

Garcia said only a handful of legislators are interested in the topic. He did vow, however, that next year — his last at the Capitol, due to term limits — he'll make it a priority.

By the time the legislature convenes in January, Moffat County voters will have made up their minds on EMS funding. The ambulance crew there is nervous, but they also have a hard time picturing themselves just exiting the field. The instinct is to always find a way.

They recently had four simultaneous calls — one patient needing a helicopter transport, an elderly man with a traumatic leg injury, a cardiac patient and a domestic violence victim with injuries — and just one ambulance running.

"It did all work out," Bingman said. "It was, you know, stressful."

At some point, Trevenen said, the love of the work and the sense of purpose just won't keep the ambulances running. If nobody in Moffat County will pay for this, how do he and his colleagues begin to meet the need moving forward?

"You don't," he said.