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In a medical emergency, where you live may determine IF you LIVE
by Sandy Heick, paramedic with West Branch Fire Department Linda Frederiksen, Director of Medic EMS in Davenport · September 7th, 2017

The unthinkable has happened: you, your family member or a friend is experiencing a heart attack, stroke, diabetic issue, or serious injuries from a car crash. Did you know when you call 911, you are guaranteed a police and fire response, but not an ambulance response? Sadly, it's true -- our state government requires the funding of fire and law enforcement, but has chosen not to fund emergency medical services, also known as "EMS."

Did you know the majority of urban ambulance services are paid, while rural ambulance services are mostly volunteers? And 67 percent of all ambulance services in Iowa are staffed by volunteers that receive no compensation, 8 percent receive minimal compensation (paid/volunteers) and 25 percent are paid. Rural Iowa accounts for about 46 percent of the population served mostly by volunteer ambulance services, while paid ambulance services are located mostly in urban areas where the majority of Iowa's population resides.

Did you know the majority of our higher level care hospitals are in urban areas served by paid ambulance services, most of which are at a paramedic, or advanced care level? In contrast, Iowa's rural areas have community hospitals, accounting for 79 percent of the hospitals in our state; these hospitals can only stabilize and transfer critical patients to higher level care hospitals, typically located a significant distance away. In fact, 11 percent, or nine of Iowa's 99 Iowa counties don't have a single hospital.

Iowans who become critically ill or catastrophically injured don't have the luxury of choosing where this may occur in our state; what if it happens in a county without a hospital? When the 9-1-1 call comes in for that patient, what if an ambulance staffed at any level of care is NOT available? Patients of this nature typically demand an advanced level of ambulance transport which is lacking in rural Iowa, requiring rural ambulance services tier with advanced ground services during transport, or air ambulances if available, weather permitting. Because of the longer transport times to a higher level of care, advanced level ambulance transport is even more important in rural Iowa, in comparison to urban areas that have a shorter distance to hospitals, and quicker access to definitive care.

Did you know that in 2015 58 percent of our EMS providers were certified at the EMT level providing basic care ambulance transports, with 23 percent providing advanced care ambulance transports as Paramedics? This is an issue when rural Iowa needs advanced care, which is either delayed or nonexistent, which could mean the difference between life and death.

Did you know not all rural ambulance are 24/7/365? This means that some ambulance services cannot provide around-the-clock staffing, which requires those services to hold transport agreements with other area ambulances to cover their jurisdictions. All too often, the ambulance service providing that coverage also has a staffing shortage, holding transport agreements with other ambulance services for coverage. Despite best intentions of the coverage agreements in place, the dangerous potential for zero-rural ambulance coverage has become a chilling reality in Iowa. The actual ambulance responding to a rural emergency may be from a paid service from a very distant, but closest available location, IF the paid service has an available ambulance.

As you can imagine, this is a dispatch nightmare for emergency dispatchers, who struggle to find the closest available ambulance when local ambulance service after ambulance service is unavailable. As seconds, and then minutes tick by, the members of your community wait precious minutes to receive lifesaving care and stabilization. How long will you wait for an ambulance with your sick or injured family member? Will you tire of the wait, panic, and try to transport that person in your personal vehicle? If so, could this potentially kill, further injure or disable that person? How well would you drive under this stress? What if you crash, causing more injuries that require another ambulance?

Some rural volunteer ambulance services are closing due to lack of volunteerism and high call volumes. When an ambulance service shuts down, surrounding ambulance services are forced to expand their coverage area, further taxing personnel. This could lead to volunteers of those agencies quitting, forcing those services to close. This is becoming a distressing trend in Iowa.

In Iowa, 46 percent of EMS services are non-transport services, usually based out of the fire service, which provide emergency care on scene until an ambulance arrives. Thirty-five percent of EMS services are 24-hour ambulance transport services, 17 percent of ambulance services have transport agreements when they are not staffed round the clock and 2 percent are air ambulances. Some fire services graciously fund their EMS first response units out of their mandated fire budget money as EMS calls are the majority of their call volume, but that does nothing to help the ambulance transport services.

Those who are providing EMS in Iowa are aging at an alarming rate. Did you know that 75 percent of EMS providers in Iowa are between 30-59 years of age? 19 percent are less than 30 and eight percent are over 60. Although many reasons exist for the lack of EMS providers in our state, factors that complicate this issue include, but are not limited to the rising costs of becoming an EMS provider, often beyond the reach of a volunteer service. In addition to facing shortages in qualified applicants for current positions, Iowa's EMS programs will soon need to replace those who have been in the profession for 30 or more years. IEMSA (Iowa Emergency Services Association), the voice of Iowa EMS, has been urging the Legislature to review the current requirements to start and continue a career in EMS, and create incentives (such as tuition tax credits or a match program) that will allow our programs to replenish the supply of qualified EMS professionals for the next generation.

Do you know what it costs to be an EMS provider in the state of Iowa? The basic level EMR (Emergency Medical Responder) that functions on first responder services (non-transport services) costs approximately $800-$1,000 and requires about 64 hours of class. The EMT (Emergency Medical Technician) which is the lowest level of provider that can provide care on an ambulance costs between $2,000-$4,000 and requires approximately 128 hours of class, 24 hospital clinical hours, and ambulance ride time. The paramedic program costs approximately $12,000 and has approximately 640 hours in class, 280 hours hospital clinical hours, and approximately 360 hours of ambulance ride time; a two-year Associate Degree Paramedic program is also available for a cost of $15,000. After completion of the above courses of study, students are required to successfully complete the National Registry of EMTs practical (skills performance) and written certification exams to become eligible for certification in the state of Iowa.

Once certified, EMS providers must recertify every two years, which requires mandatory continuing education, translating into additional time and expense. How much education is required every two years for recertification? EMRs must complete 12 hours, EMTs 24 hours, and Paramedics 60 hours; would you pay this much to work for free or minimal compensation in addition to sacrificing your free time or being away from your family? Requirements for maintaining an Iowa EMS certification are the same, whether the EMS provider is paid or volunteer.

Did you know that 64 percent of EMS calls are during the day between 6 a.m. and 6 p.m., when the majority of volunteers are at work? Do you think this would tax the rural volunteer ambulance response system, which typically consists of a few volunteers who are home during the day, are retired or self-employed, or are allowed to respond from work? What will Iowa do without ambulance volunteerism, which is actively and rapidly dying?

Doesn't rural Iowa deserve the same level of care as urban Iowa? Although we pride ourselves on being known as a rural farming state, Iowans who work hard each day to support this distinction are truly at greater risk, forced to wait extended times for an ambulance to transport them greater distances to a hospital.

According to a recent EMS study cited on the IEMSA website "several members of the legislature commented that EMS should be made an essential service, just as law enforcement and fire services are, but that how such service is paid for also needs to be addressed."

Iowa Code Chapter 359 requires townships to provide for fire protection, cemetery maintenance and fence line disputes. IEMSA believes that although those might have been great ideas in the 19th and 20th centuries, times have changed. Townships should be required to provide or help fund emergency medical services within their jurisdictions.

Our rural population must not only demand, but insist that the state of Iowa recognize "EMS as an Essential Service" just as Law Enforcement and Fire, and create a funding stream to support prompt, lifesaving ambulance services in our communities. And although urban Iowans may feel safe in their communities served by paid paramedic services, it's important to know that you could potentially depend on a rural EMS service as you travel through our state, with no guarantee that an ambulance will respond. When the unthinkable happens, YOUR life may truly depend on the guaranteed response at the right time, and also, the right capability. As an Iowan, where you live should not depend on IF you live.


Sandy Heick, paramedic with West Branch Fire Department

Linda Frederiksen, Director of Medic EMS in Davenport


***Statistics provided are from the Bureau of EMS Status Report 2015, IDPH Trauma Facilities Map (FYI, the Iowa counties without hospitals are Butler, Cedar, Louisa, Mills, Tama, Taylor, Warren, Worth and Winnebago), IEMSA website and an EMS Instructor Workshop March 2017.***
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