Broken emergency response system endangers Iowans
Worth County on Iowa's northern border is home to 7,600 residents — but no ambulances covering its 400 square miles.
In northwest Iowa, the town of Oyens recently closed its ambulance service due to a shortage of volunteers, a problem also being felt elsewhere across the state.
And in Cedar County, the director of one ambulance service says EMS is at a "critical stage" in his region, with some services going out of business and others struggling with staff shortages.
A Des Moines Register analysis of data from the Iowa Bureau of EMS shows nine counties in the state have fewer than 40 active-duty EMTs, and many are part-time volunteers. EMS professionals attribute the shortage to several factors: People have less time to volunteer, training requirements and costs have increased significantly in recent years, and there's less financial and structural support for EMS at both the state and federal level.
Brian Donaldson, the director of Sumner Emergency Medical Services, said those factors jeopardize EMS service in Iowa and in rural areas throughout the country. Nationally, at least three rural ambulance services close their doors each month, he said.
Part of the problem in Iowa is that EMS is not a mandated service, Donaldson said. Cities and counties are under no obligation to provide or help fund ambulance service, causing many to heavily rely on a mix of donations and the fees billed to patients. But those fees are largely determined by Medicare, Medicaid and commercial insurers.
State officials acknowledge the Iowa Bureau of EMS has floundered in recent years due to a lack of leadership, and they can't pinpoint Iowa's most underserved areas for EMS. But, they say, they also don't know whether researching that question would be of any use.
"I'm not sure the data sets we have would help us quantify that," said Ken Sharp, an Iowa Department of Public Health division director who oversees the Bureau of EMS. "And even if we did, are we as a bureau able to effect a change?"
The Register's investigation into the most underserved areas in the state comes 15 months after the news organization exposed widespread problems in Iowa's EMS system. Among them: Ambulance services, despite repeated violations of basic patient-care standards, have little to fear from state regulators; and EMTs are sent into the homes of vulnerable Iowans in times of crisis, despite convictions for drug abuse, theft, attempted murder and other violent crimes.
The latest Register investigation focused on the lack of EMS coverage in many rural areas across the state — a complex issue that has no easy solutions but can endanger lives.
Donaldson pointed to a 2007 study by the National Conference of State Legislatures that says the relative risk of a rural victim dying in a motor vehicle crash is 15 times greater than in urban areas, after adjusting for other contributing factors. In rural settings, 87 percent of the trauma deaths involving children occur before the child can reach a hospital.
The Register, in analyzing data from the Iowa Bureau of EMS, found:
• FEW PARAMEDICS: Lyon County has no highly trained paramedics — the sort of emergency personnel capable of providing advanced life-support services such as administering drugs and starting an IV. Nine Iowa counties have fewer than 40 EMTs living within their borders.
• ONE-PERSON AGENCIES: At least 11 state-licensed EMS "agencies" consist of single individuals working out of their home and car — with no other EMTs to accompany them on emergency calls that might involve more than one patient.
• FEW AMBULANCES: Twenty-nine of Iowa's 99 counties have one — or zero — ambulances within their borders that are capable of providing full-time, 24/7 service. Those 29 counties are home to 426,549 Iowans.
• FEW FIRST-RESPONDERS: Davis County has only one part-time ambulance service, plus one first-responder unit that doesn't transport patients. Monroe County has one full-time ambulance and one first-responder unit. A total of 14 Iowa counties have four or fewer EMS agencies of any kind within their borders.
• DECLINING SERVICE: Despite a population that has grown slightly, Iowa has significantly fewer EMS agencies now than it did nine years ago. In 2005, there were 891 EMS agencies in the state. By 2013, that number had dropped 12 percent, to 781 agencies.
• SERVICE IMBALANCE: Woodbury County, with 102,000 residents in 873 square miles, has one full-time ambulance service — while Sioux County, with roughly one-third as many residents and 100 fewer square miles, has 10 full-time ambulance services.
Bureau sees lack of leadership
Iowa's Bureau of EMS has seen a dramatic shift in recent years in its staffing levels and operating philosophy.
Nine years ago, the bureau not only knew which areas of the state were underserved, it had established written goals to "pursue funding opportunities to provide education in underserved areas."
Today, the agency no longer defines an "underserved" area, nor does it specifically track or analyze data about the services that have been forced to shut down, merge, or scale back their hours of coverage due to volunteer shortages or other problems.
The bureau hasn't had a full-time chief in three years, and Iowa is one of only 13 states without an EMS medical director — a position that's been vacant for 11 years here. Since 2002, the bureau's staff has dropped from 17 positions to 10.
Still, its only budget requests for new money in 2014 are tied to the replacement of a computer-data system and an assessment of Iowa's trauma care.
At a legislative hearing late last year in response to the Register's investigation, Rep. Art Staed asked bureau officials why they weren't requesting additional funding to hire a medical director, a bureau chief or more regional consultants to help EMS agencies in the field.
"And they would not tell me why they're not asking for any additional (positions)," Staed said. "I assume that's because the governor has told them they can't ask for that."
A spokesman for Gov. Terry Branstad declined to say whether the governor believes the bureau is adequately staffed.
Sharp said the EMS bureau needs medical advice and expertise, but added that the need might already be filled through the Iowa EMS Advisory Council, a 20-member panel that meets four times per year. That council provides guidance on EMS policies and includes physicians and other health care professionals.
Sharp said the bureau, which tracks the licensure and status of all ambulance services, is now attempting to redefine its role in state government.
"We recognize the bureau has not had strong leadership," Sharp said. "It has really floundered."
Service declines in N.W. Iowa
In northwest Iowa, ambulance service has been in a state of decline for several years.
In the town of Merrill, the ambulance service that once provided around-the-clock coverage scaled back to just evenings and weekends. If a resident needs an ambulance on a weekday, it comes from Le Mars or Hinton — eight to 11 minutes away.
Recently, Le Mars EMS and an ambulance service in nearby Remsen stepped up to provide coverage for the town of Oyens, where the ambulance has been mothballed due to a lack of volunteers.
"There aren't a lot of people volunteering now," said Bill Rosacker, the director of Le Mars EMS. "That has gone down. And at the same time, the educational requirements to become an EMT or a paramedic have gone up. So it's a bigger commitment of time now just to get certified."
When one EMS agency cuts its hours or pulls an ambulance out of service, it puts more pressure on the remaining agencies that must expand their service areas and increase their patient load.
"And when their stress level gets too high, those services are going to be in trouble, too," said Kevin Rollins, president of the county's EMS association. "Here in Plymouth County, I think we're just beginning to see these dominoes start to fall."
Rosacker said if state legislators made EMS an essential government service, similar to police and fire protection, that would at least establish a reliable source of funding.
"There are a lot of smaller services out there that need the funding, and they just don't have the tax base to support it," he said. "To put a $130,000 ambulance on the street, it takes a lot of EMS calls to pay that off."
The Oyens ambulance was taken out of service in February when the director realized his crew of six would soon be reduced to three — with no new volunteers coming on board to replace those who were leaving.
Response-time data kept secret
Under Iowa law, response-time data for individual ambulance services can't be disclosed by the state, so the effect of service shutdowns like those in Oyens is hard to gauge. And data made public by the Bureau of EMS can be misleading.
For example, the bureau says that under the law, it can only disclose countywide averages, and only for the 48 counties that have at least five EMS agencies. That list shows Montgomery County ranking at the bottom, with an average response time of 19.7 minutes — significantly longer than any of the other 47 counties.
But EMS officials say the data can be flawed because it doesn't take into account the number of calls, the refusal of some agencies to report their data and inconsistencies in how agencies define "response time."
Brian Pollard, head of Montgomery County's leading EMS provider, said the lack of full public disclosure, along with the anomalies in the data, has an unintended and damaging effect: It inaccurately and unfairly labels certain services — namely, his Red Oak Fire & Rescue Department — as the worst.
"That's because when people think of Montgomery County, they think of Red Oak," he said. "Are we the worst in Iowa? No. I've worked in six different Iowa counties, and I can tell you that Montgomery County is the best of them."
It stands to reason that Iowa's longest response times are in areas underserved by ambulance services. But those are the same areas where the secrecy provisions of the law are most stringent. The result: the law is most likely shielding Iowa's slowest providers from public disclosure of their response times.
Even state lawmakers, who are in the process of trying to craft legislation aimed at improving Iowa's EMS system, can't get the averages in 51 counties.
How bad could those response times be? John Bruce, the EMS chief for the Villisca Ambulance Service, said it was only a few years ago that his agency was recording response times of up to 45 minutes. By coordinating with ambulance services in neighboring jurisdictions, that number has been greatly reduced, he said.
Even so, a shortage of volunteers means a Villisca resident who calls 911 might have only a first responder — with no ambulance — at the door in about five minutes. It may be another 10 to 15 minutes before a fully trained paramedic from Red Oak, 18 miles away, shows up with an ambulance that can transport the patient to a hospital.
In Lyon County, 31-year-old Matthew Mydland is the sole EMT certified at the paramedic level and skilled in advanced life support. But because the Inwood Fire Department's rescue unit, where he plans to volunteer, is not certified for advanced life support, Mydland will only be able to provide basic-level care.
"So I won't be able to administer drugs, or start IVs, or use an intubator," he said. "But the knowledge I have is still there, and that's priceless."
Mydland said Lyon County is facing the same pressure as others when it comes to the volunteer shortage.
"We need young people to volunteer," he said, pointing out that many of the current volunteers are closing in on retirement age. "I would say the time commitment that's involved is the biggest hurdle to recruiting young volunteers. How can you work full time and raise a family when you're also taking EMS classes at night?"
ABOUT THIS PROJECT:
This special report examines the most underserved areas for emergency medical services in Iowa.
The project, a follow-up to The Des Moines Register's award-winning 2013 investigation into EMS, documents how many rural areas in the state struggle to maintain emergency medical services and attract people who want to volunteer to provide the services. The lack of emergency medical technicians in some areas can lead to long response times that endanger lives and stretch existing ambulance services as they try to cover massive geographic areas.
THE REPORT ALSO EXAMINES:
-- How several communities rely on sole providers to respond to calls for help.
-- The work of a task force, formed after the Register's 2013 investigation, that disbanded before making any significant legislative recommendations.
-- The volume of EMTs who continue to be disciplined by the state.