It's not all lights and sirens

It wasn't an abnormal day in most respects. No wreck-causing foul weather slicked the winding mountain roads. There hadn't been an accident at any of the three underground coal mines just upvalley, where a steep canyon cradles the sinuous North Fork River. Even so, both of the ambulances that serve tiny Paonia, Colo. were out responding to other emergencies when a third resident dialed 9-1-1. The two other ambulances that serve the town of Hotchkiss, just nine miles down the highway, were also out responding to calls. So the dispatcher paged the last ambulance in the area -- 17 miles away in Crawford. The response time -- probably 20 to 30 minutes -- wasn't ideal for any emergency, but it was certainly better than waiting for an ambulance to arrive from the closest hospital, 30 miles away in Delta. 

A North Fork Ambulance Association rig cruising the agency's 1,500-square-mile coverage area. Courtesy NFAA.

Most folks take for granted that speedy help waits on the other side of every 911 call. But in rural areas like Colorado's North Fork Valley -- High Country News' base, where just a few thousand residents are scattered between the three communities -- rapid response has always been a tall order. And it's getting ever taller.

With just over 700 calls a year, the nonprofit, volunteer-based North Fork Ambulance Association's rigs don't run that often compared to those in more developed areas. Indeed, demand falls far short of the 5,000 or so annual transports that would attract a for-profit ambulance company. But the coverage area is huge and rugged -- 1,500 square miles -- and "the calls never come in evenly," notes longtime North Fork EMT and board member Kathy Steckel. This unpredictability necessitates multiple stations and ambulances to ensure decent service. And "it costs the same amount of money to staff and stock an ambulance whether it runs 5 calls a year or 5,000 calls a year," says Randy Kuykendall, chief of emergency medical and trauma services for the Colorado Department of Public Health and Environment.

So it is that many of the state's rural ambulance services have reached something of a crisis point. Budgets are stretched from Fort Morgan on the eastern plains to the mountainous recreation mecca of Summit County, reports the Denver Post, sometimes to the breaking point. "This isn’t sudden. But it's becoming more and more acute" in Colorado and in much of the rural West, says Kuykendall, who consults with agencies around the state to help improve emergency care and serves as president of the National Association of State EMS Officials.

The heart of the problem, he explains, is that ambulance services are compensated on a per run basis, not for ensuring adequate emergency care. Under Medicare and Medicaid, and even under private insurance, he says, they typically recoup an average of 40 cents on every dollar of cost. That forces higher charges for ambulance rides (in the North Fork, it's up to 1,000-$1,200 per run to the hospital, says Steckel). Meanwhile, the price of life-saving equipment keeps going up. Some portable cardiac monitoring devices go for $35,000 a pop, Kuykendall says. A fully-equipped new ambulance might cost $120,000. And those ambulance services that are supported by tax districts (the North Fork is not one) are seeing revenues plunge with property values in this rotten economy.

State grant programs can help, as can tax increases. So can reliance on volunteers. The North Fork Ambulance Association, for example, is doing just fine with its budget, says North Fork bookkeeper Karina Nicewicz. The nonprofit's 1,800 members pay a modest annual fee that covers unlimited runs. It also receives occasional donations, and its volunteers are compensated at a much lower rate than paid staff would be -- providing a cushion against financial losses from underpayment.

North Fork Valley volunteer firefighters and EMTs stage a  rescue for local high school students in advance of prom as a warning against drunk-driving. Courtesy NFAA.

Still, volunteer staffs like the North Fork's often don't have many young people rising in their ranks to replace aging, experienced members because recruitment and retention have gotten more difficult, says Kuykendall. That may have to do with increased time-commitments in peoples' lives as they try to make ends meet, says Richard Kinser, who's been an EMT with the North Fork agency for nearly 40 years and serves as the organization's president. But it also seems that fewer folks are interested in making sacrifices to serve their community, he says. "Honestly and truly, we shouldn’t have to campaign this hard."

The North Fork Ambulance Association has some 80 people on its rosters, but maybe 40 of them take the bulk of shifts, says Steckel, and sometimes shifts don't get filled. To help address the critical shortfall, the agency recently made a recruitment video and is getting more aggressive with outreach. It also just increased the minimum number of required shifts per volunteer from 24 per year to 48. The move is partly to "give the new volunteers coming on a better idea of the amount of help we really need," says Steckel, though increased practice also makes for better EMTs. Steckel and Kinser say those efforts are showing some early success, and as always, the agency's stalwarts go above and beyond. "It really comes from the heart," says Steckel. "That’s pretty neat to have... That people care enough to go out and help their friends and neighbors."

Sarah Gilman is High Country News' associate editor. She's also an EMT-in-training with the North Fork Ambulance Association.