How long until an ambulance gets to you? Kentucky services struggle with staffing. [Lexington Herald-Leader]

Oct. 29—Concerns about long waits for an ambulance in some Eastern Kentucky counties hit home for Jim Dockery's family after he started having chest pains one evening in August.

His longtime companion, Lisa Gibson Koch, called 9-1-1 and her son, Daniel Koch, rushed to Dockery's house a few miles away in Magoffin County. After Dockery lost consciousness, Koch, a corrections officer, performed CPR for more than 20 minutes while waiting for the ambulance, said Koch's wife, Amber.

When the ambulance arrived, Dockery, a 62-year-old former mechanic, had no heartbeat.

It's a drive of 15 minutes or less to Dockery's house from Salyersville, where a company called Lifeguard Emergency Medical Services has an ambulance station, but it took more than 45 minutes for a Lifeguard unit to arrive the night Dockery died, Koch said.

"This has been an ongoing issue for years," Koch said of long ambulance response times. "We're not the only people who've had experiences like this."

A spokesman for Lifeguard said the company staffs two ambulances in Magoffin County. When both are responding to calls, it has to contact an ambulance from an adjoining county, said Terence Ramotar.

Lifeguard has faced staffing shortages, Ramotar said.

"The core problem here is the workforce shortage," he said.

That is a problem in many parts of Kentucky and the nation, and it's causing longer response times for some calls, according to emergency medical service (EMS) officials.

Ambulance services run by local governments, non-profits and private companies have struggled to recruit and keep workers, especially paramedics.

There are a number of reasons. The job can involve long hours and high stress, and the coronavirus pandemic of the last 18 months has made that worse, raising worries among EMS workers about getting sick or carrying COVID-19 home to family members, and forcing some to quarantine after being exposed.

The pandemic reduced the number of training classes in 2020, meaning fewer people in the pipeline. It can take up to two years to become a paramedic.

Many rural services can't afford to pay as well as urban ambulance services or hospitals, making it harder to keep paramedics.

Ambulance providers said another factor is that Medicaid and Medicare, two primary payment sources for ambulance services in much of rural Kentucky, pay less for many runs than it costs to treat and transport patients. That affects their ability to pay paramedics and emergency medical technicians (EMTs).

There were 14,816 certified and licensed emergency medical service providers in Kentucky in 2020, ranging from emergency medical responders, who qualify after 50 hours of training, to paramedics, who must have at least 2,000 hours of training, according to the Kentucky Board of Emergency Medical Services.

However, not all those providers were working on ambulance crews, said Michael E. Poynter, director of the agency.

The state could use several hundred more ambulance crew members, Poynter said.

"The system is strained right now," he said.

The shortfall is being met by ambulance crew members working extra shifts, sometimes 80 hours or more a week and often at more than one service, according to directors around the state.

It's not unusual for a rural county in Kentucky to have two ambulances on duty but for both to be tied up, forcing dispatchers to call for an ambulance from another county under mutual-aid agreements, adding to the time needed to respond.

Without measures to get more people to train as EMTs and paramedics and stay in the field, the EMS system in Kentucky "is in danger of collapsing," Keith Sanders, head of the ambulance service in Edmonson County, told Kentucky lawmakers at a committee hearing in August.

"It's a dire situation," Sanders said.

'No ambulances in the county'

Magoffin County Judge-Executive Matt Wireman dealt with complaints about ambulance response times by applying to start a county ambulance program to supplement Lifeguard's service.

Wireman said he started hearing complaints about response times after Lifeguard took over for another service in 2019.

When he looked into the issue, he learned that there have been times when Lifeguard had no ambulances available in the county of 11,600 people, Wireman said.

On 107 calls to 9-1-1 over 45 days in July and August, there were 13 times when Lifeguard did not have an ambulance in the county at the time of the call, Wireman said.

That's what local officials were able to track based on notices. Wireman thinks the number was higher.

"We've had multiple instances here where . . . we're at level 0, what they call it, no ambulances in the county whatsoever for 9-1-1 calls," Wireman said.

Michael Blake Cantrell, a pharmacist who is on the Magoffin County Rescue Squad and also works with two volunteer fire departments in the county, said he has responded to several emergency calls in which it took a long time for a Lifeguard ambulance to arrive.

He recalled two cases where it took 45 minutes, once while he helped a drug overdose victim and another involving a woman who was struggling to breathe.

"When minutes can define the difference between life and death, this is not only unacceptable, but abhorrent and unethical," Cantrell said in a letter supporting the county's request to start its own service.

Asked about the response time in the case involving Dockery, the Magoffin County man who died, Ramotar, the Lifeguard spokesman, said the company could not comment on specific patient transports.

However, a Lifeguard unit arrived at the scene that corresponds with Dockery's address in 27 minutes, he said.

The crew had trouble finding the address "as many of the road signs and markers in Magoffin County are missing or not accurate with GPS mapping," Ramotar said.

Dockery's family believes Lifeguard began counting the 27-minute response time after a company ambulance from another county reached the Magoffin County station, then headed to Dockery's house.

A hearing officer approved Magoffin County's request to operate its own service to answer any emergency calls on Sept. 14.

Wireman said he intends to have the service up and running within six months.

Lifeguard is part of Global Medical Response, the largest medical transportation company in the world. In Kentucky, Lifeguard has operations in Pike, Magoffin, Floyd, Knott, Leslie, and Harlan counties.

Prestonsburg Mayor Les Stapleton, a retired state police officer, said Lifeguard has good, professional staffers, but hasn't had ambulances readily available in Floyd County at times.

"I've got people that have literally died," Stapleton said.

An analysis of calls to Kentucky State Police, which dispatches for emergency calls in Floyd County, showed that between April and September 2019, it took Lifeguard 50 minutes or more to arrive at a scene in 43 percent of the recorded calls, and 20 minutes or more in 80 percent of cases, according to testimony in the case of another private company applying to start an ambulance service in the county.

Lifeguard questioned the accuracy of the data, but a hearing officer concluded the other company, Emergent Care EMS, had shown there was an unmet need for additional ambulance service in the county.

Like Magoffin County, the city of Prestonsburg also has applied for a certificate of need to open an ambulance service.

Stapleton said he has an agreement with Lifeguard that if Prestonsburg gets to open its own ambulance service, it will only handle emergency runs, not non-emergency transports such as taking people to doctor's offices.

'Never seen a time like this'

Ramotar, the Lifeguard spokesman, said starting more ambulance services won't solve the shortfall in EMS workers because there aren't enough to meet demand already.

However, Stapleton said the city has more than 25 firefighters with the the necessary certification to staff the service he wants to open.

Ramotar said Lifeguard has taken steps to try to boost staffing, including providing several EMT classes in the last year. The company offers tuition assistance and has a program to pay people while they take EMT training, he said.

The company also is working with government officials to try to establish more training programs.

The loss of EMS training programs during COVID-19 created a shortfall nationwide in the number of EMTs and paramedics, and the competition for paramedics from other employers who can pay more has become stiff, Ramotar said.

"Unfortunately, for every paramedic we hire, one is hired away by a fire department or other provider who is also short staffed," he said. "The industry is essentially solving one problem and creating another somewhere in the state or other part of the country because we are all trying to hire a finite workforce with few new recruits."

Staffing concerns are common around the state.

The starting salary for a paramedic at the non-profit Ambulance Inc. of Laurel County is $15, but hospitals in the area pay $20 or more, plus a hefty bonus, said James Hacker, chief executive officer of the service.

"We have never seen a time like this, to where we are struggling to keep our roster filled," he said.

The service has had to use supervisors to work on ambulances, he said.

Patricia Cole, deputy director of the ambulance service in Lee County, said the service needs 21 people to be fully staffed, but has only 15 full-time workers plus three or four people who help fill in.

As a result, some people are working more than 80 hours a week to keep the ambulances running, Cole said.

The situation is stressful, but people go into EMS work because they want to help their communities, Cole said.

"You have to have the heart to do it," she said.

There was a recent case when both ambulances on duty were out of the county at the same time when a third call came in, Cole said.

The dispatch center tried to get an ambulance to respond from adjoining counties but there were none available, so the call had been pending for an hour before a Lee County ambulance returned to respond, Cole said.

"Thank God it was not serious because if it was serious somebody would die," Cole said.

The situation is compounded for ambulance services in Kentucky counties with no hospital, meaning more time out of the county for runs to hospitals elsewhere.

The state has taken steps to try to deal with the staffing crunch, such as allowing people with less emergency medical training to drive ambulances and waiving the recertification fee for trained EMS workers who had allowed credentials to lapse.

But relatively low pay remains a challenge that has to be addressed at some point, Poynter said.

Sanders, the Edmonson County EMS director, said many ambulance services can only afford to start EMTs at $11 or $12 an hour — less than some restaurants are offering these days.

"Why would you spend a thousand dollars to take a class to make $11 an hour when you can go serve fast food and make $15?" Sanders said during an Aug. 26 legislative hearing.

Lifeguard starts EMTs at $10 to $11.44 an hour and paramedics at $16 to $17.44 an hour, Ramotar said.

Providers said Medicare and Medicaid reimbursements for transporting patients need to be increased, which could help services increase pay.

Jon Allen, emergency management director in Lee County and head of the county's ambulance service, said one Medicaid managed-care provider the service deals with reimburses just $100 for ambulance runs.

"That basically pays the fuel," Allen said, leaving nothing for other costs.

The service billed $165,580 in July, most of it to Medicare and Medicaid, but received just $49,246, or about 30 percent, which is typical, Allen said.

The county supplements the ambulance service's budget.

Sanders said the average cost of a run for his ambulance service in Edmonson County is $880, while the average reimbursement from Medicare and Medicaid is $386. County taxpayers have to cover the rest, he said.

Payments from private insurance companies and individuals help make up for relatively low reimbursements from Medicare and Medicaid, directors said.

Medicaid reimbursements have gone up this year under a measure the legislature approved in 2020, but still don't fully cover the cost of ambulance runs, said Troy Walker, president of the Kentucky Ambulance Providers Association.

Other suggestions for dealing with the shortfall in EMS staffers include changes to induce retirees to return to work and tuition help for EMS training. The cost to become a paramedic has gone up, and the number of available classes dropped under accreditation standards adopted several years ago, ambulance directors said.

There could be proposals in the regular legislative session beginning in January aimed at dealing with the concerns over EMS staffing, said Rep. Michael Meredith, a Republican who chairs the Local Government Committee.

"I think especially the rural legislators understand what a problem this is," Meredith said. "Whatever can be a good, viable solution, I think we need to look at."

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