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Indiana’s rural EMS system is having an emergency

By Emma Hopkins-O’Brien
Indiana Correspondent

When you dial 911you expect someone to answer and you expect qualified help to be immediately dispatched. However, what if that didn’t happen? 
According to speakers at a recent Indiana Rural Health Conference, Indiana EMS system is under-funded  and under-staffed, and it’s only getting worse. As with many statewide public services, those challenges are exacerbated in rural areas. Keynote presenters Tim Putnam, CEO of Margaret Mary Hospital; and Michael Kaufmann, state EMS medical director for the Indiana Department of Homeland Security (IDHS), explained the challenges, causes and potential solutions for EMS gaps in rural Indiana. 
“Indiana EMS is a dynamic and ever-changing system that stands ready at the intersection of public safety, public health and healthcare,” Kaufmann said. “Though IDHS is proactively working to improve the way EMS operates, many challenges face EMS in the days to come.”
The roadblocks EMS faces are many, including hospital culture, outdated regulations and, most troublingly, a declining EMS workforce. Kaufmann and Putnam outlined some potential solutions to these issues, such as more collaboration between EMS and hospital personnel to address issues of hospital tradition and attitudes. They also specified laws that involve EMS that need to be updated and further defined to explain clearly how EMS is to be funded.
“There’s no clarification as to who is ultimately responsible to provide EMS services,” Kaufmann said. “Is it a city or township? Is it a county? Likewise, there’s no specific mention of as to who is fiscally responsible to provide the funding, and at what level of care.”
Arguably the trickiest issue plaguing the Indiana emergency medical services system is the critical shortage of emergency medical technicians (EMTs) and paramedics. Many EMS agencies are now short-staffed and unable to fill their schedules. 
“The number of ambulances available has decreased dramatically,” Putnam said. “This is not due to a shortage of ambulances, but due to a lack of staffing. We just can’t hire enough EMTs and paramedics to fill more ambulances. It’s been increasingly hard to find an EMT or paramedic who is available. I’m not even talking about in our hospitals—but just at a basic level to staff our ambulances.”
 Kaufmann said the declining EMS workforce isn’t going to end anytime soon, as this is a complex issue and there is not a quick fix. EMS reimbursement for care is low, because care has evolved over the last 50 years, but reimbursement to EMS agencies has not. For example, ambulances are considered “transportation” in the sight of the law, and thus have historically only been reimbursed for transportation—not medical services.  Some counties are covered on a completely fee-per-service basis and other EMS-provided agencies need tax subsidies to help cover their cost and readiness of response
“The system is heavily weighted towards the urban 911 response, with many counties and rural hospitals uncovered both for 911 calls and interfacility transfers. One question I often get from hospitals—and specifically rural hospitals—is ‘why is it so difficult to get a vehicle to my facility to transfer my patience to a higher level of care?’”
Interfacility transferring—that is, ambulance rides from one hospital to another that is equipped to handle more complex or specialized cases—are especially difficult, because even fewer EMTs are available. To explain why, one must step into the shoes of an EMT or paramedic. According to Putnam, rural EMTs are currently paid between $10 and $12 an hour.  
“The only benefits many of them receive is a flat place to sleep between runs,” he said. “It’s just not a lot of pay to make enough people want to be in it.”
“It’s a hard job,” Putnam explained. “Sometimes at shift change, it’s a therapy session with people talking about what they had to deal with on the night before. You know, every EMT has the ride that haunts them—or the story that they go through over and over in their head, and what they could’ve done differently.”
Few people can really understand the challenges EMTs and paramedics face. Getting a certification or licensure to become one is costly, especially when wages and salaries have not kept up with demand or inflation, and do not accurately reflect EMS as a healthcare provider. A paramedic typically goes through 12 to 18 months of instruction to learn life-saving skills such as how to start an IV, administer life-saving medications, perform EKGs and do advanced cardiac monitoring. Kaufmann said fewer and fewer certifications have been issued for this kind of work on average per year since 2010.
“Likewise, the number of academic programs designed to provide initial training and provide EMT and paramedic licensure certification continues to decline,” Kaufmann said. “We’re finding more and more EMTs and paramedics now working within the walls of a hospital because there is a need for more skilled providers in a healthcare setting.”
Due to the pandemic, a need for more in-hospital workers resulted in staff being asked to do more with less—which, in this case, forced them to employ paramedics and EMTs to work alongside them instead of nurses and doctors, to help extend their reach and decrease their patient load. This further strains EMS providers on the ambulance to provide emergency care. 
So why would anyone want to be an EMS provider at all? Putnam explained that a passion for the job can be the biggest incentive, along with what makes the work so hard. 
“Just showing up and being there makes everyone feel better,” he said. “You say ‘we’ve got this taken care of’ and all of a sudden you’re the hero, and everything I do with that patient makes them feel better. I’ve talked to paramedics who have held the hand of someone who only has moments to live, or before they make it to the hospital, they only have a few words to say to that one EMT who’s with them.”
However this benefit is subverted when it comes to interfacility transfers, which is why, Kaufmann said, it is so difficult to find EMS providers to do such transfers, especially on the long rides in rural areas.
“On a transfer I’m taking a stable patient and I’m trying to deliver a stable patient, so it feels like anything I can do with that patient can potentially make it worse,” Putnam said. “Not every EMT or paramedic sees it that way, but keep in mind these are some of the reasons why the people that work long, hard hours with low pay in order to do 911 work, do not want to work hard, long hours at low pay to do transfer work.”
Kaufmann said solutions are being formulated, including a research study assigned via House Bill 1259 and innovative programs such as paramedicine. But they will need the support of public awareness and understanding. With the challenges facing Indiana EMS, Kaufmann and Putnam said solutions are needed in an EMS fashion—as soon as possible and in a way that provides high-quality care to Indiana citizens.
Members of the Indiana Rural Health Association believe House Bill 1259 could shine a light on the downfalls of Indiana’s current EMS system compared to other states in order to form comprehensive all-inclusive solutions to issues such as a declining trauma care workforce, outdated statutes, a clear plan on how the system should be funded and on what authority, as well as other prominent challenges.  
Kaufmann believes understaffing may be alleviated somewhat with a system that would expand the tasks paramedics could do with the ultimate goal of making the work less intensive and preventing re-admissions to hospitals. This is commonly known in states that provide it as paramedicine or mobile integrated healthcare. For instance, EMTs could be dispatched to someone’s house to help with chronic disease management education or guiding would-be ER patients to places more suited to their needs such as primary care centers, urgent care, mental health centers or substance abuse treatment. Paramedics could also act as telephone triage, assisting non-urgent 911 callers instead of sending in an ambulance crew. 
“The EMS of the future should be community-based health management, fully integrated with the whole healthcare system,” Kaufmann said.
Ideally, EMS in Indiana will become a team with the ability to identify and modify illness risks, provide acute illness and injury care follow-up, treat chronic conditions and monitor the overall health of the community. 
“A central premise unique to paramedicine or mobile integrated healthcare, is that EMS providers are trained professionals,” Putnam said. “They are available 24/7 and really should be embedded within every community across our state and across the nation.”