What happens when a small town loses its only ambulance service
The service does not usually collapse dramatically. It resigns, or the contract is not renewed, or the volunteer roster falls below the number needed to crew a truck, and the change takes effect on a date printed in a letter.
Then the nearest unit is thirty or forty miles away, and everything about living there is different.
Why it happens
Rural emergency medical services run on a model that does not work any more, and people in the business have been saying so for years.
Most services bill insurance for transports. Medicare and Medicaid reimbursement rates are set nationally and frequently do not cover the cost of a rural call, where the distances are long and the call volume is low.
A city service runs many calls a day across a small area. A rural service might run three calls in a day across a thousand square miles, and it has to maintain a truck, equipment and a crew for all twenty-four hours regardless.
Then there is staffing. Volunteer services are ageing and recruitment is hard, because the training requirement has risen substantially and the people who would once have volunteered are now working two jobs. Paid services compete for paramedics against urban employers who pay more.
And in most states emergency medical services are not what is called an essential service, which means no level of government is legally required to provide them. Fire and police are. Ambulances, in much of the country, are not.
That surprises people and it is the central fact of the whole problem.
What changes for residents
Response time. That is the number that matters and it is the one that goes up.
For a cardiac arrest, the window in which intervention makes a difference is measured in minutes. For a serious trauma, the standard people talk about is the first hour. A forty mile response, plus a forty mile transport to a hospital that may itself be an hour further, puts a lot of calls outside both.
Mutual aid covers it, and mutual aid means the neighbouring town's truck. While that truck is with you, it is not in its own town.
Air ambulance becomes the answer for serious cases, and air ambulance billing is its own subject. Protections against surprise billing have improved, and patients still receive alarming invoices.
What communities do
Some contract with a neighbouring service or a private company, which works if somebody will bid.
Some form a special district with taxing authority, which is the most durable solution and requires a vote.
Some merge with the fire department, which shares the staffing and the building.
Some rely on first responders: trained volunteers who arrive in their own vehicles with a defibrillator and oxygen and start care before a truck arrives from far away. That helps genuinely and it is not a substitute for a transport unit.
Some simply do without, and that is more common than it should be.
What to do if you live somewhere at risk
Find out who currently provides your service and how it is funded. Most residents cannot answer this and it is a five minute question at a town meeting.
Find out the actual average response time for your address, not for the district.
Learn hands only cardiopulmonary resuscitation. In a place where the ambulance is forty minutes away, the person who starts compressions is the treatment, not the first step before it.
Find out where the nearest public defibrillator is, and whether there is one at all.
And go to the meeting when the funding comes up. These decisions get made in rooms with eleven people in them.
The uncomfortable part
I have covered a few of these closures and the pattern is the same. The service warns for two or three years that the finances do not work, the warnings are noted, and nothing changes until it stops.
Then everybody is surprised, and the response is faster and more expensive than it would have been if anyone had acted on the warning.
The warning is usually in the minutes of a public meeting, available to anyone, read by almost nobody.
