Rural Emergency Medicine

A car swerves across the center-line and slams into you head-on in a sickening thud, a spray of glass, an exploding air bag.

You’re alive, but you’re hurt and you need help – fast. Someone calls 911. Who comes to render aid, how much training and experience they have, and even how long it takes them to arrive will vary drastically, depending on where you are in Colorado.

And so will your chances of dying.

That’s because in emergency medicine, minutes matter. And Colorado is a state with 82 percent of its 5.2 million people concentrated along the Front Range from Fort Collins to Pueblo. And a state with vast sweeps of rural land, including three of the country’s 15 least-populous counties.

Those realities have spawned a patchwork emergency medical system where a wide disparity exists between the on-the-ground care you could expect along a rural highway and what you would see along the urbanized Front Range.

Colorado traffic fatality rates between 2002 and 2011 While 82 percent of the population is concentrated in the urban Front Range, more than half of fatalities occurred on rural roads.

Colorado traffic fatality rates between 2002 and 2011. While 82 percent of the population is concentrated in the urban Front Range, more than half of fatalities occurred on rural roads.

It’s a state with dead zones, where no dedicated ambulance service exists. And a state where many rural communities are fighting to maintain even a basic emergency medical service.

“We struggle day in and day out,” said Sue Kern, the emergency medical system coordinator and coroner in Cheyenne County on the eastern plains, and director of nursing at Keefe Memorial Hospital in Cheyenne Wells.

Part of the disparity is the result of geography – huge swaths of rural land means long distances from crash scene to emergency room. Part is the result of philosophy – emergency care is concentrated where the most people live. And part is an outgrowth of Colorado’s long history of “local control” – where local officials figure out how best to care for those who suffer life-threatening traumatic injuries, and where many rural areas are served by volunteers whose dedication is not in question but whose training and experience may pale compared to their urban counterparts.

“If you live in urban Colorado, the response is quick,” said Randy Kuykendall, interim director of the state’s emergency medical system. “If you live in rural Colorado, it’s longer, and it’s a day-to-day struggle.”

Denver Health paramedics Marsha Davis, far left, and Erin Cronin, right, treat Tony Davis in an ambulance in downtown Denver on Thursday, Aug. 22, 2013. Paramedic lieutenant Dennis Baker looks on, far right. Paramedics in Denver respond to about 100,000 calls per year. Medical responders in isolated and less populated rural and mountainous areas may answer a small fraction of that number. A patchwork emergency medical system has emerged with a wide disparity between the on-the-ground care you could expect along a rural highway and what you would see along the urbanized Front Range. (Joe Mahoney/I-News at Rocky Mountain PBS)

Denver Health paramedics Marsha Davis, far left, and Erin Cronin, right, treat Tony Davis in an ambulance in downtown Denver on Thursday, Aug. 22, 2013. Paramedic lieutenant Dennis Baker looks on, far right. Paramedics in Denver respond to about 100,000 calls per year. Medical responders in isolated and less populated rural and mountainous areas may answer a small fraction of that number. A patchwork emergency medical system has emerged with a wide disparity between the on-the-ground care you could expect along a rural highway and what you would see along the urbanized Front Range. (Joe Mahoney/I-News at Rocky Mountain PBS)

And Kuykendall acknowledged that no one from the state has tried to determine exactly which areas fall into an emergency ambulance no-man’s-land – places where there is no contracted ambulance service. As it stands now, surrounding agencies respond into those areas, but there’s no guarantee it will always be that way.

But none of that matters when you’re injured. Minutes are what matters.

“The ‘Golden Hour’ is a real thing,” said Dr. Gregory Jurkovich, chief of surgery at Denver Health Medical Center. “The concept is valid – you have a limited amount of time before you’ve lost your opportunity to save someone’s life.”

Dr. Gregory Jurkovich

Dr. Gregory Jurkovich

Jurkovich has experienced the high of treating a critically injured patient and later seeing that person walk out of the hospital, healing. And he’s seen accident victims, hurt in outlying areas of the state, who died because they didn’t get to a hospital quickly enough.

Get hit head-on Federal Boulevard, and you can expect that an ambulance operated by Denver Health will arrive in a matter of minutes, two highly trained paramedics on board. Get hit head on in Poudre Canyon west of Fort Collins, and it’s likely to be a very different experience.

First, you have to find a phone in an area with no cell service, said Bill Sears, president of the board of the Poudre Canyon Fire Protection District.

“In the lower part of the canyon, a couple of our volunteers work close, in the western part of Fort Collins, and they’re close enough that they can respond into the lower canyon in about – worst case is about half an hour,” Sears said. “If you’re bleeding to death, of course, that’s no consolation. But that’s the reality of being out in the boondocks. But if everybody’s working or they’re out of town or you know, whatever, nobody may respond.”

In that case, a call for help would go to the Poudre Fire Authority in Fort Collins, and the response would come from there, adding another 10 or 15 minutes – or more.

On a recent day in Cheyenne County, only one of the nine volunteer members of the ambulance service was able to work, and then he left town to transport a patient to another hospital. So, Kern was asked, what would happen if a trauma emergency was reported in the county?

“I would go, with firefighters, and I’d probably take a couple of my nurses,” she said.

The backbone of Colorado’s on-the-ground emergency medical system is a patchwork of ambulances operated by more than 225 individual organizations – cities, hospitals, ambulance districts, fire districts, private companies – and the emergency medical technicians and paramedics who staff them. Colorado is one of two states – California is the other – that leaves it to counties to license ambulance providers. And while the work of all those different organizations is coordinated by the state through 11 regional councils, there is no statewide oversight of such benchmarks as response times.

Colorado traffic fatality rates between 2002 and 2011 While 82 percent of the population is concentrated in the urban Front Range, more than half of fatalities occurred on rural roads.

Colorado traffic fatality rates between 2002 and 2011
While 82 percent of the population is concentrated in the urban Front Range, more than half of fatalities occurred on rural roads.

Those seriously or critically injured are treated at a system of designated trauma centers, from Level 1, where the most grievously hurt are taken, to Level 5.

But in one part of the system after another, there are dramatic differences between the available care in urban and rural areas.

All three of the state’s existing Level 1 trauma centers are in the Denver area – Denver Health Medical Center, Swedish Medical Center, and St. Anthony Hospital.

And in much of rural Colorado, the wounded are likely to be treated by volunteer emergency medical technicians, who have to leave homes or jobs, respond to the garage where the ambulance is parked, and then speed to an accident scene. Those EMTs – while highly dedicated – may initially have as little as 150 to 200 hours of training. Paramedics – such as those that staff all of the Denver Health emergency ambulances – have at least 1,500 hours of training.

Dean Cole, administrator of Nebraska’s EMS and trauma system, said he believes who responds matters.

“A positive or a negative outcome for a patient is directly affected by them because they are often the first one to put their hands on that patient,” he said.

Privately operated medical helicopters exist, and can dramatically cut the time between the scene and the emergency room, but they are largely clustered along the Front Range – and often they aren’t called until those initial responders have gotten to a scene and assessed the injured.

One area where the playing field has been leveled in recent years is equipment. Thanks to a $2 charge on each motor vehicle registration, the state has about $7.5 million a year to assist local jurisdictions as they need to update their equipment and train their members.

At the same time, Colorado does not establish benchmarks for things like response times, and there is nothing in the law that obligates anyone to provide emergency medical services.

“We provide advanced life support ambulance service,” said Deputy Chief Tim Rossette of the Kiowa Fire Protection District, “but if my board decides to stop providing that service, they can do that and there’s nobody that’s required to come in and fill that void.”

Just that kind of scenario has played out in recent years.

The hospital in the southeastern Colorado city of Lamar, for example, dropped out of the trauma system a few years ago. Get badly hurt in that area, and the effort there will focus on rendering you stable enough to transfer you to another hospital, probably along the Front Range, a process that may delay life-saving treatment.

And most recently, administrators at the Rangely District Hospital in northwestern Colorado announced plans to drop ambulance service in the area around the town of Dinosaur. Plans call for an ambulance service out of Vernal, Utah, to take over that responsibility.

All of this is happening in a state where the population has exploded – from about 2.2 million in 1970 to more than 5 million in 2010. But against that reality, there is this: More than one-third of the state’s counties (23 of 64) have populations today smaller than they once were – and 16 of those counties lost population between 2000 and 2010.

That dwindling population in rural counties makes it more difficult for local organizations to raise money from a shrinking tax base or find volunteers willing to give up hours at a time for no pay.

Volunteer firefighter Matt Araki leads his horses "Cat" and "Cash" to the arena at the Squair Deal Riding Center as he waits for an emergency call on Monday, Aug, 26, 2013 near Aspen Park, Colo. Araki is one of about 70 firefighters in the all-volunteer Inter-Canyon Fire Protection District that covers a 55-square-mile section of mountainous and heavily forested land in Jefferson County southwest of Denver.  Inter-Canyon responds to about 325 call per year of which early two thirds are medical emergencies. Fewer than twenty emergency medical technicians and paramedics are available for those requests. Thirty miles away in at Denver Health, those paramedics answer about 100,000 calls per year and have 40 full-time, paid paramedics on duty at any given time.(Joe Mahoney/I-News at Rocky Mountain PBS)

It’s nearly impossible to know how many people may be dying because their initial care comes too late, or the initial needs of the patient are too complex for an EMT, or it takes those first responders too long to get them to a trauma center.

I-News examined 10 years of traffic fatality data, compiled by the Colorado Department of Transportation, and then compared it to the average population in each county over a decade – calculating a rate equal to the number of deaths per 10,000 residents in road crashes.

The five counties with the highest rate off traffic fatalities – Mineral, Cheyenne, San Juan, Kiowa and Baca – are all small, remote counties, and four of them lost population in the first decade of the 21st century. Two of them are among the three Colorado counties with less than 1,000 residents.

Colorado traffic fatalities Rural vs. Urban

On the flip side, the five counties with the lowest rate of traffic deaths – Arapahoe, Boulder, Jefferson, Douglas and Denver – are in the highly populated metropolitan area.

It is impossible to gauge how many of those who died in road crashes might have lived if they’d treated by highly trained paramedics and moved quickly to a high-level trauma center. And calculating the data required extrapolating the population in many small counties.

A new report by the National Highway Traffic Safety Administration found that 55 percent of those who died in road crashes in 2011 lost their lives in rural areas – and that the rate of deaths per 100 million vehicle miles traveled was significantly higher in rural areas than in urban ones, 1.82 compared to .73. In Colorado, 51 percent of those who died in 2011 crashes perished on rural roads, according to the same report.

Dramatically changing Colorado’s system would probably require a major infusion of money – most likely through taxes or fees or a combination of the two.

One state that has built such a system is Maryland, where the breakdown of ground ambulance services is a lot like Colorado’s but where the state has taken steps to cut the urban-rural disparity in care for those most seriously hurt. Motorists there pay $14.50 a year in vehicle registration fees that are dedicated to the state’s emergency medical system. The fee generates roughly $55 million a year, and it funds a fleet of seven medical helicopters operated by the state police.

The choppers are based around the state, meaning rural areas have roughly the same response times in serious emergencies as the cities experience. And if you’re injured badly enough to require a helicopter flight to a hospital, you won’t pay a dime – all operating expenses are covered by the vehicle registration fees, which also support the state’s EMS certification system and pays for a statewide medical communications system.

A look at the systems for providing emergency ambulance service in Colorado and selected surrounding states:

A look at the systems for providing emergency ambulance service in Colorado and selected surrounding states:

According to the same federal report, 35 percent of those who died in auto crashes in Maryland in 2011 lost their lives on rural roads.

But even people in the Colorado system question whether there’s value in dramatically increasing funding in rural areas for a relatively small number of calls.

In Dinosaur, where the nearest hospital is cutting off ambulance service, each year sees about 50 emergency calls.
“Unfortunately, 50 calls a year – you can’t really justify putting an ambulance out there, with paid staff, for 24/7,” said Tom Soon, Moffat County emergency management coordinator. “For those 50 people, that need that service, it’s really, really, really important. But I mean, how do you do that? I mean, financially, it’s just not feasible. It’s impossible to do.”

In Hinsdale County – where the Continental Divide crosses twice – EMS director Jerry Gray said people simply have to accept that the reality in rural Colorado is very different from that in urban Colorado.

“The reality of the situation is that up on Stony Pass you’re never going to get a response like you will in downtown Denver,” Gray said. “It’s just the nature of the beast, and people need to realize when they’re headed out into the area. People come here for the solitude and the remoteness of it, and that brings with it delayed response times.”

Kuykendall, the acting head of the state’s EMS system, said that while little can be done to change geography one thing that can change is the way people think about ambulances.

Historically, ambulance services got paid if they transported a patient. That’s very different from police and fire departments, which are funded to be ready.

Kuykendall said he’d like to see EMS funded the way police and fire protection are, “because what you’re really paying for with an ambulance or a fire truck is you’re paying for it to be ready to go when the public needs it, as opposed to only paying for it when it actually is in use.”

Paramedic lieutenant Dennis Baker takes Leandra Olivas' blood pressure after she was in a minor car accident in Denver on Thursday, Aug. 22, 2013. About 82 percent of Colorado’s 5.2 million residents live along the urban Front Range from Fort Collins to Pueblo. And yet more than 50 percent of all traffic fatalities in the state occur on rural highways. Simply put, the emergency care you can expect to receive if you’re in a serious accident on one of Colorado’s far-flung rural highways can be vastly different than the response along the urbanized Front Range.

Paramedic lieutenant Dennis Baker takes Leandra Olivas' blood pressure after she was in a minor car accident in Denver on Thursday, Aug. 22, 2013. About 82 percent of Colorado’s 5.2 million residents live along the urban Front Range from Fort Collins to Pueblo. And yet more than 50 percent of all traffic fatalities in the state occur on rural highways. Simply put, the emergency care you can expect to receive if you’re in a serious accident on one of Colorado’s far-flung rural highways can be vastly different than the response along the urbanized Front Range.

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