In Colorado’s emergency response, a rural-urban divide between life and death
September 5, 2013
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.
So will your chances of living or 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 urban Front Range.
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.
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"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.
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 of 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.
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.
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, while only 19 percent of the population lived in rural areas.
In Colorado, 51 percent of those who died in 2011 crashes perished on rural roads, according to the same report.
Part of this disparity is the result of geography. 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.
Also, 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."
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, neighboring agencies respond into those areas.
But none of that matters when you're injured. Minutes matter.
"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."
Get hit head on 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. 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."
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 mandated response times.
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.
Privately operated medical helicopters exist, but they are largely clustered along the Front Range — and often they aren't called until 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, there is nothing in Colorado 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."
The dwindling population in many 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.
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. 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 based around the state and operated by the state police.
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. According to the same federal report, 35 percent of those who died in auto crashes in Maryland in 2011 were 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 Hinsdale County — where the Continental Divide crosses twice — EMS director Jerry Gray said people simply have to accept that emergency response 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 state EMS chief, 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 are paid when they transport a patient.
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."
I-News is the public service journalism arm of Rocky Mountain PBS. For more information, go to inewsnetwork.org or call 303-446-4932. Senior reporter Burt Hubbard contributed to this report.
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