When seconds count

Where does a small city draw the line when it comes to providing measures for saving lives?

Only those who have been a part of a medical crisis — the horrible accident, the cardiac assault, the unexplained collapse — understand in the ways that rural rescuers do, that life can hang on a thread.

And first responders like Shawna Bolstad and others who work the spectrum of life and death, know that what happens as life dangles can mean everything.

Bolstad is the newly hired advanced life support paramedic, part of the International Falls Ambulance Service’s partial upgrade, a longtime vision of those who work in the local field.

The new service comes with a degree of confusion for the public, as well as conundrums and some controversy.

Borderland’s emergency center

The atmosphere inside the Falls Fire Hall is one where emergency vehicles and first responders are synchronized for action. Ready to dart, three ambulances point toward their corresponding doors. On this day, the mood is calm and jovial camaraderie fills the air.

Fire Chief Jerry Jensen and Bolstad share a table in the midst of the station’s ambulance bays. In an office nearby, firefighter and emergency medical technician, Bruce Bergstrom mans the phone. A startling clang of an incoming emergency could abruptly turn record keeping, shelf stocking, cleaning and camaraderie into teamwork. A life may literally depend on it.

If an ambulance is dispatched, Jensen, the 30-year veteran firefighter, EMT and chief, will be in charge. But with recently added Bolstad’s paramedic skills, Jensen will be the driver. In the back of the ambulance, it is Bolstad who will make the medical recommendations regarding the transported patient.

This new protocol evolved with the city’s upgrade to advanced life support, following emotional appeals by department members and other medical professionals in response to the community’s emergency needs.

Along with Jensen, physician Jay Knaak and Falls Medical Director Jeri Vergeldt are fortifying the push to give area residents full-time paramedic service.

But for now, local ALS service is only part time. Bolstad, whose training certifies her to provide a higher level of medical response, is the sole paramedic and works one shift from 8 a.m. to 4 p.m. on weekdays.

A medic emerges

Although Bolstad is the service’s first ALS paramedic, she is not new to the environment. She was first hired by the city about six years ago as a summer employee, assigned to blight issues.

The young woman remembers being repelled by the ambulance action which she initially witnessed. “I never thought I’d be doing this,” she says, recalling her feelings.

Jensen explains that as a new employee, Bolstad was exposed to the psychological decompressing revealed by the service’s EMTs following ambulance runs — the worst of which may haunt them. He said that if not for the emotional accessibility which fellow rescuers offer each other, counseling might sometimes be needed.

But to Bolstad’s surprise, she began to take a shine to the work when seasoned EMTs and firefighters, such as recently retired Wayne Lepper, familiarized her with the service. The nurse went on to earn the required 11-month training and emerged a street-ready medic.

Now she knows that emotions must be blocked during emergencies, she says, “but the body will let go” when the crisis has passed.

Services by definition

What’s the difference in the ALS emergency care that Bolstad may offer, versus that which is given with basic life support services through the city’s trained EMTs? In some cases, the difference is dramatic — in others, the distinction is minimal.

And while supporters continue working toward a full-time local ALS service — the EMTs who have sustained the BLS system remain integral to emergency response, Jensen says. “EMTs still have an important role in this field. ...”

EMTs are primarily trained to assess and initiate trauma treatments in situations such as bleeds and bodily injuries, Bolstad said, adding that the Falls EMTs are highly capable. But in medical cases which Bolstad calls “the puzzlers,” paramedics, such as herself, are skilled and licensed with capabilities to administer a higher degree of treatment. Cardiac and cerebral injury situations, for which Bolstad said she is trained in a “plethora of treatments,” provide dramatic examples.

“This is a team approach,” Jensen said. “An average call is a broken ankle. But something as serious as a stroke, reaction is everything. Our goal is to do the best we can.”

For those who have a heart attack during Bolstad’s watch, a 12-lead electrocardiogram can be administered, allowing her to react to a readout. Part of the ALS upgrade, heart monitors have been added to each of the city’s three ambulances at a cost of $50,958.

Cardiac and diabetic patients, who are involved in the most frequent emergency calls locally, may be intravenously and immediately administered a larger variety of medications and treatment because of Bolstad’s training. In addition, pain relief at accident sites is now an option — during Bolstad’s shifts.

Not only can patients in emergencies receive more specific care while in transport, but ongoing inter-facility medical transfers which require medical professionals on board, are also served. Those transfers are deemed a priority in the blueprint for the ALS upgrade. It is interesting to note that ground transfers are often made in about the same amount of time (or less) as helicopter transfers, according to Jensen. The availability of helicopters, which require additional arrival time, is influenced by weather. However, helicopter transfers, which offer critical care, will always be imperative in some situations, Bolstad said.

Recent city data says 70 percent of area emergency calls happen during the shift that Bolstad works.

The cost of services

Jensen, and members of an ALS Ambulance Task Force, have appealed to Koochiching County to create an emergency medical services taxing district to supply the estimated $304,000 needed to fund a full local ALS system employing four paramedics. Jensen told the county board about a year ago that property owners with a home value of $150,000 would see taxes raised just $68.

Right now, emergency runs using ALS are paid by the patients who use the service.

A current ALS emergency transport, billed to the patient, includes a base cost of $1,250 plus $20 per loaded mile. The base cost of an ambulance run under basic life support services is $550 plus $15 per loaded mile.

Does a patient automatically pay ALS fees if an ambulance is summoned during the weekday hours of 8 a.m. to 4 p.m.? Not if just basic life support skills are used, according to Jensen. But if Bolstad feels it necessary to implement a treatment for which only she is licensed, ALS fees will be applied.

Increasing medical costs are a somber reality for many people in these economic times; and unexpected emergency needs could financially devastate some families.

“But I would never compromise my patient’s health for financial reasons,” Bolstad said. “I do empathize, and I do understand, but I also know what I have to do.”

Jensen said that 70 percent of local runs are being paid at fixed rates by Medicare and Medicaid, but he acknowledges that other insurance coverage varies.

The 2009 total ambulance revenue is reported to be $738,944 versus its annual expenses of $738,363. This is right where it should be, Jensen says. If revenue were to significantly overlap expenses, lower ambulance rates (or taxes) would follow, he noted.

Bolstad is paid $20 per hour by the nonprofit service and is subject to the contract benefits of city employees.

It has been suggested that the ability to increase inter-facility ground transfers with service paramedics could position the ambulance department to become better self-supported.

On behalf of Koochiching taxpayers, accordingly, action by the county on this matter has been tabled due to current economic conditions.

Inevitable inconsistencies

The unavoidable conclusion is that ALS services will not be available for every emergency.

Bolstad says she lives with that anxiety 24/7.

“Whatever affects her life affects our ALS,” adds Jensen.

Even when her shifts are finished, Bolstad said she feels a gnawing apprehension about leaving town or having a glass of wine. Although she carries a phone and a pager, Jensen said he is leery about calling Bolstad for added evening or weekend shifts. “We have to be very careful,” he said. “It’s dangerous to overwork somebody.” When Bolstad is not on duty, other required medical professionals are still used as for inter-facility transfers.

“I want to be able to do more,” Bolstad said, distressed, “but I just can’t. It’s hard.”

Becoming emotional himself, Jensen said that those who have saved a life, and those who have been unable to save a life, feel deeply that offering ALS full time is the most assuring response to local emergencies. “The guys here (EMTs) know it. They’re very passionate about this,” he said.

Jensen noted that with each biennial ambulance inspection by the regulatory board, comes the question: “Where are you with ALS?”

How much is enough?

Cost-conscious officials and ALS skeptics extend the questions: “Is there a tangible measure of the outcomes of an upgraded system?” “Why stop at ALS? If all it takes is money, what is the price tag on a human life?” “Where do we draw the line?”

Those who are strangers to medical emergencies will likely have a different view than those who are not.

Jensen says knowing that patients in crisis have been provided ALS is a comfort to those who live their lives as rescuers. “This is by far the best thing that’s happened, in my eyes, in this community as far as emergency service,” he said. “In 30 years, I’ve made a lot of runs and it (losing a patient) can affect you badly,” he said. “I can’t tell you the sad days.”

And while funding is more difficult in small towns, it is ironically rural people who need ALS the most, Jensen said, by reason of the distance to major medical centers.

Bolstad is also adamant in her belief. “We do need ALS around the clock, and we do need the money to provide it,” she said, explaining that until she has additional ALS personnel “to lean on,” she won’t rest easy.

This paramedic and her chief speak confidently that it’s too soon to draw the line. Adding one paramedic is just the first step toward a full service which they believe is not only attainable, but will save local lives.