Written by Kim Krisberg

The West Texas town of Alpine is a popular spot for travelers on their way to Big Bend National Park — a destination the National Park Service recommends for its “splendid isolation.” The rural town, with a population of about 6,000, sits just north of the park, more than two hours from the nearest airport and an hour from the closest Walmart.

That remoteness is exactly why so many flock to the region. But for the local hospital, it can represent a significant challenge.

Alpine has a locally owned and operated emergency medical service that responds to local 911 calls. However, it also can be tasked with a number of other responsibilities that come with small town life in a remote part of the state. The challenge is to sustain ground transportation services for patients who eventually require a higher level of care than what the Alpine hospital can provide, such as more complex stroke, heart attack and premature newborn care.


Moore
“It’s a big issue,” said Diane Moore, CEO and chief financial officer at Alpine’s 25-bed Big Bend Regional Medical Center. “We’ve had instances in which we’ve literally thought about putting people in the back of our own cars and transporting them ourselves.”

Moore said the hospital typically arranges between 30 and 40 transfers each month with the majority headed to Odessa, more than 120 miles away.

In 2017, the Alpine hospital began partnering with First Flight for the bulk of its ground transfers. It marked the third time in three years that the hospital had to find a new transport service, Moore said. The two previous companies were losing too much money to stay in Alpine.

“I worry about it,” she said. “It is very wearing — for lack of a better term — both emotionally and mentally trying to figure out how to best service our community.”

Alpine’s experience is a familiar one in Texas, where more than half of the state’s 254 counties are considered rural. Texas’ rural residents — similar to their rural counterparts nationwide — often face greater transportation barriers to care and regularly prioritize emergency transportation as a pressing community health need. For example, in 2013, Texas Tech University Health Sciences Center assessed emergency medical services in rural West Texas, finding that “great expanses of geography are often covered by a single, sparsely equipped EMS unit, manned by a few dedicated volunteers.” Gaps in medical transportation services can have serious consequences, increasing morbidity and mortality risks for a range of time-sensitive health conditions.


Francis
Overcoming those gaps and reducing their impacts on patients are a constant challenge for many rural hospitals.

“It’s been really tough,” said Christy Francis, CEO of Hemphill County Hospital District in Canadian, 100 miles northeast of Amarillo.

RECRUITING, TRAINING A LOCAL WORKFORCE A MAJOR BARRIER

Just west of the Oklahoma border, the 26-bed Hemphill County Hospital is located in a county of less than 5,000 people. Like many rural providers, the hospital originally depended on an all-volunteer EMS service, eventually transitioning to a paid EMS staff as demand grew.

Still, it’s hard to find and attract personnel. “We kind of have a bidding war out here because we’re all so desperate for paramedics,” Francis said. The hospital has long invested in EMS training to grow its workforce, but Francis said new education requirements are straining that effort as well. In 2013, Texas mandated that all paramedics complete a two-year, college-accredited program and be tested via the National Registry of Emergency Medical Technicians. The new college requirement meant the Hemphill hospital had to revamp its training efforts and boost its competitive edge to attract qualified paramedics.

“You want well-trained individuals, so I don’t mean to complain about (the new education requirements),” Francis said. “But it takes a huge amount of cooperation by all involved.”

First, the hospital district committed to increasing paramedics’ pay, which Francis said allowed the hospital to sustain a full staff of paramedics. And within the next six months, the hospital plans to launch its first paramedic training class since the 2013 requirement took effect, partnering with a local college to offer a mix of online and in-person education to ease the travel burden on potential students, many of whom already have full-time jobs.

“Three-fourths of our paramedics don’t live in Canadian, so we really need to be able to grow our own,” Francis said.

Today, the Hemphill hospital has three ambulances — though only enough funding to fully staff two at any time — six paramedics, five emergency medical technicians and two advanced EMTs. The ambulances do both emergency calls and medical transfers, with nearly all transfers making the 200-mile round-trip to Amarillo. Every year, she said, the hospital district typically loses about $450,000 to maintain its EMS service for the community.


Henderson
About 100 miles south of Canadian, Childress Regional Medical Center’s EMS fields about 120 calls to 911 each month. That number on its own isn’t overwhelming “by any means” for the hospital-based EMS service, according to John Henderson, the hospital’s former CEO and current president/CEO of the Texas Organization of Rural and Community Hospitals. But when combined with medical transfers for higher levels of care, it does stretch the service thin, he said.

The hospital typically does about 20 ground transfers a month at about 280 miles round-trip, which puts one of the hospital’s two ambulances out of town for hours at a time. If a second medical transfer is urgently required when only one ambulance is available for local 911 calls, the hospital can call in air transport. Henderson said the arrangement is meeting local needs for now, but it’s always a challenge to keep the ambulance service staffed.

“At this moment, we’re as good as we’ve ever been,” he said. “But it’s not because we have a lot of funding or resources, but because we have a lot of good people.”

Henderson points to telemedicine as a potential “game-changer” in rural health care. For instance, he said such a service could help EMS personnel keep patients stable during long transfers. Still, he said it would take a lot more than hospital investment to encourage the kind of broadband infrastructure to make that a reality.

“On an average day, we’re fine; on a busy day, you just can’t find enough help,” Henderson said. “That’s the nature of rural health care. Either everything’s fine or you’re scrambling.”

'WE WORK OUR WAY THROUGH IT AS BEST AS WE CAN’

Teresa Callahan also thinks telemedicine could transform rural emergency care, but right now it’s not financially feasible for the 14-bed hospital of which she is CEO in Iraan, about 80 miles south of the Midland-Odessa area.

“I do think the wave of the future will be (telemedicine) right there in the ER for us small guys,” said Callahan. “But right now, we’re just trying to survive financially.”

The small critical access hospital used to depend on a volunteer EMS service that served both Iraan and the nearby town of Sheffield. But about 10 years ago, Pecos County decided to invest in its own ambulance service, posting an ambulance and crew just down the street from the Iraan hospital to respond to 911 calls. But the logistical challenges of facilitating medical transfers to higher-level care while maintaining full 911 coverage in Iraan are significant. Fortunately, Callahan said the hospital can depend on ambulance services at nearby Fort Stockton and Rankin to help fill in the gaps, but it still takes longer than is ideal when “time is of the essence.”

She said more flexibility in the rules governing medical transfers could help rural hospitals maintain all the transportation services they need while lessening the burden on local 911 responders.


Callahan
“Our ER is fully equipped and we can stabilize people very well,” Callahan said. “But sometimes we have to get them to a specialist.” Back in Alpine, the tenuous transfer situation has Big Bend Regional Medical Center boosting its internal capacity to care for more acute patients. Moore said the hospital has offered critical care training for its nurses, hired a full-time hospitalist, and is working with hospitals in El Paso and Odessa to provide teleneurology and telecardiology services to its patients. The transportation issues, however, remain a concern.

“We work our way through it as best as we can,” she said. “But I still worry about it. When transportation is out, it’s just — it’s just really hard.”

“We’ve had instances in which we’ve literally thought about putting people in the back of our own cars and transporting them ourselves.”
DIANE MOORE, CEO & CHIEF FINANCIAL OFFICER, BIG BEND REGIONAL MEDICAL CENTER


“The ambulances do both emergency calls and medical transfers, with nearly all transfers making the 200-mile roundtrip to Amarillo. Every year, she said, the hospital district typically loses about $450,000 to maintain its EMS service for the community.”
CHRISTIE FRANCIS , CEO, HEMPHILL COUNTY HOSITAL