Emergency medical services is a tough, demanding and necessary service in today’s society.

Paramedics and emergency medical technicians (EMTs) are on call around the clock to respond to anything imaginable from broken bones to heart attacks, car crashes and assaults, and everything in between.

They also get non-emergency calls to transfer patients to doctor’s offices or from one facility to another.

The wheels on the ambulances rarely stop rolling.

In recent months, Winchester and Clark County officials have discussed a proposal to add new positions to Winchester Fire-EMS to staff a fourth front-line ambulance.

Demand for both emergency and non-emergency runs has grown tremendously, and shows no signs of slowing down.

At the same time, the job market has opened for EMTs and paramedics within the health care field, making it harder and harder for ambulance services to recruit people.

This month, the Winchester Board of Commissioners voted to create six new positions at the department with the goal of adding the fourth ambulance.

The vote was split, and there is caution from the Clark County Fiscal Court, which partially funds the ambulance service with the city.

At this point, the city commissioners approved the first reading of a budget amendment to add nearly $470,000 to the budget to cover salaries and benefits.

The fiscal court has not acted on it so far.

It’s a relationship and a situation which dates back nearly 30 years in Clark County, and it’s only gotten more complex.

Merging the departments

Until 1991, Winchester Fire Department and the Winchester-Clark County Ambulance Service were separate entities. The ambulance service covered all of Clark County, while the city’s fire department provided only fire protection within the city limits,

In October 1990, the city and county agreed to merge the two departments under the city’s authority. The department, now called Winchester Fire-EMS, would still provide fire protection within the city along with EMS services for all Clark County.

Winchester Fire-EMS Chief Cathy Rigney, who was working for the ambulance service when the departments merged, said 11 people transferred to the department, one stayed in nursing school and one decided to retire.

The agreement, as signed by then-Winchester Mayor Gene Kincaid and Clark County then-Judge-Executive James Allen, established the terms. The city would administer the department, and the employees would be city employees. The city and county would then split any budget deficits from EMS services. The current agreement, which was last amended in 1997, calls for the county to pay 45 percent of deficits, which was based on population.

Demand, run volume keeps increasing

Through the 28-year history of the merged department, the amount of EMS calls has increased most years.

In 1991, the first year of the combined department, there were 3,225 ambulance calls, according to information from the department. In 2018, there were 6,103, down from the 2017 peak of 6,459 calls.

The department has not responded to less than 5,000 calls a year since 2004.

Changing workforce

Within the last decade, there has been a significant change within the health care field. Hospitals and other providers began finding themselves short of nurses. So they started opening jobs traditionally reserved for nurses to others, including paramedics and EMTs.

The situation is now affecting ambulance services and EMS providers.

There are many more opportunities that offer more money than municipal agencies, and those agencies are scrambling to find employees to staff departments and ambulances.

Rigney said she’s noticed the change in the last five to seven years as people have left for other opportunities.

“You can’t blame them,” she said. “It’s a mentality change. You have to look at the hourly rate. Our retirement package was very attractive.”

Keeping up with private employers, though, is tough to do.

“That’s a very hard thing to overcome,” she said. “I’m not begrudging them by any means. It’s not that they don’t want to do this job any more. You have to pay your bills. It comes down to doing what’s best for your family.”

A 2017 study by the Kentucky Board of Emergency Medical Services surveyed EMS providers who allowed their licenses to lapse during 2017. Of the 883 licensed providers, 113 responded to the survey.

Among those, 28 percent said they retired from the field and another 26 listed external factors. The next highest response at 14 percent was a tie between low salary and poor benefits, or they relocated.

Sixty-seven percent said EMS providers deserve a higher salary, and 77 percent said EMS is a rewarding career.

They also said EMS is a highly-stressful career (83 percent) while 32 percent said there were not always opportunities to advance within the field.

Going outside the box

Recruiting and retaining employees is not a new challenge in the public sector and emergency services.

Through the last decade, Winchester Fire-EMS has implemented several new programs to try and bolster the ranks and keep its ambulances fully staffed while handling as many hospital transfers as possible.

In late 2016, the city and the department added the position of a single-role paramedic. Previously, all city firefighters had to be either an EMT or a paramedic, which had been a requirement since the city fire department and the county ambulance service merged in 1991.

At the time, Rigney said the firefighting aspect may have kept some people from applying with the department.

The department was also functioning with only four paramedics. A full staff includes nine paramedics, or one for each of the city’s three fire stations for a 24-hour shift.

Earlier in 2016, the city voted to increase the salaries for patient transfer specialists at the fire department. Those part-time positions, whether EMT or paramedic, were created about a decade ago primarily to handle transfer calls to or from the hospital and doctor offices.

Presently, the department employs five single-role paramedics and 25 patient transfer specialists, including EMTs and paramedics.

Other options have been discussed in recent meetings including signing bonuses and incentive pay. To date, none have been implemented locally.

Not just a local issue

Governments and ambulances throughout the state have been feeling the effects of the shortage of paramedics and EMTs.

In Montana, the city of Great Falls changed its policy in late 2018 in light of its paramedic shortage. According to an article on FireRescue1.com, the city amended its agreement which originally required a paramedic on every ambulance that responded to 911 calls. The city’s emergency services and fire department worked out the arrangement to continue providing service to the surrounding districts.

South Carolina officials said up to 75 percent of spots in EMS training programs are vacant.

An Associated Press story published in June said Greenville County, South Carolina, recently added $1 million toward hiring more EMTs, but it still has not attracted any candidates.

The South Carolina EMS Association said those who graduate from training programs only stay in the field for about eight years.

In northern Kentucky, officials said there were fewer programs available and fewer people applying for the available positions. An article published in 2017 indicated fire chiefs were anticipating needing 175 new paramedics within the next five years.

Part of the vacancies were attributed to retirements and competition with hospitals and other businesses hiring paramedics at higher salaries.

A 2018 article in the Messenger-Inquirer in Owensboro quoted its ambulance service director as saying his service was almost constantly understaffed, largely because of increased competition for employees.

“Hypothetically, there may have been 10,000 EMTs out there but only ambulance services were hiring them,” Yellow Ambulance Service director Jamie Hardin said at the time. “Now, if there are 15,000 EMTs, you have ambulances, nursing homes, factories, fire departments and so many other places that are hiring.”

Recruiting, retaining

Finding qualified staff is not a new problem, nor is retaining them.

Recently, Rigney presented four new firefighters to the city commissioners. The original plan was to present six, but two changed their minds. One decided against EMS as a whole.

Winchester City Commissioner Ramsey Flynn thinks it may be a generational issue. When he joined the city fire department in 1995, he was part of a new generation of firefighters. Since 2015, a number have retired leaving spots open for the next batch.

Whether they are coming remains to be seen.

“When I went through the hiring process, we averaged 30 to 50 applications,” he said. “It’s the generation. Not every kid wants to be a firefighter (anymore).”

As Rigney said, the city’s retirement package isn’t as attractive as it once was, and increasing salaries make it hard to compete.

“The pay wasn’t attractive but you had this great retirement,” Flynn said. “Now we’re going into 2020 and all that’s changed. We aren’t getting as many qualified applicants and battling a run volume problem.”

Short-handed

Being short-staffed has led to other complications.

Rigney said in recent government meetings she often has to take people off fire trucks to staff ambulances.

Emergency calls are the top priority, meaning the department has to pass on some transfer calls, which generate revenue for the department.

For Clark Regional Medical Center, that presents a problem in getting patients to the next level of care.

Clark Regional CEO Aphreikah DuHaney-West cited one incident where a patient needed to go to a Lexington hospital at 11 p.m. It took an hour and 26 phone calls to find an ambulance crew to take the run.

Ambulances from other counties often bring patients to CRMC, and they have responded to the hospital’s calls for other transfers.

Rigney said Winchester can’t possibly take them all, but would like to pick up more. Additional staff would help in that area, she said.

The fire department’s staff has remained largely the same size for most of the last two decades. Belcher said three positions were added in 2017 after the department received a grant to partially fund them. Rigney said the grant was focused on fire protection, rather than EMS.

Aside from that, the department’s staff has been at 56 since at least 2002, Belcher said. The six additional positions would bring the staff to 65 people.

The county

Since 1990, Clark County has been a partner in EMS operations with the city.

Based on population at the time of the agreement, the county is responsible for 45 percent of any budget deficits beyond the budgeted amount. The proposal to add $470,000 to the city’s EMS budget means the county’s share would be about $211,000.

Earlier this year while working on the county’s budget, Clark County Judge-Executive Chris Pace said he was expecting an increase of up to $500,000 for EMS operations. That did not include the latest vote by the city to add positions.

Pace said the county is not interested in getting into the EMS business, but said the time may be right to reexamine the agreement and possibly re-negotiate the terms.

“It’s a priority of my administration and this fiscal court to be fiscally conservative,” Pace said. “We are skeptical when it comes to getting requests for large amounts of money. The billing goes through the city and the city requests its part.

“The county budget can’t compete with the city’s budget. There may very well be some middle point we can all agree on.”

The hospital

Clark Regional Medical Center has an interest in the city’s EMS staffing as well, especially when it comes to transferring patients to the next level of care which requires an ambulance.

Duhaney-West said if Winchester Fire-EMS can’t take the run, they have to call around. At times it has taken two hours and 16 calls, she said.

“You call all the outlying areas to find someone to come in,” she said. “It’s very timely. It’s a delay in care the doctor prescribed.”

The hospital can not get involved financially to support the department, she said, because it would violate anti-kickback laws. The hospital can advocate for the local EMS and the community and be involved in finding the solution.

“Hiring personnel is not a full solution, but it is a step in the right direction,” DuHaney-West said. “Do we need to work with BCTC to start a paramedicine program? It’s an opportunity to stop, assess, re-assess and reevaluate. The labor force is shrinking for everyone.”

Timing

Pace expressed the same frustration as the dissenters on the Winchester Board of Commissioners when Commissioner JoEllen Reed made her motion to create the jobs earlier this month.

“A month ago, we thought we had our budget set and were ready to move forward,” Pace said. “Then this issue comes back up.”

During the city’s budget process, Rigney requested 10 new positions be created within the department for EMS, to handle additional run volume and demand. The proposal was not recommended by City Manager Matt Belcher, and it was not included in the final budget after multiple discussions.

During the July 2 commission meeting, Reed made the motion to create the six positions. It was approved on a 3-2 vote, with Mayor Ed Burtner and Commissioner Shannon Cox voting no.

A subsequent budget transfer ordinance was approved on its first reading with the same vote.

Reed said staffing the fire department has become a critical issue.

“The lack of resources is more than a discussion now,” she said. “It has to be a decision now.”

Reed said the city has the funds available to cover the additional salary and benefits, and additional revenue from transfers and other calls should help offset the costs.

“I took the middle ground,” she said. “Adding six should not cost as much as 10. We have a great opportunity to create additional revenue. My understanding is we make about $250 a run. We had been making about 66 runs per month. We should be able to make that money back.”

Flynn and Reed said they have spoken with constituents who said they didn’t want an ambulance from another agency coming to pick them up. They wanted a Winchester unit.

Cox said in a recent meeting if he needed an ambulance, it did not matter to him who came, as long as it came.

Like Pace, Cox was frustrated after having just approved a budget for the new fiscal year and then suddenly facing a significant change shortly after it took effect.

“We voted on a budget a month ago and to amend it by 5 percent a month later … Why did we spend the whole month of May working on it?” Cox said July 16.

Burtner said there needed to be a serious discussion between the city and the county before taking any action.

Pace said he wants to have that discussion as well.

“I’d like to work with the city on the document and renegotiate those percentages based on how the city is funded and how the county is funded,” he said. “If the city needs to expand services, it’s not fair to put that on the county.”

Belcher said he doesn’t see EMS as a county vs. city issue.

“When it comes to the ambulance service, it’s a county (wide) issue,” he said. “The county merged it with the city fire department. I don’t look at it as a city-county problem.”

Reed said there is no guarantee the positions will be filled, but she wanted to have the funds available.

“If we can’t fill the positions, it won’t hurt us,” she said. “If we can’t fill the positions, we haven’t lost any money.”

Rigney, pointing to a stack of resumes and applications on her desk, believes they will.

“I think we can,” she said. “I’m staying optimistic. The community needs it. We will always be there for our community.”