As Rappahannock’s population gets older, so do the volunteers who handle its medical emergencies
Second in a three-part Foothills Forum/Rappahannock News Special Report
J. B. Carter still remembers a particular middle-of-the-night conversation.
Carter, who’s been chief of the fire and rescue squad in Amissville for 25 years, had roused himself out of bed that night in response to an emergency call from Sperryville. He rushed to the station, and, with another crew member, jumped into an ambulance and raced down 211.
When they arrived at the caller’s home, he was asked, angrily, what had taken them so long.
Carter started to explain that he had been asleep, that he and the crew had had to drive in from Amissville.
“You’re getting paid!” the woman snapped.
“No, ma’am,” he responded, “I’m not getting paid to do this. I’m volunteer.”
“So, where are the paid people?”
“There are no paid people.”
Served by seniors
That, in a nutshell, is the story of emergency care in Rappahannock: A county entirely dependent on volunteer crews — the last such one in Virginia — serving an aging population with rising expectations.
“We have a changing demographic,” Carter noted. “People are moving out here from Fairfax and Arlington and they’re expecting a service like they had there.”
Instead, their calls for help are answered by men and women who aren’t just volunteers, but often are their own age, or older. Of the 210 members with the six emergency medical services (EMS) stations in the county, 45 percent are older than 50, and 28 percent have passed 60. The participation of older men and women is particularly pronounced at some rescue stations, such as Sperryville. There, the average age of a volunteer is 58, and almost 60 percent of the members are older than 60. Its chief, Harold Beebout, is widely credited with revitalizing an operation that had so few certified EMS volunteers less than a decade ago that it was answering fewer than 50 calls a year — about one-sixth of what it handled in 2016. But he’s 76.
The big role seniors play in Rappahannock’s emergency care becomes even more apparent when you look more closely at who’s actually answering most of the calls. The stations keep track of which of its members respond to more than 10 percent of the calls, although for the most active ones, the percentage is much higher. More than half in that group are older than 50. About a third are 60 and beyond.
That’s a big change from back when Carter, now 52, first became a volunteer at the Amissville station. He was a teenager then, as were about 20 others who were part of the crew. Now, he says, there are just two volunteers under 18 who answer calls from Amissville.
“The youth movement is gone,” he said. “They get their excitement online. Where’s the next generation of volunteers going to come from? I don’t know. Those people aren’t here.”
It would be a mistake, however, to assume that older volunteer emergency medical technicians (EMTs) are somehow inferior to younger ones. At least that’s not what Chief Beebout has seen. He contends that retirees who have joined local rescue crews are, in key ways, better suited for handling the stress and unpredictability of medical emergencies.
“They’re more mature. They’ve seen a lot more. They’re often people who were accomplished in some profession. They tend to be more compassionate,” he said. “And they’re not going to leave in six months.”
Nor has the older skew of Rappahannock’s EMTs slowed response times. Crews are on the scene within 20 minutes of being dispatched more than 96 percent of the time, according to the latest reports submitted to the county. Less than two percent of the time do they take longer than 25 minutes. Usually, those are calls that come in the middle of the night or involve trips to more remote corners of the county.
It’s also worth noting that the aging of the county’s population has not led to a spike in the number of Rappahannock residents transported to hospitals — at least not yet. In fact, the Washington and Sperryville stations — two of the county’s busiest — have seen the number of patients over 65 actually drop slightly in recent years.
Beebout and Washington Chief Ann Spieker, who’s 69, say their crews are seeing fewer heart attacks or cases of congestive heart failure than in the past. Overall, calls from elderly patients these days are as likely to involve falls as they do chronic poor health. Spieker thinks it has to do with more effective medications and treatments for conditions like diabetes and asthma. Beebout and Russell Collins, EMS assistant chief at the Washington station, point to other changes. More people here are just weekenders, while there’s been a shift to what’s sometimes described as a “younger older” population.
“My theory is that it’s because a disproportionate share of our calls are from lower-income residents,” said Beebout. “And that group is declining as the county becomes more gentrified and more people with higher incomes are moving in.”
The latter, he said, generally have better access to health care, and tend to have more awareness of lifestyle changes and palliative care that can help them prolong their healthy years.
So, for now, the combination of an aging population and rescue crews comprised of middle-aged and older EMTs doesn’t overly concern Beebout and Spieker. They both feel any talk of an emergency care crisis is overblown. A far greater threat, they agree, is a major fire.
“These active retirees can make great EMTs,” Beebout said. “But those folks can’t fight fires.”
Worries about the future
Still, Beebout is worried about the future. So is Spieker. So is Carter in Amissville. They know that while the people in the county with the most experience in handling medical emergencies and running a volunteer rescue squad can do many things, they can’t stop time. As Carter puts it, soon they are going to “age out.”
Of the 200 or so volunteer members of the county’s rescue stations, only a subset, maybe 10 percent, is certified to do advanced life-saving procedures. An even smaller subset actually does them regularly.
“You have maybe five or six people who do two-thirds of all the paramedic calls,” said Beebout. “It’s the hard work of those people that allows us to cover the county. But when you have that few people carrying the load, and you lose even two or three — which could happen at any time — you’re in bad trouble.”
Unfortunately, the pipeline to replace them has been far from a steady flow. The problem, put simply, is that becoming an EMT, even at the most basic level, is a big commitment. It requires first that a person take 140 to 150 hours of classes — a course Beebout described as “college level” — and then pass a challenging exam. Even with that training, basic EMTs are limited in what they’re permitted to do — handle minor trauma and illnesses, provide oxygen and give some medications.
Advanced EMTs can do more, such as starting IVs to provide fluids to trauma patients and medications to treat diabetic emergencies and allergic reactions. But they also need to complete an additional 100 hours of training, plus clinical time in hospitals and riding along on Advanced Life Support (ALS) calls.
Paramedics are the most highly skilled EMTs, able to deal with heart attacks and severe trauma, resuscitate patients, and perform other advanced life-saving procedures. The course load to be certified? At least 1,200 hours.
“What you do out in the field probably hasn’t really changed that much, but the requirements to be able to do it have changed a lot,” Beebout explained. “The focus has shifted from practical field knowledge to basic anatomy and other knowledge that are building blocks to becoming the highest level paramedic. So, now it’s much more theoretical and much more difficult. It’s not really geared to a rural rescue squad.”
‘Bored out of my mind’
The demands prove to be too much for a lot of hopefuls, particularly younger ones with full-time jobs and families. Many drop out, and some who make it through all the coursework aren’t able to pass the exam. In Virginia, about a third of the candidates fail on their first try.
The response to a new course at RappU, the nonprofit adult education and training school just west of Sperryville, gives some indication of the challenge Rappahannock faces in restocking its rescue crews. It’s a hybrid course for basic EMT certification, meaning that almost half of the 140 hours can be completed online, instead of in the classroom. Eighteen spots were available when the course started in early July. Eight people signed up, but only six showed up for the first class. One has since dropped out. Of the remaining five, three are older than 55.
Beebout, who set up the training course in conjunction with a company named Associates in Emergency Care, insists that he’s not disappointed in the response. “I will be overjoyed if we get four new EMTs from the class,” he said.
Even when volunteers get certified and are able to go out on calls, it can be hard to keep them engaged. They often have unrealistic expectations about how much rescuing they’ll be doing. “The demand can be a very mixed thing,” Beebout acknowledged. “One of my retired volunteers at the station just the other day told me: ‘Man, I am bored out of my mind.’ Too many calls is a problem, but too few can be a problem, too. Your volunteers get bored and they drift away.”
“We may go three or four days without a call, then have six the next day,” explained Assistant Chief Collins. “It would only discourage volunteers to have them stand by and have nothing happen.” So, volunteers aren’t required to be “on duty” at the stations, although on most days at the larger ones, officers are there handling administrative or maintenance chores. Volunteers from all six stations — Amissville, Sperryville, Washington, Castleton, Chester Gap and Flint Hill — can respond to less serious emergencies, but only crews from the first three companies are certified to answer more critical life-saving calls.
Chief Carter says he sometimes gets pushback from volunteers about doing fundraising. It’s an important part of the job, but doesn’t jibe with their notion of being an EMT. “They’ll come and run calls,” said Carter, “but they’ll say they didn’t sign up to do bake sales and raffles.”
The Amissville station, thanks in part to its annual carnival, raises about 40 percent of its budget through fundraising. For other stations, the figure is closer to 25 percent, with the county covering about 60 percent. Most of the remainder comes through grants, which are often used to buy equipment. A new ambulance can cost more than $225,000.
Others prospects find that they’re simply not cut out for the job. Chief Spieker remembers one she took out with her on a call. “It was a DOA call,” she said. “He wasn’t mentally prepared for that. He said, ‘I can’t do this.’ He’s gone.”
So, given that even the chiefs of Rappahannock’s rescue squads believe that staying all-volunteer is not realistic, what’s the alternative?
It seems most likely that county officials will, within the next year or so, take another look at how the community would make the transition to a hybrid setup, one where paid EMTs would augment the volunteers. That’s what a number of rural Virginia counties, faced with a shrinking supply of volunteers, have done in recent years.
Back in 2014, an outside consulting firm, JLN Associates, was hired to analyze Rappahannock’s fire and rescue operations. It called out the need to bolster staffing, but stopped short of recommending that the county begin hiring EMTs, suggesting such a move might be “premature.”
“I’m not sure where it’s going to go,” said county supervisor Ron Frazier (Jackson District). “I imagine it will be inevitable to have some paid EMTs, but the volunteers are still trying to make this work. They have a right to be proud of the service they’re delivering to the county for the amount of money we’re spending on a volunteer system.”
Supervisor John Lesinski (Hampton District) acknowledged that dealing with the EMT issue has moved to the back burner, particularly since the local government was rattled by first, the retirement of Richie Burke, the longtime emergency management coordinator and then, the resignation of county administrator Debbie Keyser. Permanent replacements would probably need to be hired before such a critical matter is addressed.
A major consideration, obviously, is the jolt the move could have on the county’s budget. The cost could vary widely depending on how many paid EMTs are added and how things are structured, but various estimates put the potential annual expense at anywhere from $500,000 to $1 million. That hit could be softened a bit with the use of grant money, but it could have repercussions in a community where tax increases are viewed with as much joy as a copperhead on the back porch.
Lesinski appreciates the sensitivity of the situation. “We’d like to maintain the volunteer system as long as possible, but not at the expense of compromising the public safety,” he said. He also feels that when the county does begin focusing on the details of a hybrid arrangement, the leaders of the volunteer rescue squads need to be involved.
Not surprisingly, those leaders agree. While the chiefs recognize the likely end of Rappahannock’s all-volunteer legacy, they’re wary of how it could play out. If it’s not handled right, they say, volunteers could fall away quickly.
“We’re the people who know what’s needed in this county. This county is different,” said Spieker. “There was talk about running a private ambulance service to answer calls during the daytime. That’s when I answer a lot of calls. Do you think I want to be their 2 a.m. medic? If that happens, I’m leaving.”
“The heart of what I see is that making a transition to a hybrid model combining paid and volunteer staff is always negative in terms of retaining volunteers. But how negative it is depends on how well it’s set up, and who’s hired on the paid side,” Beebout added. “Also, how much they respect and value the volunteers. That’s going to be important.”
The job: Challenges — and pride
There is a deep sense of pride among Rappahannock’s EMTs, especially those for whom it is pretty much a full-time, unpaid job. They know their commitment to helping people in the community through dark, frightening moments has allowed the county to hold down the cost of emergency care.
They also know that in Rappahannock, fulfilling that role comes with its own particular challenges — not just the late-night drives on winding, pitch-black roads, but also the frustration of trying to find homes that, in the owner’s zeal for privacy, aren’t marked with an address. Or the locations where an ambulance can’t turn around, or sometimes even get close to the house. When time is of the essence, all those things matter.
There, too, are the complications that come with attempting to take advantage of technology in a place full of cellphone and broadband dead zones.
J.B. Carter provided one example. “If we have a stroke patient down in Sperryville, we would call the hospital from the person’s house and let them know we had a stroke call coming in. But then, we might not have cell service again until we got to Amissville.”
Harold Beebout gave another, this one regarding what could be involved with a heart attack patient: “We could do an EKG soon after we got to the house. If we had a good cellphone connection, we could just transmit directly from the house to the hospital. But if we don’t, we need to print out the EKG reading, use a phone to take a photo of the EKG, use the patient’s broadband connection in the house if they have one, and then in the middle of this, you have to ask for their password to use their broadband connection and get on their network and send it. We have to do a lot of workarounds.”
It’s all part of the job. While they don’t get paid, there are rewards that, as Carter put it, come with “knowing you helped someone you know.”
Beebout concurs. “It’s wonderful to see one of our patients who a few months earlier had been on death’s door out walking around. Or helping someone lying on the cold floor get back in bed. And then seeing them around town and they give you a big hug,” he said. “That’s one of the things I’m afraid the community would lose if we went to a paid staff.”
Carter has a similar story.
“More than 20 years ago, I remember a lady I transported in the ambulance, and she was so badly traumatized from a traffic accident that I couldn’t tell who she was. And, we couldn’t find her ID. Then, when I got home, I found out it was a woman I knew.
“Now, every time she sees me, she wraps me up in a big bear hug, and thanks me again. That’s payment you can’t get anywhere.”
Part 3 (August 17): A community takes on its health care challenges. Plus, a peek into the future.
Also see Part 1: In Rappahannock, health care headaches for an aging community.