A paramedic for about 30 years, Susan Farren knew all was not well with first responders: Eight of her colleagues had died by suicide. Others had grappled with substance abuse or gone through painful divorces.

So, in 2018, Farren founded a nonprofit in Santa Rosa to train and support emergency personnel struggling with trauma and stress. Hundreds of firefighters, police officers, and other first responders have since availed themselves of the organization’s timely help.

“Nobody prepares you to walk into a house where four people have been murdered,” said Farren, executive director of

Firefighters, paramedics, and police often respond to the worst days of people’s lives — accidents, deaths, fires, and other distressing events. After the deadly mass shootings earlier this year in Monterey Park and Half Moon Bay, and countless others across the country, has grown.

But there is no national consensus on when and which emergency personnel should be provided workers’ compensation benefits.

“We wouldn’t think twice about taking care of a first responder who broke their leg, and we shouldn’t think twice about taking care of their mental health needs,” Karen Larsen, CEO of the Steinberg Institute, a nonprofit public policy institute, said in an email.

This year, there has been a push in California by first responders for laws that expand access to workers’ compensation for post-traumatic stress injuries among their ranks. But some business groups and local governments want to pump the breaks, citing worries about potential fraud or abuse of the workers’ compensation system.

The allegation that some people could take advantage of a more open workers’ compensation system should not deter California from providing immediate access to mental health treatment to those who need it, said Farren, who noted that many of the first responders she works with are denied workers’ compensation coverage or have to go through many steps to get it approved.

“That shouldn’t keep us from getting help to those who really need it. That help should be available often, and affordably, and it should be available immediately,” Farren said.

Perceptions about employers’ responsibility for alleviating work-related mental stress have changed over time, and that’s showing up in workers’ compensation. Each state has its own workers’ compensation laws, which provide benefits like disability pay and medical care to workers injured or sickened on the job.

More than half have enacted PTSD policies or policy changes since 2018, according to a by Optum, a company that creates workers’ compensation programs. Coverage varies widely for post-traumatic stress injuries, which can be triggered by a single traumatic event or continued exposure to high stress and traumatic events.

In 2019, Gov. Gavin Newsom signed legislation into law to give California firefighters and police officers a stronger chance at earning workers’ compensation. The bill, , authored by state Sen. Henry Stern (D-Calabasas) changed state law so that post-traumatic stress “injury,” such as PTSD, is legally presumed to be work-related for those first responders.

It was a small step by lawmakers in a state where recognition of work-related injuries for workers’ compensation has typically been limited to physical illnesses such as heart disease and cancer. Previously, psychiatric conditions were handled differently, with employers and insurance companies long contending that psychological injuries can have many sources and might be too easy to blame on work.

Researchers at the Rand Corp. suggested in a that further study is needed to evaluate the financial toll the 2019 law has had on employers — particularly counties and other municipalities that pay for police, firefighters, and other publicly employed first responders. Rand researchers estimated the added costs for local governments and the state to cover post-traumatic stress injuries could rise from $20 million to $116 million annually.

Firefighters and police in most cases now no longer have to prove that work was mostly responsible for their PTSD. But the law sunsets in 2025 and excludes many other first responders, including dispatchers, paramedics, and first responders at state hospitals.

This year, legislation by state Sen. John Laird (D-Santa Cruz), , co-sponsored by an advocacy group representing firefighters in the state — California Professional Firefighters — would extend PTSD workers’ compensation coverage until 2032 and open it up to state firefighters, additional law enforcement officers, public safety dispatchers, and other emergency response communication employees who work for public agencies. The Senate Labor, Public Employment and Retirement Committee unanimously approved the bill in April, and it is awaiting a vote by the Senate Appropriations Committee.

Business groups and local governments — many of which opposed the 2019 law — are lobbying against more expansion. In letters to lawmakers, groups including the California Chamber of Commerce, California Coalition on Workers’ Compensation, California Hospital Association, and California State Association of Counties warned that pending legislation could “open the door to abuse and fraud.”

“There is no evidence that workers are being inappropriately denied the care or benefits that they need,” Virginia Drake, a spokesperson for the California Coalition on Workers’ Compensation, told ºÚÁϳԹÏÍø News. The group represents employers, cities and counties, insurance brokers, and government agencies on issues of workers’ compensation.

Legislation that would extend benefits to more first responders would “put taxpayer funds at risk by tying the hands of public employers and forcing them to pay even the most questionable claims,” she added in a statement.

In addition, there does not seem to be consensus on which emergency personnel should get covered.

A measure by Assemblymember Freddie Rodriguez, a Democrat from Chino who worked as an emergency medical technician for three decades, has stalled. would expand workers’ compensation coverage to paramedics and emergency medical technicians, but it didn’t get a hearing in the Assembly. Unions representing paramedics and EMTs in California did not return messages seeking comment.

“It’s a very stressful job,” said Rodriguez, who told ºÚÁϳԹÏÍø News that two of his paramedic friends had died by suicide. “It affects people differently.”

Clearing a path to speedy mental health recovery, particularly after traumatic incidents, “should be automatic,” he added.

It’s unclear if Newsom will back Laird’s bill extending coverage for groups of emergency responders, amid a . A spokesperson for his office, Omar Rodriguez, said the governor typically does not comment on pending legislation and “will evaluate the bills on their own merits if they reach his desk.”

Last year, the Democratic governor , saying in a statement that it would be premature to shift coverage of PTSD before any studies had been conducted on how the current law has worked for those who are covered.

Broadening coverage, Newsom wrote, “could set a dangerous precedent that has the potential to destabilize the workers’ compensation system going forward.”

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A paramedic recently arrived at her doorstep again, but this time it wasn’t for an emergency. Jason Frye was there for a home visit as part of a new community paramedicine program.

Frye showed up in an SUV, not an ambulance. He carried a large black medical bag into Lane’s mobile home, which is on the eastern edge of the city, across from open fields and train tracks that snake between the region’s massive open-pit coal mines. Lane sat in an armchair as Frye took her blood pressure, measured her pulse, and hooked her up to a heart-monitoring machine.

“What matters to you in terms of health, goals?” Frye said.

Lane said she wants to become healthy enough to work, garden, and ride her motorcycle again.

Frye, a 44-year-old Navy veteran and former oil field worker, promised to help Lane sign up for physical therapy and offered to find an anti-slip grab bar for her shower.

Community paramedicine allows paramedics to use their skills outside of emergency settings. The goal is to help patients access care, maintain or improve their health, and reduce their dependence on costly ambulance rides and ER visits.

Such programs are expanding across the country, in , as health care providers, insurers, and state governments recognize the potential benefits to patients, ambulance services, and hospitals.

Gary Wingrove, a Florida-based leader in community paramedicine, said the concept took off in the early 2000s and now includes hundreds of sites. of 129 programs found that 55% operated in “rural” or “super rural” areas.

Community medicine can be helpful in rural areas where people have less access to health care, said Wingrove, chair of the International Roundtable on Community Paramedicine. “If we can get a community paramedic to their house,” he said, “then we can keep them connected to primary health care and all of the other services that they need.”

Frye works at Campbell County Health, a health care system based in Gillette, a city of about 33,000 in northeastern Wyoming. Leaders of the community paramedicine program plan to expand it into two adjacent, largely rural counties dotted with ranches and coal mines on the rolling prairie that stretches more than 100 miles from the Black Hills to the Bighorn Mountains.

Gillette serves as a medical hub for the region but has shortages of primary care doctors, specialists, and mental health services, according to a . People who live outside the city face additional barriers.

“A lot of them, especially older people, don’t want to come into town. And basically, those tiny communities don’t usually have health care,” Lane said. “I think it’s just kind of a pain for them to drive all the way into town, and unless they have a serious problem, I think they tend to just figure, ‘Well, it’ll work itself out.’”

Community paramedicine programs are customized to the needs and resources of each community.

“It’s not just a cookie-cutter-type operation. It’s like you can really mold it to wherever you need to mold it to,” Frye said.

Most community paramedicine programs rely on paramedics, but some also use emergency medicine technicians, nurses, social workers, and other professionals, according to the 2017 survey. Programs can offer home visits, phone check-ins, or transportation to nonemergency destinations, such as urgent care clinics and mental health centers.

Many programs support people with chronic illnesses, patients recovering from surgeries or hospital stays, or frequent users of 911 and the ER. Other programs focus on public health, behavioral health, hospice care, or post-overdose response.

Community paramedics can provide in-home vaccinations, wound care, ultrasounds, and blood tests.

They can offer exercise and nutrition tips, teach patients how to monitor their symptoms, and help with housing, economic, and social needs that can affect people’s health. For example, paramedics might inspect homes for safety hazards, provide a list of food banks, or connect lonely patients with a senior center.

Paramedics and patients said some rural residents struggle to access health care because of long distances, cost, lack of transportation, or dangerous weather. Some hesitate to seek help out of pride or because they don’t want to be a burden to others. Some limit trips to town during ranching and farming crunch times, such as calving and harvesting seasons.

Delayed care can let health problems fester until they become an emergency.

Advocates say providing in-home care, resources, and education can help patients reduce such crises and associated costs. Fewer emergencies mean fewer ambulance runs and hospital patients. That could help ambulance services and hospitals reduce costs and the time patients wait for help.

found that more studies are needed but that data so far suggests these programs reduce costs. It also found links to improved health outcomes and decreased use of ambulances and hospitals.

For example, a pilot program in Fort Worth, Texas, saw a 61% reduction in ambulance rides, . MedStar, the operator, made the effort permanent and says its 904 participants , saving an estimated $8.5 million over eight years.

But rural ambulance services, especially volunteer ones, can struggle to staff and fund community paramedicine programs.

Kesa Copps, a co-worker of Frye’s, previously worked as an emergency medical technician in Powder River County, Montana, which has fewer than 2,000 residents. Some people there must drive more than an hour to reach the nearest hospital. The area’s volunteer ambulance service started a community paramedicine program in 2019.

Copps said the program reduced hospital readmissions and extended some elderly patients’ ability to live at home before being admitted to a nursing facility. She visited patients between ambulance runs and had to leave early when a 911 call came in. That’s different from the Campbell County Health model, in which community paramedicine is a full-time position, not split with emergency work.

Adam Johnson, director of the Powder River ambulance service, said the community paramedicine program shut down in 2021 after everyone with the necessary training left the area. Johnson said paramedics are signing up for training to restart the program.

States are , and some require licensed paramedics to obtain extra training to work in the field.

Some ambulance services and health care organizations have piloted community paramedicine programs with the help of state or federal grants. If they find the service saves money, they may decide to continue the program and fund it themselves.

Private insurance companies are increasingly covering community paramedicine, Wingrove said. Wyoming and several other states allow operators to bill Medicaid for the services.

Advocates are now pushing Medicare to expand its of community paramedicine, Wingrove said. That would benefit Medicare patients and could spur more private insurers to offer coverage.

The Campbell County Health program’s home visits cost up to $240 per hour and are billed to Medicaid or Medicare, said Frye. That compares with more than $1,300 for an ambulance ride and thousands of dollars for a visit to a hospital ER.

Community paramedicine may soon expand in neighboring South Dakota, another largely rural state.

South Dakota ambulance services have experimented with community paramedicine and lawmakers to authorize and regulate it.

Eric Emery, the state representative who introduced the bill, plans to start a program on the sprawling, rural Rosebud Indian Reservation, where he works as a paramedic. He said the operation will focus on diabetes and mental health care.

Emery, a Democrat, said some people struggle to pick up their medication and attend appointments because they lack vehicles or gas money and there’s no public transportation to the hospital. He said some parents and grandparents raising children also struggle to find time to drive to appointments.

“They’re putting the needs of the younger generation or their grandkids before their own,” Emery said.

Back in Gillette, Frye also checked in on Linda Quitt, a 78-year-old facing diabetes, depression, and a lack of social support after her husband was hospitalized with dementia. Quitt said her husband was her walking buddy and helped care for her.

“I had him to wait on me, and now I have nobody,” Quitt said.

Frye said he would see if he could help start a senior walking group that Quitt could join. He told her that socializing can improve health.

“You’re not alone,” Frye told Quitt.

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“I’ve had as much as 100 hours of overtime in a two-week period,” said Lewin, the battalion chief for the Miles City Fire and Rescue department. “Other people have had more.”

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don’t have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn’t have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn’t balance the intense program with their day jobs. Others didn’t want the added workload that comes with being a paramedic.

“If you’re the only paramedic on, you end up taking more calls,” Lewin said.

What’s happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

“The patients who need the paramedics the most are in the more rural areas,” said Dia Gainor, executive director of the . But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

“Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education,” Gainor said. “The list goes on.”

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage “” and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, its of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in covid cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school .

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state’s five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties don’t have a single licensed EMS paramedic.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they’re often poached by larger stations. “Paramedics get siphoned off because as soon as they have those skills, they're marketable,” Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn’t always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a “minimum level” of ambulance services. But legislators didn’t appropriate any money to go with the law, leaving the added cost — estimated to be each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn’t contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said it’s a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven’t attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can’t match.

“The public has this expectation that if something happens, we always have an ambulance available, we're there in a couple of minutes, and we have the highest-trained people,” Smith said. “The reality is that's not always the case when the money is rare and it's hard to find and retain people.”

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic health care in rural areas. Montana is among the states trying to to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana’s Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic health care is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana’s EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

“Realistically, you're just not going to have paramedics in those rural areas where there's no income available,” Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she’s not sure she’ll be able to fill the spots. She has a few new EMT hires, but they won’t be ready for paramedic certification by then.

“I don’t have any people interested,” Lewin said. For now, she’ll keep that emergency care rig in her driveway, ready to go.

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An air ambulance flew Hoechlin, then 32, to an airport near Loma Linda University Medical Center in Southern California’s Inland Empire. There she underwent emergency 12-hour surgery to remove bone fragments and replace the crushed vertebra with a metal cage that was fused to the rest of her spine with rods and screws to provide structure and stability.

Hoechlin was still in intensive care when her husband, Matt, got the bill for the 300-mile air ambulance ride. The total: $97,269. The company wasn’t in their health plan’s network of providers, and the PPO plan they had through Matt’s job agreed to pay just $17,569.

The Hoechlins were on the hook for the $79,700 balance.

“It was just shocking,” said Hoechlin, who worked as a business analyst project manager in Highland, California. “I was just focused on, ‘Am I going to be able to walk again?’ I thought I was going to have a heart attack when he told me.”

A California law that took effect Jan. 1 aims to for out-of-network air ambulance services. The measure limits what consumers owe if they’re transported by an air ambulance that’s not part of their insurance network to the amount that they’d be charged if they used an in-network provider. The health plan and the air ambulance provider must then work out payment between themselves.

But the new law won’t protect consumers like Hoechlin, whose health plan isn’t regulated by the state. Matt’s employer pays its workers’ medical claims directly rather than buying state-regulated insurance, a common arrangement called “self-funding.” Self-funded plans are regulated by the federal government and generally not subject to state health insurance laws.

In this regard, the new air ambulance law is like laws in California and other states that protect consumers from surprise medical bills: They don’t apply to residents in federally regulated health plans. Those plans of people who get insurance through their jobs nationwide.

In California, that translates to .

Federal legislation is the best solution for those consumers, experts say. One of the leading bills before Congress to address surprise medical bills includes air ambulance charges. But that, and other measures, are up in the air, although members of Congress say they are working to reach an accord this year.

Another legal wrinkle affects even consumers with health plans the state does oversee. Under the federal Airline Deregulation Act of 1978, states aren’t permitted to regulate the “rates, routes, or services” of air carriers, including air ambulances. It’s unclear whether the California law, which doesn’t spell out a payment rate for a health plan, would be preempted by federal law if challenged in court, according to legal experts.

“It’s a very big step in balance billing, but it’s not a definitive one,” said Samuel Chang, a health policy researcher at the Source on Healthcare Price and Competition, a project of the University of California-Hastings.

Although people rarely need to be transported by a helicopter or airplane for medical care, it’s often an emergency when they do, and they’re unable to shop for an in-network provider, even if their health plan offers one. According to a federal Government Accountability Office analysis of air ambulance private insurance claims, were out of network in 2017.

The median price charged in 2017 was $36,400 for a transport by helicopter and $40,600 by plane, according to the report. If an insurer doesn’t have a contract with an air ambulance provider, the air ambulance company may bill the consumer for whatever the insurer doesn’t pay, a practice known as balance billing.

“The air ambulance issue is such a big deal because it’s just such an eye-popping bill,” said Yasmin Peled, the policy and legislative advocate at Health Access California, a consumer advocacy group.

Air ambulance providers defend their charges, saying the rates offered by commercial insurance companies barely cover their costs. And public insurance programs often pay even less.

“Seven out of 10 of our transports are Medicare, Medicaid or uninsured,” said Doug Flanders, director of communications and government affairs at Air Methods, a large air ambulance company that provides services in 48 states, including California. Medicare pays Air Methods an average of $5,998 per transport, and Medicaid payments are typically half of that, Flanders said via email. That presents a “huge financial challenge,” he said.

In recent years, Air Methods has focused on joining the networks of some major insurers, including Blue Shield of California and Anthem Blue Cross of California, Flanders said. In addition to protecting patients, being in network “stabilizes operations and eases the administrative burden of the claims processing procedures created by insurers,” he said.

For the past several years, reimbursements by Medi-Cal, the state’s Medicaid program, for air ambulance services have been bolstered by funds collected from penalties for traffic violations. But the penalty was slated to sunset in 2020. Under the new California law, the state will extend supplemental funding of Medi-Cal payments for air ambulance services until 2022. Without that agreement, the rates would have reverted to much lower 1993 levels.

With the higher Medi-Cal rates, the industry supported the bill, including the prohibition on balance billing. In fact, the California Association of Air Medical Services sponsored the bill, although it didn’t respond to requests for comment.

In contrast, when other states have tried to prohibit air ambulance balance billing, the companies have often successfully challenged those laws on the grounds that the federal Airline Deregulation Act of 1978 prohibits state rate setting, according to Erin Fuse Brown, an associate law professor at Georgia State University who has studied air ambulance billing.

Legal experts say California’s approach may thread the needle where other states have failed.

“I do think the state has a pretty tolerable argument here that they are not regulating rates,” said Christen Linke Young, a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “They are telling the air ambulance providers who they can go to to get paid, but they’re ultimately not telling the amount that is getting paid.”

Kathleen Hoechlin and her husband, who now live in Riverside, California, eventually negotiated the amount they owed down to $20,000, arguing to the air ambulance firm that by tapping their savings and using money from a GoFundMe campaign, that was all they could afford.

She is now able to walk with only a slight limp. But she continues to deal with severe pain due to nerve damage. She recently underwent a fourth surgery to implant a spinal cord stimulator to interrupt the pain signal to her brain.

“When you look at the bigger picture, at the total amount, we’re feeling very fortunate,” she said.

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A crowd had gathered to see the display prearranged by staff at the town’s historic fort.

“It’s going to show us how it’s going to help other people because we don’t have the hospital anymore,” the redheaded girl explained.

Mercy Hospital Fort Scott closed at the end of 2018, leaving this rural community about 90 miles south of Kansas City without a traditional hospital. The community has outpatient clinics run by a regional nonprofit health center and — at least temporarily — an emergency department operated as a satellite of a hospital in the next town over.

Since the hospital closed, air ambulance advertising has become a more common sight in mailboxes and at least one company’s representative has paid visits to a local nursing home and the Chamber of Commerce, offering memberships. A prepaid subscription would guarantee that if an AirMedCare Network helicopter comes to your rescue, you will pay nothing.

Nationwide, though, state insurance leaders, politicians and even one of the nation’s largest air ambulance companies have raised alarms about the slickly marketed membership campaigns.

The air ambulance industry expanded by more than a hundred bases nationwide from 2012 to 2017 and prices increased as well, The median price charged for a medevac helicopter transport was $36,400 in 2017 — a 60% increase compared with the roughly $22,100 charged in 2012, according to the March report from the U.S. Government Accountability Office.

Insurance seldom covers the trips and consumers often are surprised to get a bill showing they are responsible for the bulk of the cost. However, both Medicare and Medicaid control the price of the service, so enrollees in those government insurance programs face much lower out-of-pocket costs or have none.

AirMedCare Network, which includes 340 bases across mostly rural America, has more than 3 million people enrolled in memberships, said Seth Myers, president of Air Evac Lifeteam, one of the medevac companies under the AirMedCare Network umbrella.

One brightly colored AirMedCare advertisement mailed in southeastern Kansas promised entry in a summer vacation giveaway as an incentive to sign up. A one-year membership is $85 — unless you are 60 or older, which qualifies you for a discount. Buying multiyear memberships increases the odds of winning that summer trip.

“We’re a safety net for people in rural areas,” Myers said. “Generally, if I tell you the names of the towns that most of our bases are located in, you wouldn’t know them unless you lived in that state.”

Increasingly, though, state regulators have a skeptical view.

North Dakota Insurance Commissioner Jon Godfread called the memberships “another loophole” that air ambulance companies use to “essentially exploit our consumers.” The state banned the memberships in 2017, noting that the subscription plans don’t solve the problem of surprise medical bills as promised.

Too often, the company responding to a patient’s call for help is not the one the patient signed up with, Godfread said. North Dakota has nine different air ambulance operators who respond to calls and patients have no control over who will be called, he explained.

Air Evac’s Myers said his company, which operates mostly in the Midwest and Texas, doesn’t get many complaints from customers about other companies picking them up. He counted three this year.

Texas Rep. Drew Springer, a Republican, introduced a bill passed by the state legislature this year that would require companies to honor the subscriptions or memberships of other air ambulance companies.

But Texas Gov. Greg Abbott, also a Republican, vetoed Springer’s reciprocity bill, saying it would unnecessarily intrude on the operations of .

Myers said that AirMedCare Network was “very careful to educate the legislature and the governor’s office” in Texas. A letter signed by Myers and other industry executives noted that the 1978 Airline Deregulation Act — a law created for the commercial airline industry — protects them. The federal law limits states’ ability to regulate rates, routes or services. The law is at the core of the industry’s defense of its prices.

Like North Dakota, though, Montana used insurance regulations to limit the memberships. A 2017 law requires air ambulance subscriptions to be certified by the state’s insurance department. As of August, no company had applied for certification — essentially opting out of the state.

Air Methods, one of the nation’s largest private air ambulance companies, decided memberships “aren’t right for patients,” according to Megan Smith, a spokeswoman for the company.

While membership programs promise customers will avoid out-of-pocket expenses, in reality the contractual fine print “isn’t as cut and dry,” she said in an email.

Patients who sign up for memberships and have private insurance would still receive a bill and then must work through their insurance company’s claims, denial and appeal processes.

And while Air Evac’s Myers said the AirMedCare Network memberships or subscription fees replace copays and deductibles, Air Method’s email highlighted in bold print that “a membership is not necessary” for Medicare patients because federal law prohibits companies from charging more than copays and deductibles. Myers said having a membership offers peace of mind, particularly to those Medicare enrollees who do not have an added supplemental insurance plan that covers transportation.

Also, because the memberships are not officially insurance or a covered benefit, air ambulance companies can end them at any time “without obligation to notify the customer,” stated the Air Methods email. This means a patient could believe his or her emergency air transport was taken care of, only to face a rude awakening when the bill came.

Air Methods is the preferred helicopter service for Fort Scott’s dispatch service, according to city officials. Yet, Midwest AeroCare operated the helicopter that dropped in during the Good Ol’ Days festival.

Midwest AeroCare is part of the AirMedCare Network — not Air Methods. Families like the Andersons were there looking for reassurance that someone would come for them if needed, said Dawn Swisher-Anderson, Kaidence’s mom. Her son, Connor, has frequent and severe asthma attacks that require hospitalization.

“It’s obviously scary with a young one when he’s having breathing complications,” Swisher-Anderson said.

Once the helicopter landed, a tall pilot and two crewmembers stepped out and the onlookers quickly formed a line on the grass. Susan Glossip, who brought her grandchildren to see the helicopter, encouraged them to pose for a picture.

Midwest AeroCare representative Angela Warner stood nearby and asked if she could post the picture on the company’s Facebook page.

After Glossip said yes, Warner began talking about the membership program emphasizing that “with Fort Scott losing its hospital … having a helicopter be able to fly in can mean the difference between living and dying for some people.”

Glossip agreed and asked for a membership brochure.

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Investigadores hallaron que los pacientes de raza negra analizados en el tuvieron un 40% menos de chances de recibir medicamentos para el dolor que los blancos no hispanos.

, jefe de los programas de servicios médicos de emergencia en la Oregon Health and Science University y el Oregon Institute of Technology, dirigió la investigación, que en un simposio en Orlando, Florida

Para el trabajo, los investigadores recibieron fondos del departamento de Servicios Médicos de Emergencia de Oregon y la Oficina de Salud Rural del estado.

Los investigadores dicen que la discriminación abierta por parte de paramédicos es algo raro, e ilegal. Agregan que es posible que haya una suerte de prejuicio inconsciente.

Hace unos años, era una de las pocas mujeres técnicas de emergencias médicas de raza negra que trabajaban en el condado de Lenawee, en Michigan. Dijo que, en base a su experiencia, los hallazgos del estudio son ciertos.

Recordó una llamada en particular: el paciente se había caído y sentía dolor. Cuando los paramédicos llegaron a la casa, Gregory vio que el paciente era de raza negra. Y ahí fue cuando escuchó la queja de uno de sus colegas.

“Creo que fue algo como: ‘Oh, Dios mío. Aquí vamos de nuevo ‘”, dijo Gregory. Le preocupaba, entonces, como ahora, que, porque el paciente era de raza negra, su colega asumiera que estaba simulando el dolor para que le dieran medicamentos.

“Estoy absolutamente segura que fue inconsciente”, agregó Gregory, quien ahora vive y trabaja en Portland, Oregon, donde fundó una organización sin fines de lucro para crear conciencia sobre las disparidades raciales en la atención médica. “En ese momento, recuerdo que me sentí estresada y pensé: “Ahora voy a tener que pelear con mi colega por más analgésicos”.

El sesgo inconsciente puede ser sutil, pero, como muestra este nuevo informe, puede ser uno de los factores detrás de las vinculadas a la raza que se registran en los Estados Unidos.

El estudio examinó 104,000 historias clínicas de pacientes que fueron traslados en ambulancia o atendidos por paramédicos de 2015 a 2017. Encontró que los pacientes de minorías tenían menos probabilidades de recibir morfina y otros medicamentos para el dolor en comparación con los pacientes blancos no hispanos, independientemente de los factores socioeconómicos, como si tenían o no seguro médico.

Durante un cambio de turno en la sede de en Portland, los técnicos de emergencias médicas y los paramédicos discutieron el problema con un reportero mientras preparaban sus equipos.

Jennifer Sanders, quien ha sido paramédica durante 30 años, insistió en que la raza del paciente no impacta en su trabajo. “Nunca he tratado a nadie de manera diferente”, aseguró.

La mayoría de los trabajadores de emergencia entrevistados, entre ellos Jason Dahlke, dijeron que la raza no afecta el tratamiento que brindan. Pero Dahlke también dijo que él y algunos de sus compañeros de trabajo están pensando profundamente en el prejuicio inconsciente.

“Históricamente, es la forma en que este país ha sido”, dijo Dahlke. “Al principio teníamos esclavitud, después segregación… te puedes perder en una gran escala macro, pero sí. Está allí”.

Cuando se le preguntó por dónde creía que se podía deslizar el prejuicio inconsciente, Dahlke habló sobre un paciente que acababa de tratar.

El hombre era de raza negra y tenía alrededor de 60 años. Dahlke es blanco y tiene unos 30. El paciente tiene diabetes y llamó al 911 desde su casa, quejándose de dolor extremo en sus manos y pies.

Cuando Dahlke llegó a la casa del paciente, siguió el procedimiento estándar y le hizo una prueba de glucosa en sangre. Los resultados mostraron que el nivel de azúcar del hombre era bajo.

“Así que mi decisión fue tratar el azúcar en la sangre primero. Asegurarte que el número suba”, dijo Dahlke.

Le dio glucosa al paciente, pero no medicina para el dolor.

Dahlke dijo que no abordó el dolor del hombre en este caso porque cuando lo estabilizó, había llegado al hospital, donde el paciente ya era responsabilidad del personal de la sala de emergencias.

“Cuando las personas están gravemente enfermas o lesionadas, los medicamentos para el dolor son importantes”, dijo Dahlke. “Pero no es lo primero que nos va a preocupar. Vamos a preocuparnos por las amenazas a la vida. No necesariamente va a morir de dolor, y vamos a hacer lo que satisfaga la necesidad en el momento de llevarlo a la ambulancia y al hospital y a un nivel más alto de atención”.

Dahlke dijo que no está seguro si, si el paciente hubiera sido blanco no hispano, le habría administrado analgésicos, aunque no lo cree.

“¿Es algo en lo que pienso cuando me encuentro con un paciente que no se parece a mí? No sé si eso cambia mi forma de tratarlo”, dijo.

Cuando se le preguntó si las disparidades en el tratamiento a veces se debían a que las personas blancas (no hispanas) tenían más probabilidades de pedir más medicamentos, Dahlke sonrió.

“Me pregunto, si en este estudio hablamos de personas de color a las que se les niega o no se les dan medicamentos narcóticos tanto como a los blancos (no hispanos), tal vez estamos tratando demasiado a los blancos (no hispanos) con medicamentos narcóticos”.

La investigación ha encontrado que los afroamericanos son más propensos a , y eso también podría desempeñar un papel en la disminución de la atención. Tal desconfianza es comprensible y se remonta a generaciones, dijo Gregory.

“¿Cómo puede una persona de color no faltarle el respeto a un sistema que está constantemente estudiando y hablando sobre estas disparidades, pero no hace nada para solucionarlo?”, se preguntó.

Gregory escribió a los Centros para el Control y Prevención de Enfermedades (CDC) en 2015, pidiéndole que declarara al racismo como una amenaza para la salud pública.

Las declaraciones de crisis anteriores, como las que centran la atención en problemas como el tabaquismo o el VIH, han tenido resultados significativos, destacó Gregory.

Pero los CDC le dijeron a Gregory, en una , que, si bien apoyan las políticas del gobierno para combatir la discriminación racial y , “el racismo y la discriminación racial en la salud es un problema social y de salud pública, que requiere una estrategia social de base amplia para desmantelar efectivamente el racismo y sus impactos negativos en los Estados Unidos”.

Kennel dijo que los falsos estereotipos sobre las diferencias en la fisiología basadas en la raza que se remontan a la esclavitud también desempeñan un papel en las disparidades en la atención médica. Por ejemplo, a pesar de la falta de apoyo científico, algunos profesionales de salud todavía piensan que la sangre de los afroamericanos se coagula más rápido, dijo Kennel, citando realizado con estudiantes de medicina en la Universidad de Virginia.

También se les preguntó a los estudiantes si pensaban que los afroamericanos tenían menos receptores del dolor que los blancos. “Un porcentaje incómodamente grande de estudiantes de medicina dijo: ‘Sí, eso es cierto'”, agregó Kennel.

Además de eso, dijo, los técnicos y los paramédicos a menudo trabajan en situaciones de presión temporal, donde se limitan a información clínica ambigua y recursos escasos. “En estas situaciones, es mucho más probable que los proveedores tomen decisiones (basadas) en estereotipos”, dijo.

Las . Los blancos no hispanos tienden a recibir mejor atención y experimentan mejores resultados, ya sea que estén en el consultorio de un médico o en la sala de emergencias. Pero antes del estudio de Kennel, nadie sabía si lo mismo sucedía en la parte trasera de una ambulancia.

Y casi no llegaron a saberlo, porque la investigación requirió que las compañías de ambulancia divulgaran datos altamente confidenciales.

“Estábamos preparados para no lucir tan bien”, dijo Robert McDonald, gerente de operaciones de American Medical Response (AMR), en Portland. AMR es una de las organizaciones de ambulancias más grandes del país y compartió sus datos de más de 100,000 pacientes con Kennel.

Algunas personas atribuyen las disparidades que encontró a las diferencias en la demografía y en si se tiene o no seguro de salud, pero Kennel dijo que controló esas variables.

Entonces, ahora que AMR conoce las disparidades en su atención, ¿qué puede hacer la compañía?

“Mi opinión es que probablemente vamos a impartir cierta educación y entrenamiento a nuestra gente que sale a las calles”, dijo McDonald.

Además, dijo, AMR va a contratar más personas de color.

“Queremos ver más grupos étnicos representados en emergencias, que históricamente ha sido una fuerza de trabajo blanca dominada por hombres”, agregó.

Las políticas de AMR también deben cambiar, expresó McDonald. La compañía ha comprado un software que permitirá a los pacientes leer los formularios de permisos médicos en 17 idiomas. Y la firma está planificando un esfuerzo para llegar a las comunidades de color para explicar el papel de los trabajadores de emergencias.

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Specifically, the scientists found that black patients in were 40 percent less likely to get pain medication than their white peers.

, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study’s findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,'” Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?'”

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at headquarters in Portland,Ìý EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn’t affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke said. “In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man’s pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke said. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has found African-Americans more likely to be , and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she asked.

Gregory wrote an to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its , that while it supports government policies to combat racial discrimination and , “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. “An uncomfortably large percentage of medical students said, ‘Yes, that’s true,'” said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he said.

Disparities in health care are . Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald said.

In addition, he said, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald said.

AMR’s policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

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“Her mother was having some pretty severe shortness of breath,” said Tim Gattis, the third paramedic to arrive on scene late last year. “She was certainly working very hard to obtain a breath, and was just not being successful.”

Gattis pulled up in a sports utility vehicle shortly after the ambulance had arrived, and the first two responders were already loading the 64-year-old woman into the back. The daughter was insisting that her mother go straight to the hospital, Gattis said.

But the role of Gattis and other Fort Worth paramedics trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwideÌýthat have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home but reduces the potential for costlier and likely unnecessary care.

Hospices also can financially benefit, she said, since they’re paid a flat rate — typically just under $200 a day — regardless of where their patients are treated. So, any hospital treatment related to the patient’s condition, such as pain stemming from advanced cancer, would come out of that payment, she said. “For [the agencies], it could definitely be worth it, particularly for the one or two outlier families who seem to be using the emergency department fairly heavily during a hospice stay,” Aldridge said.

An Expanding RoleÌý

These emerging programs rely upon a new type of emergency responder. Dubbed community paramedics, they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips. MedStar’s community paramedicine program had already been launched, when VITAS got in touch.

The Affordable Care Act had been passed, and with it the inclusion of financial penalties for hospitals to the hospital. John Mezo, senior general manager for the Fort Worth region of VITAS, said that since many VITAS patients come from hospital referrals, it’s important that the hospice not become “a big problem for our referral sources,” he said.

So in 2012, Fort Worth’s VITAS program began contracting with MedStar, targeting patients who have been flagged during the hospice admissions process as moderately to highly likely to call 911 or end up in the hospital. (VITAS pays a flat monthly fee to MedStar for each patient enrolled.)

Once signed up, hospice patients calling 911 can be identified through various routes, including their address, name or phone number. Then a community paramedic like Gattis, who is available for home health and other types of calls, including hospice, is dispatched along with the traditional ambulance response, said Matt Zavadsky, MedStar’s chief strategic integration officer. The ambulance provider now contracts with two hospice agencies and is in talks to add others, he said.

In Ventura, Calif., a similar hospice initiative is being piloted through a state agency — part of a larger multicity effort there to study the use of community paramedics. That pilot, which has worked with some 20 hospice agencies since 2015, sends out a community paramedic to any 911 call involving a hospice patient. Also, a large Long Island, N.Y.-based health care system added similar paramedic backup last year for a portion of its hospice patients living in Queens under a grant-funded project.

If any of those nearly 180 patients or their family members calls the 24/7 hospice number with an urgent situation, a community paramedic can be immediately sent, said Jonathan Washko, assistant vice president of emergency medical services for the system, Northwell Health.

It’s “extremely rare” that patients call 911 directly, Washko said, “because we get them help, just as if they would have called 911.”

Navigating Final Days

The uncomfortable truth is that a patient on hospice can develop unsettling and sometimes scary symptoms during their final weeks or days. Secretions can accumulate in the throat, which might sound like choking, even though the patient is not, Mezo said. The patient might suffer a breathing crisis or a seizure.

VITAS stresses that a hospice nurse is available around-the-clock, by phone or to stop by. But family members can understandably be loath to wait for a nurse who might have to drive from an hour away, Mezo said.

“When it’s your loved one there and you’re in charge of them, it’s very frightening,” he said. “If you’ve ever had to call 911, even five minutes waiting on an ambulance seems like an eternity, right?”

For paramedics involved, the work has proven to be challenging and gratifying, requiring a mix of psychology and social work skills along with medicine. “You can’t Google what to do in these situations,” said Ambrose Stevens, a Ventura community paramedic, who has responded to aboutÌý40 hospice calls.

By the end of 2016, Ventura paramedics had responded to 258 hospice calls, but paramedics needed to access hospice-provided medications for pain, nausea and other symptoms in fewer than 2 percent of those calls, said Mike Taigman, project manager of Ventura County’s Hospice Community Paramedicine Pilot Project. “Most of what we do is really helping coordinate, talk people down from being upset, helping remind them of what hospice is all about,” he said.

Offering The OptionÌý

Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016, according to data provided by Taigman.

That difficult night in Fort Worth, Gattis put the VITAS nurse on speaker as they talked to the daughter about ways to keep her mother more comfortable at home. The daughter agreed to hold off on ambulance transport and see if anti-anxiety medication and morphine would ease her mother’s breathing struggles.

Within a half-hour, Gattis said, it was apparent that the medicine was helping. “She was feeling better to the point that she could eat a little bit of a sandwich.”

Gattis stayed for more than an hour until the hospice nurse arrived. The woman died several days later in her own bed.

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Kjelstrom, 45, is a community paramedic in Modesto, California. Part of his job is to help psychiatric patients in need of care avoid winding up in the emergency room, where they can get “boarded” for days, until they are released or a bed frees up at an inpatient facility.

Here’s how the concept of community paramedics works. When the local 911 system comes upon a patient with a potential mental health crisis, these specially trained paramedics are dispatched to the scene. They’ve learned to identify problems, intervene and de-escalate the situation.

After a physical assessment, paramedics like Kjelstrom talk to the patientÌý— to figure out what, precisely, the issue is, asking also about issues like a patient’s mental health history, drug use and insurance status. They use that information, along with details about resources available, to figure out the next steps for the patient —Ìýmaybe it is a hospital or a psych facility, or maybe it is outpatient care.

“If we could coordinate care —Ìýif we have the right medications and the right coordinating approach to these patients, we can avoid shooting people,” Mackey added.

Jurisdictions are beginning to see the benefits.

In Wake County, North Carolina, for instance, a third of mental health-related 911 calls are now sent to specialized psychiatric facilities, said Michael Bachman, deputy director at the county’s Office of Medical Affairs. That’s about 350 patients a year who would otherwise have gone to the emergency department.

But patients can only be connected with the treatment they need if there are doctors or treatment sites available. Often, they aren’t.

In addition, no one has been able to track whether these patients stay healthier, Bachman acknowledged.

And that’s in part because of another issue. Paramedics can only redirect patients from the ER if there’s somewhere else to take them and if they’ll get proper follow-up care after. Far too often, experts said, that isn’t the case.

“This works,” Bachman said. “But the thing that has to improve is there has to be more access to places for patients to go.”

In Modesto, Kjelstrom will see patients who would most benefit from a short stay in a dedicated mental health facility. But he’ll often run up against the issue that the local centers just don’t have enough beds to take patients in need. That limits how effective he can really be, he said.

Mackey said he estimates 30 percent of the time that patients needed to go to an inpatient facility, there wasn’t a bed available. It’s a similar story elsewhere. For Atlanta-based Grady Health System, which launched a paramedic program in 2012, finding available bed-space remains “a pretty big challenge,” said Michael Colman, the system’s vice president of EMS operations.

And then there’s follow up.

“If we’re talking about using community paramedics —Ìýor social workers, or some other community organization —Ìýto connect people with behavioral health care services, [these kinds of barriers] are an issue,” said Kate Blackman, senior policy specialist for the health program at the National Council of State Legislatures.

Even so, experts said, it’s a promising first step.

“We’re moving in the right direction with programs like these,” said Karen Shore, a principal at the California-based consulting firm Transform Health. “It isn’t solving all of our health system problems. But that’s not a fair expectation.”

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But one of the most powerful initiatives in trauma care in the past 15 years might make a difference.

Across the country, a public safety campaign is underway to teach both first responders, such as police officers, and average citizens how to stop trauma victims from bleeding to death. United under the banner of a White House-led public safety campaign called “,” federal agencies, major health care and law enforcement trade associations, local governments and some companies are backing the effort.

The national push for broader training is “a direct descendant of the 9/11 experience,” said Oscar Guillamondegui, medical director of the trauma intensive care unit at the Vanderbilt University Medical Center.

In , trauma surgeons are instructing teachers at schools run by the Archdiocese of Boston on how to stop bleeding. Cities also are teaching police officers how to apply tourniquets and arming them with bleeding-control kits —Ìý officers from Phoenix to Philadelphia had taken such training by 2014, according to the American College of Surgeons.

In Denver, at least six citizens and five police officers have been saved over the past five years because officers at the scene were trained in bleeding control, said Dr. Peter Pons, an emergency physician who created that city’s program. He is also professor emeritus at the School of Medicine at the University of Colorado.

Tourniquets

Tourniquets were rarely used in civilian accident scenes even 10 years ago because it was assumed that applying one would lead to amputation of the injured arm or leg.

When a tourniquet did need to be applied, paramedics and emergency medical technicians often created their own, using triangular fabric bandages and other materials carried in their vehicles.

While tourniquets could not have helped the many 9/11 victims who died when hijacked airplanes crashed into the twin towers and the Pentagon, their usefulness has been proven in other circumstances.

Today, commercially designed , called combat tourniquets, can be found in nearly every ambulance and emergency response unit in the country, and that’s due in part to years of successful military use in Iraq and Afghanistan.

“At the start of the war, [tourniquets] had a bad name; by the end of the war, it was recognized as absolutely lifesaving,” said Dr. John Holcomb, a trauma surgeon at the University of Texas Health Science Center at Houston. Houston police alone were issued 10,000 tourniquets in 2014.

Holcomb is a member of , a joint committee drawn from the medical community and government that recommends ways to improve survivability from intentional mass casualties and active shootings. The Hartford Consensus has recommended that all first responders carry tourniquets since its formation in 2013 after the Sandy Hook Elementary School shooting in Newtown, Conn., the previous year.

Each state sets its own standards for what ambulances must carry, but EMS Resource Advisors’ Scott Moore, a consultant to the American Ambulance Association, said nearly every ambulance service in the country has trained employees in applying combat tourniquets.

Wound-Packing

When a tourniquet can’t be applied to stanch profuse bleeding —Ìýsuch as gunshot wounds in shoulders or chests —Ìýanother technique comes into play. It’s called wound-packing —Ìýliterally, stuffing a wound with gauze and applying pressure to keep blood in the victim’s body. Traditionally, only physicians were taught this technique, according to Denver’s Pons.

Now, ambulance personnel all over the U.S. are using wound-packing, aided by special gauze treated with chemicals that make blood clot faster. These “dressings,” with names like QuikClot Combat Gauze, were developed and originally used by the .

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