Population boom impacting EMS response in S. Texas
Small-town governments, police forces, social services and especially agencies that depend on volunteers have been hard-pressed to handle the new demands
By John MacCormack
San Antonio Express-News
KENEDY, Texas — Steven Ramos was serving three years for drug possession in a Karnes County state prison when he was found hanging in his prison cell June 11. Ramos, 28, had no pulse and was taken to the prison infirmary. An ambulance was called.
But the sheriff's dispatcher who took the 911 call only had bad news.
The county's volunteer ambulance service was unavailable, apparently for lack of personnel. Its backup, Texas Regional EMS, was on another call. Neither could respond.
Finally, almost an hour after the lifeless inmate was discovered, an ambulance arrived from Beeville, 30 miles away, but by then it was too late.
"I don't know if he would have died anyway, but with (the delay), you eliminate the chance of saving him," said Mike Tyran, 52, the trauma coordinator at Otto Kaiser Memorial Hospital just outside of Kenedy. "If it had been someone else with a serious injury, it might have meant a different outcome."
Tyran said he knew of two other recent serious cases when the county's EMS was unable to respond.
The ongoing emergency services dilemma here reflects the rapid changes and complex problems that have hit poor, lightly populated South Texas counties since the Eagle Ford Shale boom began three years ago.
Small-town governments, police forces, social services and especially agencies that depend on volunteers have been hard-pressed to handle the new demands.
In Karnes County, the arrival of thousands of outside workers since 2010 has led to a surge in bad traffic accidents and a steady wave of oilfield injuries.
Five people died in county traffic accidents from 2008 through 2010, according to Texas Department of Transportation. In less than three years, 27 people since have died, and many more were badly injured.
Patient visits to Otto Kaiser's tiny emergency room have almost doubled, as have 911 calls for local ambulance service and AirLife helicopter flights from San Antonio.
In 2009, the county EMS responded to 669 calls for help. This year, the call load likely will exceed 1,200. At the same time, the number of available volunteers is down.
"Before the boom, it was manageable. You didn't have half the call count. And the nature of the calls has changed. We're seeing more industrial-type accidents," said Shelby Dupnik, 62, a Karnes County commissioner and longtime EMS worker.
The EMS crisis has led some volunteers to quit, longtime director Johnny Smart to resign for health reasons and provoked personality conflicts. It also forced the county to begin paying outside crews $1,000 per 12-hour shift to fill frequent coverage gaps.
And it has emphatically raised the question of whether part-time volunteers, who are paid $36 a shift plus $40 a call, can be expected to handle the increasingly demanding job.
Dupnik is convinced full-time paid crews are needed.
"Years ago, we were so small, you knew everyone in town. When you'd hear an address, you'd say, 'That's Mrs. So and So,' Now you don't know what you're getting," he said.
"When I hear an accident involving an 18-wheeler or a school bus, I dread it. I also dread the possibility of mass casualties. The ambulance can carry two. What do you do if your have four or five dead?" he asked.
An interim director is overseeing things while the county studies its options.
Going to a full-time paid service would cost about $700,000 a year. Last year, the county spent $375,000 for its volunteer ambulance service, including $133,000 to buy a new ambulance.
Lately, it has been spending thousands a week to have Texas Regional cover shifts.
"I think the ambulance service is in disarray. There is a lot of stuff that should have been brought to the commissioners' attention a long time ago," said County Judge Barbara Shaw. "These guys are dedicated. They have taken care of the county for years. But when one person quits and you turn the whole program upside down, something is wrong."
Shaw is not convinced the volunteer era has passed.
"Everyone keeps saying 'paid service' but once the oil patch goes away, we'll have to rely on our volunteers. How could we afford a service that costs three quarters of a million dollars a year?" she asked.
Old Garage Houses EMS
For a couple of hours on Sunday mornings, the highways in Karnes County are oddly peaceful, almost free of speeding white company pickups and rumbling fracking trucks, making it seem almost like 2009 again.
But for emergency service workers, the Sabbath rarely is a day of rest.
Dupnik and his wife Gretchen, both longtime volunteers, got the first beeping call of the day on a Sunday in early July just after leaving church.
"Guy trapped under a tractor," was the cryptic summary, and within minutes they were rolling northward, lights flashing and sirens blaring.
They reached County Road 125 within minutes and were met by a clutch of anxious workers in hard hats. In the grassy roadside ditch, others were trying to free a man whose right leg was pinned under an overturned orange tractor.
"He was just screaming for help. I called 911, and then we started digging a hole around the tire," said one onlooker who declined to give his name.
When the Karnes City Volunteer Fire Department's rescue truck arrived, firemen set to work using shovels, air bladders, metal braces, wooden blocks and even a forklift.
Eventually, Bernadino Morales, an employee of Rockwater Energy Solutions, was freed and carried out on a stretcher. As he was being loaded into the ambulance, a relieved Morales gave a power salute and called for photographs.
After tending to his injured foot, the Dupniks drove him to a blue and white AirLife helicopter waiting in a nearby hay field, for the flight to San Antonio. The prognosis was good.
"I was worried about an open fracture. What was in his favor was that it had rained recently, and the ground was soft," said Gretchen Dupnik, while doing paperwork later in the decrepit EMS garage on Main Street.
To some here, the rundown garage, with its broken windows and cracked walls, captures the precarious state of the volunteer ambulance service.
Junk and old equipment are piled in the back, records and medication are kept in unlocked closets and the garage floods when it rains. The tiny office is furnished with primitive bunk beds and an old desk.
And while the county recently decided to provide a house trailer, for a long time, this has been it.
"I've been saying three firecrackers would bring the whole thing down," Gretchen said.
An hour later that Sunday, the Dupniks responded to a call for a man who had been hurt while being arrested in a drug case. After bandaging Ronnie Martinez's bloody head, they handed him off to a deputy for the trip to jail in Karnes City.
And before their 12-hour shift ended at 7 p.m., they rolled on a call of a possible stroke that ended with 23-mile trip to the Otto Kaiser hospital.
Given the continuing shortage of workers, the couple is not making plans to leave town.
"I'm the only one now who doesn't have a full-time paid job," said Gretchen Dupnik, 62, a retired teacher. "I used to spend time with my family in Sisterdale. A week or a long weekend, but I can't get away now because we need to be here."
Only Three Physicians
Before the boom, Karnes County had a depressed economy and a stable population of about 12,000 people. The single 25-bed hospital, three primary care physicians and a clinic here were holding their own.
Aside from Otto Kaiser, the closest hospitals are in Beeville and Floresville, both about 30 miles away. The only other medical facility in the county is a community health clinic that does not treat serious injuries.
Dr. Rayford Mitchell, 37, one of the local physicians, has seen sharp changes in his practice in the past three years. His new clientele is much younger and some have complicated needs.
One hint is the warning sign taped to the window in his waiting room.
It advises in part: "We no longer prescribe new patients Schedule II controlled substances such as morphine, fentanyl, dilaudid or oxycodone ... without extensive medical documentation of need from your specialist or hospice group."
"Before I put that sign up, we had a problem, but slowly it's gone away. We were getting a lot of folks coming in demanding morphine or hydrocodones," Dr. Mitchell said.
Dr. Mitchell said he's still accepting new patients, although he can't always see them as quickly as they would like.
He also has experienced problems with the ambulance service. Recently, he said, a patient in a local nursing home who had fallen and suffered a serious head injury was unable to get a timely trip to the hospital.
"They called for an ambulance, but it could not get there quickly enough, so the nursing home put her in a private vehicle and sent her to Otto Kaiser," he said.
She later was taken by helicopter to San Antonio for specialized treatment, he said.
The hospital also has seen a dramatic increase in patients, some with complex problems and injuries.
"We're seeing a large influx of people from other states. We're seeing women who have not had prenatal care. We're seeing lots of hand injuries," said Audrey Cortez, the hospital's head nurse.
Before the boom, she said, the hospital averaged about 500 emergency room visits a month. Now the average exceeds 800 and sometimes tops 1,000 visits and the injuries are often more serious.
"We have a large number of motor vehicle accidents in our ER. Most of the time they are airlifted to San Antonio, but on several occasions, because of fog or haze, there was no flying, so we ended up getting serious trauma patients," she said.
"We're seeing a huge number of hand injuries. At times it involves an amputation of a finger or several fingers, and time is of the essence. So I've worked with several of the hospitals in San Antonio to streamline the process so they have a chance of re-attaching them," she added.
David Lee, the hospital's chief executive officer, said the increased patient load has caused the hospital to add a third emergency room nurse during peak hours. And, he said, the hospital is absorbing a lot more un-reimbursed costs.
Tyran, who began working at Otto Kaiser in August 2010, just before things began getting crazy, said the number of serious injuries, including amputated fingers, deep lacerations and crushed limbs, has doubled.
But, he said, injured oil field workers never ask for a doctor's note to take time off and sometimes postpone getting treatment in order to keep working.
He mentioned the recent case of a welder who had delayed a visit to the emergency room after a bad fall in a motel bathtub.
"When it rained, they took the opportunity to get her checked. She had four broken ribs but all she wanted to know is when she could go back to work," he said.
The woman and her husband, both welders, said they together earned about $30,000 a month and could not afford to miss work.
"She said I've been working with those four broken ribs, I can do it again," Tyran added.
The emergency room has seven beds in five treatment rooms, with additional space for four beds in the halls. Tyran said it's not uncommon for all 11 to be in use.
"The busiest shift until three years ago was 22 patients seen over 24 hours. Then the oil boom happened. Since then, my colleague and I once saw 25 patients in just 12 hours," he added.
At the Karnes Community Health Center, the patient load is up about 15 percent, said nurse practitioner Pam Clark, leading the clinic to add two nurses.
"We'll see more. It's not just the oil field workers. The families are now moving in," she said. "We're trying to establish care with them. See that the kids have immunizations. Looking at it from a family aspect."
Energy Firms Pitch In
Charlie Malik, long-time chief of the Karnes City volunteer fire department, which handles rescues and extrications for the entire county, said the boom's effect has been striking.
"Last year we had 42 rescue-related calls. Five years ago, we'd have five to seven a year," he said.
At the same time, he said, volunteer firemen find it more difficult to respond when the fire claxons sound, and the force has dropped from 30 to about two dozen.
"A lot of them have gone to work in the oilfield, and they are not close to town. Their bosses won't let them come," said Malik, who owns an auto parts store in Karnes City.
Assistant Chief Gus Hernandez, 36, said the hardest calls to fill come during daytime hours.
"There's been many a time we went out on a truck with just two persons on it, Charlie and me, and the others responded later," he said.
Asked what motivates the men and women to devote their time to hard, dirty work, he said, "For me, it's the brotherhood. These people are family. And everything is to help the community."
For Jimmy Loya, 53, the longest-tenured member, it's also the fulfillment of a boy's dream.
"We do this because we enjoy it. When I was a kid on my bike, I'd chase the fire trucks. Now I'm driving the fire truck," he said.
Easing the burden on the department has been the generosity of energy companies.
Malik estimated they have collectively donated about $350,000 during the past three years to help pay for a new tanker, an expansion of the garage and buy equipment ranging from gas monitors to a trailer to haul foam and spill materials.
And, he said, while his crews are responding to many more calls, they are familiar with oilfield related incidents, including large fires, and so far can handle them.
"It's not that it's new to us. If it's beyond our capabilities and no lives are threatened, you back off and let it burn," he said of oil field incidents.
But Danny Denson, a lieutenant in the fire department and now the interim director of the ambulance service, is a bit more concerned.
"We've been fighting tank battery fires for 25 years, but all the frack trucks congested at a site pose some interesting problems," he said.
"If there's a fire at a well site they are fracking, you're looking at 50 to 60 trucks parked on a three-acre pad. That's a high concentration of hydrocarbons. Every truck has 100 to 200 gallons of fuel, plus what's in the tanks," he said.
Malik said that despite the demands brought by the boom, there are no plans to do away with the volunteer department.
"We have our ups and downs, but we're still holding our own. Our mayor is, in a sense, pushing to go to a paid fire department, not immediately, and I guess it's his job to look ahead," he said.
"We've talked about it. If it ever gets to that point, we'll let him know, but right now, everything is going good," he said.
|McClatchy-Tribune News Service|