Tackling Montana’s EMS shortage, from the supply side

By Alex Sakariassen
Montanna Free Press

At any moment, the radio clutched in Quinlan Roe’s hand could squawk, his cue to jump in one of the ambulances just a few feet away and speed out onto Missoula’s streets. The call might take him a few dozen miles south up the Bitterroot Valley or 80 miles north to Condon, with who knows what medical emergency waiting for him on the other end. His laugh, his gestures, the cadence of his speech — everything about Roe telegraphs anticipation, his energy level fixed somewhere between a simmer and a rolling boil.

“All the new people that are coming here, all the tourists, it gets really busy for sure, especially in summer,” Roe says. “We’re about to get really, really busy, where you’re not sleeping during your 24-hour shifts.”

Roe joined Missoula Emergency Services Inc. (MESI) as a paramedic at the start of 2022, fresh from the first cohort of students at Missoula College’s new paramedic program. As a former volunteer EMT with Missoula Rural Fire and the son of a longtime local firefighter, Roe knew all about the responsibility and the rush that come with first responder work. Becoming a paramedic was the next logical step in building his career in health care. The pay may not be as good as when he worked construction, he says with a smile, but helping people who are sick or injured or experiencing a mental health crisis is “what keeps me going as a paramedic.”

“There’s a lot of sick people in these rural areas that we have to go grab, and you just get so much patient contact time,” Roe says. “That’s what really keeps us here. If you spend that much time in the back of an ambulance with sick people, you’re going to get your stuff figured out.”

Roe’s entry into the ranks of certified paramedics comes at a time when Montana — and the nation — are clamoring for such professionals. Since hiring on at MESI, Roe has received calls and emails from Emergency Medical Service providers he’d previously applied to offering him jobs and even promising signing bonuses.

Last year, the Montana Department of Public Health and Human Services released the results of a survey of 61 in-state EMS agencies and 42 hospitals identifying staffing and recruitment issues as among the primary drivers of what it characterized as a “crisis.” That survey, titled “Emergency Medical Services in Montana: Crisis on the Horizon,” also noted that roughly three quarters of all EMS providers in the state rely heavily on volunteers to respond to medical emergencies — a pool of first responders that are, demographically, getting older.

Data published this spring by Kaiser Health News further illustrated just how dire the situation is, revealing that there are virtually no licensed paramedics in large swaths of the state. More urban corners of the state do boast higher concentrations of first responders, but proximity to a city is no guarantee of access to emergency services; KHN’s analysis showed only two paramedics per 10,000 residents in Silver Bow County, where Butte is the county seat. According to DPHHS, there were 1,260 licensed paramedics in Montana as of March 2022. Of those, just over half were providing emergency care in pre-hospital settings.

If the EMS shortage looked bleak before 2020, COVID-19 has made a tough situation tougher. Pandemic fatigue hit professionals in all corners of the health care industry, first responders included. And, according to Montana EMS Association President Jeremy Virts, some EMS providers also lost employees to lucrative job offers at health care facilities desperate for additional staff to relieve the COVID strain.

“We’ve seen it here in Great Falls where the [emergency room] here has offered more money to come in and do some ER tech work or flight-team transfer type stuff,” said Virts, a 24-year Montana paramedic who currently oversees EMS services at the Great Falls Fire Department. “So that draws people right out of the workforce.”

The factors driving the shortage vary considerably between urban and rural swaths of Montana. But in both cases, in-state college programs like the one Roe graduated from are exploring innovative ways to inject new blood into the EMS system. It’s a mission that Dave McEvoy, director of Missoula College’s paramedic program, considers critical as he reaches the tail end of a 30-year career in the EMS field: tapping experienced veterans such as himself to train the next generation of Montana first responders.

“What is asked of a paramedic is pretty substantial, pretty staggering,” McEvoy said. “The expectations put on a paramedic any time of day, any time of night, and the range of things that you would see, from mental health through trauma through homelessness, is a lot. We all recognize this because we all work in this field and recognize the responsibility that our students are going to have.”

Roe was among Missoula College’s first cohort of 10 graduates last December, all of whom are now employed as paramedics in western Montana — more than half in the Missoula area. The program kicked off in 2020 as a public-private partnership between Missoula College and MESI, which has been training paramedics locally for three decades. McEvoy said the collaboration has given students access to high-end facilities on the college campus including a “world-class cadaver lab,” while at the same time tapping MESI as a venue for seasoned instructors and clinical rotations.

Getting that inaugural class certified was anything but smooth, McEvoy said. The program puts students through a rigorous 16 months of classroom learning and hands-on field experience as a matter of course, and the COVID-19 pandemic piled on with heightened in-class safety precautions and the constant threat of having to halt in-person instruction. But McEvoy is confident that Roe and his classmates represent a strong start —ideally strong enough for the program to make its temporary national accreditation permanent next year.

Inspired in part by the recruitment challenges now facing EMS services, Missoula College is already planning to improve and enhance the new program. In 2020, the state health department began supporting a series of pilot projects statewide aimed at deploying local paramedics to deliver non-emergency preventative care outside of hospital settings — an emerging health care approach called community integrated health. McEvoy said the paramedic program is gearing up to deliver a state-approved curriculum tailored to that approach, allowing students to obtain a community integrated health endorsement.

“If you get discharged from the hospital here with a high-acuity problem like diabetes or you just had open heart surgery at St. Pat’s, there’s a decent chance that you’re going to end up back in the hospital for that same problem if you don’t have good follow-up care,” McEvoy said. “A community paramedic’s job in that role would be to provide some of that follow-up and have a relationship with the hospital and the patient to say, ‘We’ll show up on Tuesday and we can do some basic things and we can tele-med in with a physician and make sure that you don’t end up back in the hospital.’”

McEvoy added that the program plans to offer similar tailored instruction for critical care paramedics, who are certified to administer advanced airway and cardiac support to patients being transported between health care facilities. Just as a paramedic certification enables a person to administer various life-saving interventions and medications that an EMT is not licensed to provide, such endorsements give individual paramedics additional options and skills to treat patients in specific situations.

Flathead Valley Community College has also begun exploring ways to alleviate Montana’s ongoing EMS struggles. James LaPierre is a graduate of the college’s paramedic program and this year stepped into the role of program director. The program took several years to get its footing, LaPierre said, but now boasts student retention and graduation rates of 100%, and the program’s students have landed jobs at EMS services across western Montana, from Helena and Great Falls to Hot Springs and Plains.

“I keep kind of a mental map of this, and most of them are within the state still, including my class,” LaPierre said. “I’m only aware of two or three that have traveled outside of the state to find paramedic work.”

Photo/Dave McEvoy via Montana Free Press

Building on that success, FVCC launched a satellite paramedic program in Miles City this year in partnership with Miles City College and Miles City Fire and Rescue. LaPierre said two students are currently enrolled there, both of whom are already working as EMTs for the fire and rescue service. The satellite is designed to complement Miles City College’s existing EMT program, making the transition to paramedic education and certification for those graduates more accessible. It’s a model LaPierre hopes to replicate in other corners of the state.

“Having people that are interested is all fine and good,” LaPierre said. “I’m positive, after speaking with people around the state, that there are people that want to become paramedics. But the reason we chose to go to a distance model with Miles City is because those people that want to become paramedics don’t have the means to travel to the three programs that are currently in the state. So the best answer is to provide those smaller community colleges and things like that with the opportunity to teach under our accreditation.”

Sarah Lewin, battalion chief at Miles City Fire and Rescue and the satellite program’s resident instructor, obtained her paramedic degree from Montana State University-Billings in 2016, and knows firsthand how big an academic barrier a 150-mile trip can be. While others with her fire and rescue outfit were able to do their paramedic training a little closer to home in Hardin, a change in national certification standards several years ago made it more difficult to find local training opportunities. Now, with FVCC’s oversight, Miles City can recruit and train locally. An initial cohort of two paramedic students may not sound like much, Lewin said, but the impact of adding two more staff to a full-time EMS service of 15 with a coverage area of nearly 4,000 square miles is “enormous.”

Photo/Dave McEvoy via Montana Free Press

“We don’t have 100% coverage, but adding two more paramedics when we run four shifts puts a paramedic on every shift but one on a normal day,” Lewin said. “And then we can cover that other one with one of our chase vehicles.”

At Missoula College, the paramedic program has similarly set its sights on partnering with outlying hospitals, both to increase the opportunities for students to learn in the field and to alleviate the travel burden that prospective students in communities like Anaconda or Helena might face. That burden constitutes a “huge bottleneck” for the program right now, McEvoy said. People have lives, and many students are already working as EMTs — a level of certification that’s required of all applicants. Attending a paramedic program is “almost a full-time gig,” McEvoy added. MESI Manager Don Whalen, who also serves on the program’s governing board, agrees that expanding the program’s presence and helping bolster EMS services in rural areas is vital in addressing the broader challenges he’s seen on the ground.

“We’re getting dispatched over into Idaho, we’ve been sent to Philipsburg on 911 calls,” Whalen said of MESI. “EMS is in crisis when you get out into the rural areas because nobody wants to do it anymore.”

Whalen’s point speaks directly to the variety of factors driving the EMS shortage in urban and rural parts of Montana, and the limited ability of college programs to address the current crisis. For urban EMS providers, rampant community growth has generated an increased demand for services, while the allure of higher pay and new experiences elsewhere in the health care industry has in some cases made the role of paramedic a temporary career stepping-stone. Missoula College’s paramedic program and programs at Flathead Valley Community College, Montana State University-Billings and Great Falls College MSU are actively rolling out a steady stream of trained professionals to fill those openings.

Much of rural Montana, meanwhile, still relies heavily on volunteer EMS services. Smaller critical access hospitals are often unable to afford their own paid ambulance service. Montana Hospital Association President Rich Rasmussen attributes that lack to low hospital revenues and a federal policy prohibiting those hospitals from obtaining reimbursements for ambulance costs if another paid or volunteer ambulance service is operating within 35 miles.

And as for volunteer providers, McEvoy and others said they’re suffering from a significant decline in volunteerism. That, McEvoy added, is a nut that his program “can’t crack.”

“That is a conundrum, because those folks need paramedics, but they’re not going to be able to afford to have paramedics necessarily volunteering their time, and the paramedics themselves can’t volunteer their time as much as the community might need,” McEvoy said. “That’s just a bigger regional and national issue.”