A Different Kind of Rural EMS
A while back, I reached out to my LinkedIn network and asked them a simple question: Can someone provide me, a medic with experience in urban and suburban areas, some insight into the challenges that face rural EMS?
In my system, if I need help on a call, say I call for a fire engine, I get one. If I need ten fire engines, I can get those, too. Law enforcement backup? With quickness. Another ALS resource? Minutes. If I need 10 ambulances, I can get those, too. 15 ambulances? Sure. Regional HAZMAT? Sure. USAR? Yep. Point is, I have stuff available to me. There is a lot of the country where that is not the case.
My assumption was that I would get a lot of responses from middle America, rural farmland, and the like. I did get a few of those, but one that I did get honestly surprised me a bit. It surprised me because it was a landscape I hadn’t considered, even though I have a few agencies within driving distance from me with similar challenges.
San Juan Island EMS, in Friday Harbor, Washington, is a combination career and volunteer agency that covers seven islands with a total population of about 8,600 residents. They responded to 1184 calls (420 ALS, 560 BLS) with 922 transported and 255 not transported. 517 were transported to their local critical access hospital and 389 were transported by air ambulance to a major medical center off island. They have an average chute time of 1:56, response time of 8:14, average scene time of 21:14, and average call time of 45:20. San Juan Island EMS is trained and equipped to provide Advanced Life Support (ALS) and Basic Life Support (BLS) services on islands other than San Juan Island. San Juan Island EMS utilizes the Sherriff’s boat to go on marine calls for ALS or BLS 9-1-1 calls. There are two marine response zones San Juan Island EMS will respond in: the primary response zone and secondary response zone. Primary Response Zone is where San Juan Island EMS has a duty to respond and provide EMS services to the outer islands that are within the boundaries of San Juan County Public Hospital District No. 1. This includes the inhabited islands of Brown, Henry, Pearl, Spieden, Johns, and Stuart, as well as numerous smaller islands. While the District has a duty to respond, it is not unlimited. If a response cannot be performed within low-risk parameters, then a response should not be attempted. Secondary Response Zone is where San Juan Island EMS will support a response outside of its secondary response zone of San Juan County when possible. However, there is no duty to respond outside of the District’s primary response zone. Any response is subject to conditions and the availability of resources. They operate with a Chief, an Assistant Chief (That’s T.J.), and 11 full-time staff. The minimum staffing is 1 ALS capable ambulance, and they have a dedicated volunteer staff that frequently will put extra ambulances in service or respond from their homes if needed. They are tax funded through a public hospital district levy and through transport revenue.
Primarily a retirement community with 64% of patients over the age of 60. Their population surges in the summer with tourism, increasing their population significantly. According to Datafy, there were 506,953 'unique visitors' to the 3 main islands in 2022. Many visitors make more than one trip which accounts for 1,698,430 'total trips.' Datafy tracks people who live 20+ miles from the San Juan Islands via cell phone and credit card usage. The area is served by a ten-bed critical access hospital staffed 24/7 with board certified emergency medicine physicians. San Juan Island EMS provides 911 service, as well as interfacility transfers from the critical access hospital to the airport to one of their three air transport providers. They have a fixed wing aircraft stationed on the island operated by Island Air Ambulance, and two rotor wing aircraft, Air Lift NW and Life Flight Network, available from the mainland.
They also have a community paramedicine program. San Juan Island EMS’s Community Paramedicine Program bridges the gap between healthcare providers and the resources people need to stay in their homes, helping to avoid using 911 and the Emergency Room (ER) for preventable health care services and enabling people to get on the road to better health and keeping our first responder’s call volume lower. The main goals of the Community Paramedicine Program are to improve the quality of life and health for our community. The Community Paramedicine EMTs identify short and long-term interventions to help improve a patient’s wellbeing. They are referred patients from Peace Island Medical Center ER (PIMC), 9-1-1 first responders, the San Juan County Health Department, Hospice of San Juan, primary care doctors, Compass Health and family members.
T. J. Bishop is the Assistant Chief of Operations and Training for San Juan Island EMS. Chief Bishop is a US Army Veteran who put himself through EMT-B, EMT-Cardiac Technician and EMT-Paramedic courses while stationed in Virginia. Like many of us “back in the day”, he started as a volunteer, and again like many of us, in his words, he was hooked. After leaving active duty, he was hired as a firefighter/paramedic where he found his passion for teaching. After serving as EMS Training Officer, Captain, and Division Chief of Clinical Operations for various public agencies in WA State. Chief Bishop was recruited for his current position, which he has held for just over 2 years.
Looking at pictures while doing research for this piece, and as Chief Bishop notes, the San Juan Islands look gorgeous. They are now on my list of places I need to go. The challenge as an EMS system is that that they are only accessible by ferry, boat, or aircraft. The local, critical access hospital is a level 4 trauma center with no cardiac or stroke designation. All STEMI, Stroke, ROSC, Sepsis and Level 1-3 Traumas are air transported to the mainland, primarily to Bellingham, Everett or Seattle. This can take total transport time of well over an hour. When there is inclement weather, they sometimes use the state ferry system, the US Coast Guard or the Navy.
They do have some recruitment and retention challenges. To help overcome this, they hold initial EMT courses every 2 years. They also have around 25 volunteers of varying activity levels. They also have a pool for full time EMT positions when they are open. Most of the system Paramedics are very senior and close to retirement. The majority of them are trained at the world-renowned University of WA/Harborview Medical Center Paramedic Training Program with Seattle/King County Medic One. They are oversaturated with agency requests for students. They are also exploring lateral hiring options.
Chief Bishop and I emailed back and forth a bit before publishing this, but my favorite paragraph is from the first time I asked him about his agency. The question was “What are you most proud of about your service? What should everyone know about San Juan Island EMS?” His response is something to be proud of, and something we all hope we can say about our agencies:
“This agency has a legacy of family helping family and doing whatever it takes. Culture is everything here. The agency has over 100 years of paramedic experience. We are extremely proud of it. Our clinical care is stellar. We have some of the most progressive, evidenced-based protocols in the nation. We do finger thoracostomies, give TXA and antibiotics, measure lactate and H&H, ultrasound, IV pumps, and a huge formulary to name a few. Our medical director is Dr. Joshua Corsa, MD and he is phenomenal. He is a trauma surgeon both at a level 2 trauma center and with a Forward Surgical Team in the US Army Reserve. We meet with him monthly, can call him 24/7, and he knows everyone by name. We have some of the highest cardiac arrest save rates in the state, more AEDs per capita than anywhere we are aware of, and just received the AHA Mission Lifeline EMS Gold Award for STEMI/ACS and Stroke.”
Photos used with permission: San Juan EMS Facebook SanJuanEMS.Org
