Essential: A KCCI investigation.Below is an eight-part KCCI investigation into emergency medical services in Iowa. It spans from families who dialed 911 only to wait or not see an EMT at all, to the staffing shortage across the state, to departments closing across Iowa. Chapter One | Chapter Two | Chapter Three | Chapter Four | Chapter Five | Chapter Six | Chapter Seven | Chapter Eight |Chapter one: Iowa's EMS emergencyDonna Hansen keeps her husband Tim close to her heart.“Been almost six years and some days it still doesn’t seem like it happened,” she said, wearing a necklace with her Tim’s ashes inside while sitting in her rural Hudson, Iowa, living room. The day his heart stopped beating is one her daughter Kim Bemus tries to forget.“I try not to remember that stuff,” she said.July 16, 2016, is a day the two of them still remember, Tim had chest pains and told his daughter Kim to call 911. Instead of waiting for the Hudson volunteer ambulance to come to them, they had a different plan. “He (Tim) told me to call the fire department again, to tell them we’ll meet them there,” Bemus said, recalling that day. Once they arrived there, a few miles north, a firefighter and a police officer were there ready to respond, but no EMT. The firefighter there at the time knew Kim and her dad and was on the phone trying to find a volunteer EMT, all while Tim was having a heart attack.“He was making the calls, trying to get people there,” Bemus said. “Nobody.”With no EMT and no one to help, Bemus decided to keep driving north to what was Covenant Medical Center in Waterloo.“I knew when it turned worse (was) when he reached out and didn’t say anything,” Bemus said remembering the drive. “All I could say was ‘it’s going to be okay, we’re going to get help.’”Bemus eventually met a Waterloo ambulance on Highway 63, near U.S. 20. Tim died five miles away at the hospital.His story of an ambulance not showing up, or taking a while to respond, is not unique across the state.“Biggest surprise to us was the fact that no one did show up,” said Hansen. “Because when you call 911, you always expect that’s going to happen.”“When you call for police, or you call for fire, you’re going to get police and fire because it’s mandated by Iowa,” said Chief William Daggett, director of public safety for Van Meter, Iowa. “EMS is not.”Senate File 615, signed into law by Gov. Kim Reynolds in June 2021 provides the framework for counties to deem the service essential. It allows them to create a referendum to raise property taxes to fund EMS.“Since 1979, since EMS was on the books, it is the first time that we’ve ever seen the words EMS and essential in the same sentence in the same paragraph in the same bill,” said Mark McCulloch, Iowa EMS Association’s immediate past president and current legislative chair. “So, it was a huge step in the right direction.”A step in the right direction, but money and an essential service are not the complete answers to the problem, according to McCulloch and more than a dozen other EMS professionals across the state.“You could snap your fingers right now and say ‘here’s a billion dollars,’ and we still aren’t able to provide statewide EMS coverage because we don’t have the people.”This takes the problem back to the day that Tim Hansen died, not enough volunteers were available when his heart stopped.“We never put blame on anybody for any of this,” Donna Hansen said, explaining the system itself needs changing. “It started out as the shock that we had that no one showed up,” she said. “Because they didn’t need to.”Chapter two: Harrison's story, an 18-minute wait A mother’s love knows no end, even when the end has already come.“He just, he was very driven to be successful and he cared about other people,” said Melanie Smith, mother of Harrison.Harrison was a senior at Van Meter High School, allergic to tree nuts, but hadn’t had a reaction for years.“He ate something, he felt strange,” she said at her kitchen table. “He came home and tried to handle it on his own. He called 911, we think, immediately when he got here.”While he called 911 immediately, an ambulance that could save him did not come as fast, taking 18 minutes to get to his home southeast of Van Meter. “He called 911 and thought it was gonna save him,” Melanie said. “And it didn’t.”The reason is something Melanie learned while her son’s life was on the line.“We don’t feel like the people that were here failed Harrison, but the system we feel like failed Harrison,” she said.The system still works the same way in rural Dallas County and Van Meter as it did on that day in February 2020. When Harrison dialed 911, while having an allergic reaction, three EMS services were called. Van Meter and the Dallas County Ambulance in Adel were dispatched immediately, a Waukee ambulance was called about ten or eleven minutes later to see if it was closer than the Adel ambulance.“It took 17 minutes for my (Van Meter) first response unit to get there, and like 17-and-a-half to 18 minutes for the ALS (advanced life support) unit to arrive,” said Van Meter director of public safety, Chief William Daggett.The Van Meter service is a basic life support service, a step below the advanced life support service coming from Adel.“When you call for our response unit, we’re going to be able to put bandages if you’re bleeding,” Daggett said. “We’re going to be able to stabilize your neck and do basic first aid.”Dallas County Ambulance in Adel, and Waukee, are advanced life support ambulances. These services can do everything in their power, the most advanced life-saving techniques, to save a patient while taking them to the hospital.“If you’re in trauma and in pain, that’s the people that can do the advanced life-saving stuff,” Daggett added.The 18-minute arrival time to get an advanced life support ambulance to Harrison is within Iowa’s system standards. Iowa’s standards, most recently written in 2017, suggest an ALS ambulance should respond within 20 minutes in a rural area. Daggett said the Dallas County Ambulance did come within that timeframe, but still stresses it took too long. He believes the issue boils down to deeming EMS essential in Dallas County. Senate File 615, signed into law last year, allows counties to do this and introduce a tax referendum to fund the EMS in the county. If that were to happen, Daggett says that would put an advanced life support ambulance in Van Meter. “My deal has always been, why do the citizens that don’t live in the two metro areas… why don’t we get the same services?” he added.So far, no county has used Senate File 615 to make EMS essential across the state, though a few are in the process. Wright county deemed the service “essential” before the law was passed. Melanie Smith and Daggett believe a statewide determination to make EMS essential is the solution to saving more lives.“The people we depend on to save our lives are not seen as necessary by the state,” Daggett said.“It needs to be essential,” added Melanie Smith. “We don’t want to see anybody else have to suffer and go through the grief that we’ve had to go through.” Chapter three: Dwindling number of volunteers force some Iowa EMS to closeThe ambulance barn is still connected to the fire station in the rural Wayne County town of Allerton. The garage door still reads “Allerton First Responders,” but an ambulance doesn’t sit inside, because the emergency medical service is no longer running.“It was a hard decision,” said Becky Hysell, the head of the department. She decided the department’s curtain call, on Jan. 7, 2020, when she called the state to let them know the service of more than thirty years was closing.“They (IDPH) were really, you know, heartfelt about closing down,” she said. “Because they know how important those are.”A town of roughly five hundred that once took pride in the number of EMS volunteers was down to just one, and two nurses to help. A number that small worked until the last volunteer had health troubles of her own.“I had a heart attack, ended up having to have five bypasses,” Hysell said. “I didn’t have the strength anymore. You know, it was a really tough decision.”Now, Allerton receives EMS from the hospital in Corydon, a little more than six miles away.“Even though the response time may only be affected by a couple of minutes,” Hysell said. “You still have that concern.”Allerton is one of sixteen EMS departments across the state that closed since the start of 2020, 14 of those were closed due to a lack of personnel. “It’s important for people to get involved in their communities,” Hysell added. “That’s how we stay alive.”Overall, IDPH says the number of services for the last three years has stayed "relatively static," noting that the state has 2-3 new services authorized each year. Other departments are on the verge of having no one left to volunteer. According to data KCCI Investigates received from the Iowa Department of Public Health, forty EMS departments have two or fewer EMS workers on their rosters. One hundred and eighty-four have five or fewer and 220 have six to ten workers. Five departments in Iowa have just one person on the roster, which includes the Ringgold County town of Kellerton. Tiffany Bolles is the only person on the EMS roster and is certified as an emergency first responder because of her qualifications as a nurse.When in Kellerton, she keeps a backpack with her with everything she needs to save a person, considering it an ambulance on her back. The old Ford ambulance in the combined city hall, public works and fire station hasn’t been out on a call in a while. It was collecting dust and had quite a bit of outdated equipment and materials in it when she took over the service in September of 2021.“Why not take the ambulance?” KCCI asked her.“It would take longer for me to get it started than it would take to get my vehicle there,” she said standing inside. “By the time I would get there, the Ringgold County Ambulance would already be there.”The Ringgold County Ambulance is the advanced life support ambulance for the county, stationed about ten miles away from Kellerton at the county hospital in Mt. Ayr. That hospital is also conveniently where Bolles works. Her coworkers there asked her to volunteer for the service in September, without her the service would close and have to remain closed for at least a year. “Compassion,” Bolles said describing why she agreed to volunteer. “I don’t know, that’s one thing that’s kind of built into all nurses.”Bolles has only responded to five calls since September but does provide emergency medical assistance in Kellerton until the Ringgold County Ambulance can show up. “A lot can happen in those ten minutes,” she said about the drive between Mt. Ayr and Kellerton for the ALS ambulance.Bolles stepped in to help keep the service afloat, to keep her community safe.“You don’t have to be in that or know anything about it, just to be a volunteer,” she said. “Just go and show up, someone else is going to be able to help.”While the majority of Iowa's EMS departments are volunteer, some counties have as few as two EMS departments in them. In Ringgold County, where Bolles works and volunteers, five EMS departments are available. Though, the only ALS ambulance is located at the Ringgold County Hospital. The infographic below shows the number of providers in each county in the state of Iowa, according to numbers from IDPH. Hover your mouse over your county to see how many are in your area.Chapter four: The staffing shortage The calls to 911 don’t stop, no matter where you are in the state. The phone still rings from West Des Moines to Van Meter, to Tripoli, to Des Moines and more. But, the number of workers to respond to those calls, either paid or volunteer, is dwindling.“EMS is a tough sell,” said Mark McCulloch, legislative chair and immediate past president of the Iowa EMS Association.Across the country, turnover is about 20 to 30% annually, according to the American Ambulance Association, who sent this letter to Congress.Kip Ladage has seen the number drop firsthand as the head of the Tripoli, Iowa Ambulance and the Emergency Management Coordinator for Bremer County in northeast Iowa.“Bremer County, like most of the small counties in the state of Iowa, and especially the rural counties that depend on volunteers, we’re struggling,” he said.Tripoli Ambulance has one volunteer who helps with coverage for roughly forty hours per week, while the other volunteers work their day jobs.“There’s usually never anybody other than me around,” said Steve Hill, the volunteer who covers the service during the day. “You just sweat bullets when he’s gone,” Ladage said. “Because who’s going to pick up the slack?”Without Hill, the small-town service would not be where it is today.“If the city of Tripoli and the Tripoli Ambulance Service did not have Steve around, I would not be surprised if we would be forced to close during the day or hire somebody to come in,” Ladage said.While Hill’s story may sound like a rarity, small departments across the state are struggling to keep and recruit new volunteers.“It’s hard to get people to volunteer for EMS, you know, the training takes a while, the hours you need to keep to recertify take up time,” said Brian Jensen, EMS Coordinator for Wright County. “Everybody just seems to be busier.”At the state’s largest department, Des Moines Fire, recruitment numbers have dropped over the years. In 2022, the department registered the lowest number of applicants in six years.“Over time we’ve seen our applications drop,” said Chief Percy Coleman, chief of operations at DMFD. “Traditionally, there was a time we had a hiring process where we would have 1,200 applicants.The applicants are for firefighting positions. Des Moines runs its EMS through the fire department. So, every firefighter must become a paramedic and has the chance to work in an ambulance.In the spring of 2022, the department had 394 applicants and hired 30 of them.In the spring of 2021, the department had 536 applicants and hired 20 of them.In the summer of 2019, the department had 571 applicants and hired 17In the fall of 2017, the department had 432 applicants and hired 15 people.In the spring of 2017, the department had 515 applicants and hired 16 of them.In the spring of 2016, the department had 500 applicants and hired 12 of them.“We’re competing with the other agencies in the metro area,” Coleman said. “And we’re competing against agencies across this country.”But, it’s not just other firefighting and EMS jobs they’re competing against, departments are also competing with other jobs in today’s workforce shortage.“We’re competing against all other trades, and these other trades, many of them have better hours and pay better,” McCulloch said. “You could snap your fingers right now and say ‘here’s a billion dollars.’ We still aren’t able to provide statewide EMS coverage, because we don’t have the people,” he added.The Iowa Department of Public Health does not keep track of EMS workers over time, though McCulloch says anecdotally the number is dropping in Iowa.The IDPH did provide numbers of EMS workers based on the counties they live in, keep in mind they may work in another county. The infographic below shows the number of workers that live in each county in the state of Iowa, according to numbers from IDPH. Hover your mouse over your county to see how many are in your area.Rural counties have the lowest number of EMS workers, particularly in southwest Iowa. Ringgold, Adams and Clarke County all have 15, Monroe has 21, while Wright, Audubon and Adair all have 23. While an ideal number of EMS workers per county is hard to grasp, because the population is different in each county, every department KCCI spoke with said it was having trouble recruiting workers.The exact reason why so many areas are losing so many EMS workers is unclear, but most point to the lack of identity EMS has and competition against higher-paying or lower-stress jobs.“EMS is a tough sell,” McCulloch said. “We work long hours, nights, weekends, holidays. We see desperate situations and we’re thrown into the middle of those. We try to do our best, but it’s a very stressful job.”But the solution to the problem has more than one answer, but it can be broken down into a few areas, according to McCulloch. Those solutions are better pay, more support and identity.“We really need to take a good hard look at what we’re asking our providers to do, and pay them accordingly,” McCulloch said.For volunteers, he suggests finding a way to subsidize or incentivize being a volunteer and support all EMS workers through what to expect from them.“We need to make this a livable profession,” he added. “We cannot expect our first responders to work 60, 70, 80 hours per week.”The calls coming in won’t stop, and neither will those responding to them.But a servant’s heart can only go so far if there are only so many.Chapter five: The Iowa county that decided to fund EMSLast summer, Iowa Governor Kim Reynolds signed Senate File 615 into law, allowing counties to deem EMS essential and properly fund the service. Even before the law was passed, Wright County saw the problem coming and introduced a tax referendum to fund the services.“We saw a train wreck coming,” said Karl Helgevold, District three Wright County supervisor. “We just wanted to divert that as quick as we could.”That train wreck? Towns in Wright County not being able to fund EMS.Five municipalities serve EMS to Wright County. Without the county deeming the service essential, the Board of Supervisors was worried a town could come to them and say they couldn’t serve the county’s rural community anymore.In August 2017, Wright County deemed EMS essential across the county, a referendum was overwhelmingly passed by voters in 2018. That tax referendum added 67 cents per one thousand dollars of assessed property tax value. It generates roughly 586,000 dollars each year for EMS in the county.But, the board of supervisors didn’t create a county ambulance, instead, they created a fund to distribute the money to each city based on its response area. That money goes to equipment, vehicles, training and staffing.“It’s allowed the agencies to pay their people more, so to help with retention,” said EMS Coordinator Brian Jensen.Plus, it also funded a new quick response vehicle, staffed by a paramedic at the Iowa Specialty Hospital in Clarion.“It is available to all the outlying services in our county to use if they need some advanced level care,” added Jensen.Now, Wright County has become a model for other counties in the state, even helping others navigate Iowa’s new law that allows counties to deem the service essential and increase funding.“Our problems in Wright County may not be the problems in the county next door, but you’re able to write the rules in order to solve the needs of your county,” said Helgevold. “That’s what’s great about that chapter in the code.Wright County’s referendum has a five-year sunset on it. So, after five years it would require another vote on the ballot, it’s currently almost three years into implementation.Chapter six: Is there a solution?We’ve introduced a lot of problems in this series —staffing, funding, closing EMS departments and more.How about a solution from the EMS experts in the state?The current solution is Senate File 615, allowing individual counties to deem the service essential.“It’s the first time we’ve ever seen the words EMS and essential in the same sentence in the same paragraph in the same bill,” said Mark McCulloch, past president and current legislative chair for the Iowa Emergency Medical Services Association.SF615 allows the county board of supervisors to deem EMS essential and take a tax referendum to voters of their county. If that passes with 60% of the vote, they can use that tax to fund EMS. It also allows counties to create an advisory board to determine what the county needs, how much to ask for and recommend it to the county board.While no county has passed the full referendum quite yet, several are in the process, including Bremer County.But, it’s a tricky process, according to Bremer County Emergency Management Coordinator and Tripoli Ambulance Director Kip Ladage, who says ambulance districts blend through county lines across the state. Which, he says begs the following question.“Should the taxpayers of a county that have passed it be subsidizing EMS in a county that hasn’t passed it?” he asked.Ladage, and others in Bremer County are working through the process using SF615. “Ninety-nine different patches,” he said about the process. “If every county participates.”Ladage wants EMS to be designated essential across the state. “We’ve never had anybody say they disagree with us,” he added. “The issue is, even you may agree, but how are we going to do this? It’s going to take money, and it's going to take people. Right now, I don’t know how that’s going to happen.”Even if the funding backed up EMS as an essential service statewide, providers say they’re not sure the state would have enough EMS workers to keep up.“You could snap your fingers right now and say ‘here’s a billion dollars,’ and we still aren’t able to provide statewide EMS coverage because we don’t have the people,” said McCulloch.This is fixed, according to McCulloch, by giving EMS an identity, having more competitive pay and supporting EMS workers.“We really need to take a good hard look at what we’re asking our providers to do,” he said. “And pay them accordingly.”For volunteers, he says they need to find a way to incentivize or subsidize volunteering.“We need to make this a livable profession,” he added.The alternative is fewer employees, fewer volunteers and less help to serve you when you dial 911.“It’s important for people to get involved in their communities,” said Becky Hysell, who had to close the Allerton First Responders because there weren’t enough volunteers. “That’s how we stay alive.”Chapter seven: Missing one in four EMS calls Roger Gentz has heard the calls for EMS on his scanner, he's dialed 911 himself, but a call he made this spring is one that's become all too common in Worth County."We called the rescue 911 and we waited, ten to fifteen minutes, it seemed like an hour," he said from his front yard on the north side of Northwood, a small community near the Minnesota border.His daughter Brenda had kidney failure, and a minor stroke, while at his house."You would kind of watch what she was doing," he said. "Then come out here and look around and wonder 'where are they?'"After waiting, and no ambulance showing up, Brenda's sister rushed her to the hospital in Albert Lea, Minnesota, a 16-mile drive. After they left, Gentz went to the fire station and found two fire fighters. "They were fairly new firemen that really hadn't had the schooling," he recalled of the encounter. "So they were kind of waiting for one that was qualified."Gentz says he doesn't blame the volunteer system."As far as I'm concerned, we've got the most fine fire department in Worth County and in Iowa," he said.Brenda is okay today, but still has minor complications from the stroke, according to Gentz.More and more calls in Worth County are going unanswered because of fewer volunteers."There's a one in four shot your first responders are not going to show up," A.J. Stone said, Manly volunteer fireman and EMT and Worth County Supervisor.In those missed calls, even if a volunteer EMT doesn't show up, a transport ambulance from nearby Mason City will, but that takes time."Worth County in general has an average of 20 minutes and 13 seconds to get to the scene," said Carl Ginapp, Deputy Chief of EMS at Mason City Fire.Even if a Worth County ambulance from Manly, Northwood or any surrounding town shows up to a call, they can't legally take someone to the hospital. Worth County is the only county in the state without a transport service. "We are actually a paramedic-level service, we just don't transport," said Stone, referring to Manly Fire. "So, as long as we have paramedics on that call, we can administer necessary drugs needed until the ambulance can get here."If a Northwood EMT did show up to Gentz's call, it would still take a Mason City ambulance almost thirty minutes to drive the 22 miles to town. Northwood Volunteer Fire & Rescue Company Chief Blake Severson says via Facebook, the fire department has been dispatched to 231 calls for service so far this year (fire and EMS) and has responded to 226 of them, which adds up to a 98% response rate in 2022.County leaders, including Stone, are working to change that by deeming the service essential and raising taxes to properly fund EMS. The plan, if approved by voters in November, will bring a transport service to town in some capacity.The county board has until the end of August to figure out how much money the service will need before the referendum is up for a vote in November. It would also solve the problem Gentz experienced of no one showing up."Once people realize what little bit of money it is going to cost them to get that service, I think they're going to be okay," said Stone."I think most of the people, for what it'll raise our taxes, isn't going to bankrupt anybody," added Gentz.Worth County is one of a few across the state that are going through the process of deeming the service essential, others include Bremer, O'Brien, Guthrie, Winnebago and more. Chapter eight: Balancing staffing and service Calhoun County is one of many Iowa counties facing a funding problem. It thought it had the problem figured out, offering two 24-hour shifts each week to EMS workers who received full pay for those shifts.But, that all changed on Aug. 1, when the county reverted back to what it had before, cutting pay in half for EMS workers when they're sleeping overnight.Because of that, the county is losing workers."It's really a close-knit family," said Dallas Huddleson, sitting in the back of the ambulance he works in.Huddleson chose to leave the EMS family."I was going to have my salary cut by over $14,000 a year. We couldn't afford to do that," he added.Huddleson will take his paramedic skills to another nearby county because of the change in how he gets paid. He's not alone, on a staff of 14, two employees have resigned, another verbally stated they were switching jobs and a couple others say they're looking elsewhere for work."We had actually taken our help wanted sign down two months ago," said Kerrie Hull, Calhoun County EMs director. "We will be putting some back up again."During that sleep time, workers will revert back to the original way the county funded the program. A trial period to pay workers their full salary for all 24 hours in a shift was too costly, according to the county board."I wish that we could afford it," said board member Carl Legore. "In November of 2021, we were $200,000 over budget on EMS.""Overtime was extremely high, that really bumped up our budget for this past fiscal year," Hull said. "They did not want that to happen again. They were trying to find ways to decrease that amount."Fully staffed, Calhoun County has two ambulances ready to respond at any time. Now, it is down to just one once or twice per week."If I start losing more people, it's going to be almost impossible to have two full ambulances," Hull said."I also applaud Kerrie for her dedication to her people," Legore said. "We've put her in a hard place. We're in a hard place too because we have to delicately balance the budget with the wellbeing of the county."That balance could get a little easier if voters in November approve a tax referendum on the ballot. Using Senate File 615, the county board has deemed the service essential and is working on how much to ask for in a property tax referendum. "A positive vote is for your own safety," Legore said. "It's important. It should be an essential service. I'm confident that after the election it will be in Calhoun County."Until then, Hull and the ambulance service will work the difficult balance of staffing and service."Most of the calls are not life-threatening," she said. "They just need help. We'll make sure it's coming, one way or another, but it may take a little time."