For more than 30 minutes on a frigid February morning, Robert Findley lay unconscious in the back of an ambulance as paramedics hand-pumped oxygen into his lungs.
They were waiting for a helicopter to land at a helipad just across the icy parking lot next to Mercy Hospital Fort Scott, which closed in December. The night before, Findley had fallen on the slick driveway outside his home while checking the mail. He had laughed it off, ate dinner and went to bed.
In the morning, he wouldn't wake up. Linda, his wife, called 911.
When the Fort Scott, Kan., paramedics arrived, they suspected he had an intracerebral hemorrhage. Robert Findley needed specialized neurological care and the closest available center was located 90 miles north in Kansas City, Mo.
After rural hospitals like the one in Fort Scott close, one of the thorniest dilemmas communities face is how to provide emergency care, particularly for patients who require specialized expertise. In times of crisis, the local emergency workers can find themselves dealing with changing leadership, budgets and questions about where to take patients. Air ambulance companies are often seen as a key part of the solution.
The dispatcher for Air Methods, a private air ambulance company, checked with at least four bases before finding a pilot to accept the flight for Robert Findley, according to a 911 tape obtained by Kaiser Health News through a Kansas Open Records Act request.
"My Nevada crew is not available and my Parsons crew has declined," the operator tells Fort Scott's emergency line about a minute after taking the call. Then she says she will be "reaching out to" another crew.
Nearly seven minutes passed before one was en route.
When Linda Findley sat at her kitchen counter in late May and listened to the 911 tape, she blinked hard: "I didn't know that they could just refuse. ... I don't know what to say about that."
Both Mercy and Air Methods declined to comment on the case.
When Mercy Hospital Fort Scott closed at the end of 2018, hospital president Reta Baker had been "absolutely terrified" about the possibility of not having emergency care for a community where she had raised her children and grandchildren and served as chair of the local Chamber of Commerce.
Now, just a week after the ER's closure, her fears were being tested.
Nationwide, more than 100 rural hospitals have closed since 2010, and in each instance a community struggles to survive in its own way. In Fort Scott, home to 7,800, the loss of its 132-year-old hospital opened by nuns in the 19th century has wrought profound social, emotional and medical consequences. Kaiser Health News and NPR are following Fort Scott for a year to explore deeper national questions about whether small communities need a traditional hospital at all. If not, what would take its place?
A delay in emergency care can make the difference between life and death. Seconds can be crucial when it comes to surviving a heart attack, a stroke, an anaphylactic allergic reaction or a complicated birth.
Though air ambulances can transport patients quickly, the dispatch system is not coordinated in many states and regions across the country. And many air ambulance companies do not participate in insurance networks, which leads to bills of tens of thousands of dollars.
Knowing that emergency care was crucial, the hospital's owner, St. Louis-based Mercy, agreed to keep Fort Scott's emergency doors open an extra month past the hospital's Dec. 31 closure, to give Baker time to find a temporary operator. A last-minute deal was struck with a hospital about 30 miles away to take it over, but the ER still needed to be remodeled and the new operator had to meet regulatory requirements. So, the ER closed for 18 days — a period that proved perilous.
A risky experiment
During that time, Fort Scott's publicly funded ambulances responded to more than 80 calls for service and drove more than 1,300 miles for patients to get care in other communities.
Across America, rural patients spend more time in an ambulance than urban patients after a hospital closes, said Alison Davis, a professor at the University of Kentucky' department of agriculture economics. Davis and research associate SuZanne Troske analyzed thousands of ambulance calls and found the average transport time for a rural patient was 14.2 minutes before a hospital closed; afterward, it increased nearly 77% to 25.1 minutes. For patients over 64, the increase was steeper, nearly doubling.
In Fort Scott this February, the hospital's closure meant people didn't "know what to expect if we come pick them up," or where they might end up, said Fort Scott paramedic Chris Rosenblad.
Barbara Woodward, 70, slipped on ice outside a downtown Fort Scott business during the early February storm. The former X-ray technician said she knew something was broken. That meant a "bumpy" and painful 30-mile drive to a nearby town, where she had emergency surgery for a shattered femur, a bone in her thigh.
About 60% of calls to the Fort Scott's ambulances in early February were transported out of town, according to the log, which KHN requested through the Kansas Open Records Act. The calls include a 41-year-old with chest pain who was taken more than 30 miles to Pittsburg, an unconscious 11-year-old driven 20 miles to Nevada, Mo., and a 19-year-old with a seizure and bleeding eyes escorted nearly 30 miles to Girard, Kan.
Traveling those distances can harm patients' health when they are experiencing a traumatic event, Davis said. They also prompt other, less obvious, problems for a community. The travel time keeps the crews absent and unable to serve local needs. Plus, those miles cause expensive emergency vehicles to wear out faster.
Mercy donated its ambulances to the joint city and county emergency operations department. Bourbon County Commissioner Lynne Oharah said he's not sure how they will pay for upkeep and the buying of future vehicles. Mercy had previously owned and maintained the fleet, but now it falls to the taxpayers to support the crew and ambulances. "This was dropped on us," said LeRoy "Nick" Ruhl, also a county commissioner.
Even local law enforcement feel extra pressure when an ER closes down, said Bourbon County Sheriff Bill Martin. Suspects who overdose or suffer split lips and black eyes after a fight need medical attention before getting locked up — that often forces officers to escort them to another community for emergency treatment.
And Bourbon County, with its 14,600 residents, faces the same dwindling tax base as most of rural America. According to the U.S. Census, about 3.4% fewer people live in the county compared with nearly a decade ago. Before the hospital closed, Bourbon County paid Mercy $316,000 annually for emergency medical services. In April, commissioners approved an annual $1 million budget item to oversee ambulances and staffing, which the city of Fort Scott agreed to operate.
In order to make up the nearly $700,000 difference in the budget, Oharah said the county is counting on the ambulances to transport patients to hospitals. The transports are essential because ambulance services get better reimbursement from Medicare and private insurers when they take patients to a hospital as compared to when they treat patients at home or at an accident scene.
Added response times
For time-sensitive emergencies, Fort Scott's 911 dispatch calls go to Air Methods, one of the largest for-profit air ambulance providers in the U.S. It has a base 20 miles away in Nevada, Mo., and another base in Parsons, Kan., about 60 miles away.
The company's central communications hub, known as AirCom, in Omaha, Neb., gathers initial details of an incident before contacting the pilot at the nearest base to confirm response, said Megan Smith, a spokeswoman for the company. The entire process happens in less than five minutes, Smith said in an emailed statement.
When asked how quickly the helicopter arrived for Robert Findley, Bourbon County EMS Director Robert Leisure said he was "unsure of the time the crew waited at the pad." But, he added, "the wait time was very minimal."
Rural communities nationwide are increasingly dependent on air ambulances as local hospitals close, said Rick Sherlock, president of the Association of Air Medical Services, an industry group that represents the air ambulance industry. AAMS estimates that nearly 85 million Americans rely on the mostly hospital-based and private industry to reach a high-level trauma center within 60 minutes, or what the industry calls the "golden hour."
In June, when Sherlock testified to Congress about high-priced air ambulance billing, he pointed to Fort Scott as a devastated rural community where air service "helped fill the gap in rural health care."
But, as Robert Findley's case shows, the gap is often difficult to fill. After Air Methods' two bases failed to accept the flight, the AirCom operator called at least two more before finding a ride for the patient. Air ambulances can be delayed because of bad weather or crew fatigue from previous runs.
The 1978 Airline Deregulation Act states that airline companies cannot be regulated on "rates, routes, or services," a provision originally meant to ensure that commercial flights could move efficiently between states. Today, in practice, that means air ambulances have no mandated response times, there are no requirements that the closest aircraft will come, and they aren't legally obligated to say why a flight was declined.
The air ambulance industry has faced years of scrutiny over accidents, including investigations by the National Transportation Safety Board and stricter rules from the Federal Aviation Administration. And Air Methods' Smith said the company does not publicly report on why flights are turned down
because "we don't want pilots to feel pressured to fly in unsafe conditions."
Yet, a lack of accountability can lead the mostly for-profit providers to sometimes putting profits first, Scott Winston, Virginia's assistant director of emergency medical services, wrote in an email. Sometimes companies accept a call knowing their closest aircraft is unavailable, rather than lose the business. "This could result in added response time," he wrote.
Air ambulances don't face the detailed reporting requirements imposed on ground ambulances. The National Emergency Medical Services Information System collects only about 50% of air ambulance events because the industry's private operators voluntarily provide the information.
It took months, but Baker persuaded Ascension Via Christi's Pittsburg hospital, to reopen the ER. "They kind of were at a point of desperation," said Randy Cason, president of Pittsburg's hospital. The two Catholic health systems signed a two-year agreement, leaving Fort Scott relieved but nervous about the long term.
Ascension has said it is looking at potential facilities in the area, but it's unclear what that means. Fort Scott Economic Development Director Rachel Pruitt said in a July 23 email, "No decisions have been made." Fort Scott City Manager Dave Martin said the city has entered into a "nondisclosure agreement" with Ascension. Nancy Dickey, executive director of the Texas A&M Rural & Community Health Institute, said every community prioritizes emergency services. That's because the "first hour appears to be vitally important in terms of outcomes," she said.
And the Fort Scott ER, which reopened under Ascension on Feb. 18, has proved its value. In the past six months, the Fort Scott emergency department has taken care of more than 2,500 patients, including delivering three babies. In May, a city ambulance crew resuscitated a heart attack patient at his home and Ascension's emergency department staff treated the patient until an air ambulance arrived.
In July, Fort Scott's Deputy Fire Chief Dave Bruner read a note from that patient's grateful wife at a city commission meeting: "They gave my husband the chance to fight long enough to get to Freeman ICU. As a nurse, I know the odds of Kevin surviving the 'widow-maker' were very poor. You all made the difference."
By contrast, Linda Findley believes the local paramedics did everything possible to save her husband but wonders how the lack of an ER and the air ambulance delays might have affected her husband's outcome. After being flown to Kansas City, Robert Findley died.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.