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Long country roads and a small, aging volunteer staff have been the norm for rural Virginia’s emergency medical services for years. But the current COVID-19 outbreak has the potential to stress staffing further, jeopardizing EMS providers’ ability to respond to other emergency calls.

“That’s our biggest concern. If one of our members were exposed on a call and we had to quarantine some of our members, it could put a very big strain being able to respond to calls,” said Robby Ross, chief of the Church Hill-Five Forks Volunteer Fire Department in North Carolina’s Warren County and serves part of Mecklenburg County, Virginia, in the Lake Gaston area.

Of Virginia’s 582’s EMS agencies, 302 are licensed as volunteer, according to the Virginia Department of Health. Those are typically more concentrated in rural areas, as paid staff gravitate towards larger towns, cities and counties, say county officials and advocacy groups.

Toby Akers of the Virginia Association of Volunteer Rescue Squads said that, like all over the health care system, access to personal protective equipment like masks and face shields is the most pressing issue for rural EMS services, but the makeup and age of rural EMS staff is a major concern as well.

“Another big hurdle is some of the volunteer or paid staff have underlying conditions [that make them susceptible] to COVID-19 or family members that are susceptible,” he said.

As EMS services try to keep their older staff away from likely COVID-19 cases, agencies are worried it could tighten staffing and expose younger first responders as they treat and transport patients with respiratory issues, a problem compounded by the widespread shortage of protective gear.

Rob Logan, executive director of the Western Virginia EMS Council, is responsible for distributing PPE from the state of the Virginia and the Strategic National Stockpile. He said his organization didn’t get nearly enough supplies.

“We didn’t come even close,” he said. “We received about 2,000 N95 masks. That’s just a drop in the bucket for what’s going to be needed.”

Logan says PPE is important for all EMS providers, not just the older staff with higher risk or with family members that are higher risk. “From a personal health perspective they’re more likely to have a bad outcome but from a public health standpoint, if you lose a provider you lose a provider.

“We received almost no gloves,” he said. “And our EMS providers, they have to wear new gloves on every call.”

Wythe County, with a population of about 28,700, has eight emergency departments, five of which are volunteer. Equipment wasn’t a huge issue for the small county but when officials attempted to prepare in case of an extended outbreak, they had trouble procuring more. 

“We were somewhat prepared,” said Curtis Crawford, the county’s emergency services coordinator.

Wythe County initially received very limited supplies (including just a single gown) from the Strategic National Stockpile, Crawford said, suggesting the smaller county wouldn’t be a high priority for state health officials because of its low number of confirmed cases. 

“That being said, we put in requests for PPE for other people who might be [going into] in homes,” he said. 

Since then, Wythe County received more supplies and is set to receive another shipment this week. 

“As rural as we are, and as isolated, we’re going to be the end of the game anyway. We can’t complete with Fairfax, Virginia Beach, or Richmond,” Crawford said.

The county’s first four cases were travel-related, but now it has 10 cases, including one death, as of Tuesday. Five people have recovered.

Rural areas’ low-density helps slow the spread of COVID-19, but that distance between homes, hospitals and ambulance stations poses another problem for rural EMS agencies. 

“When you look at rural EMS, a lot of time is spent transporting from home to hospital,” said Lisa Dodd, VCU Health’s operational medical director for the systems’ partner EMS agencies. VCU started a telehealth pilot-program with three rural EMS agencies to try to reduce unnecessary trips from patients homes’ to hospitals and free up time to respond to other calls. 

“The average time to a patient’s home in these three rural agencies can be between 15 minutes and close to an hour. A call can last between one hour to three and a half hours, depending on how much time they spend in the [patient’s] home,” she said. 

Logan, of the Western Virginia EMS Council, said in some counties it’s normal for a call to last three hours. 

With the spread of COVID-19 across the state and country, rural counties without confirmed cases are often located near counties with infections. But after the stay-at-home order, the risk of the importation of cases from harder-hit urban areas rose as well. 

 “We had a large influx of people coming into their lake homes,” said Ross, the chief of the North Carolina volunteer fire department that serves southern Virginia. Every county surrounding his already has a COVID case and he worried more could be coming, as people adhere to the stay at home order in their second homes. 

Ron Hicks, a board member of the LKG 911 Task Force, an advocacy group seeking to improve rural emergency services, sees the problems facing rural EMS as indicative of bigger issues. 

“If you’re paying attention to the virus, you almost by definition touch on the same issues as the challenges rural America has with 911 services,” he said. “Our preparedness for the virus has been affected by how prepared we are to have a responsive public health system.”

The pandemic also results in constantly shifting guidance from state and federal health officials, particularly taxing for volunteer EMS providers, who have other time commitments that compete with the time needed to follow up on the new protocols. And the new coronavirus might change rural EMS provision permanently. 

“They are fluid documents, it’s very difficult for the career provider, not just the volunteer to follow,” said Logan. “This new coronavirus protocol will become a new infectious disease protocol that will change the way we respond to these types of illnesses forever. “