- This is a production of - SDPB EMS as a whole in the United States is like on the brink a collapse.

- EMS nationwide is in a death spiral.

We just are.

there are ambulance services - There are ambulance services in our state that are shutting down.

- Without EMS, without emergency services, you know, people will die.

- Ambulance services are struggling to respond to more calls with smaller staff.

And lawmakers struggle to create policy that supports a service no one hopes they need.

That's tonight's South Dakota Focus.

- This is our main bay area where we, where we put all our ambulances.

So we have a four staff, our four garage bay with three staffed ambulances.

Right now we are, staffing goal is to have between three and four ambulances per shift.

We run 24 hour shifts at a time.

So tend to have a minimum of six people on if shift and then eight.

If we are able to staff that fourth truck, - Can we see one of the ambulance?

- Sure.

Crystal will definitely show you an ambulance.

- What's going on?

- Yeah, so this is just one of my ambulances.

We have what's called a Stryker Power Load, which is a auto loading stretcher device.

What these do is it, they auto load up and down so we don't have to lift the patients back and forth each into the ambulance, which have saved our responders backs, you know, done a lot to, to decrease - Back injuries.

Eric Emery is a paramedic and program director of the Rosebud Ambulance Service.

It covers Todd and Mellette counties, roughly 2000 square miles in rural south Central South Dakota.

- We typically run about 10,000 calls a year.

A mixture of those calls are, are ill illnesses, you know, chest pain, difficulty breathing, abdominal pain, diabetic emergencies, um and traumatic injuries, you know, breaks of bones, car accidents, drownings, you know, you know, we've seen, well this, particularly this summer, we've seen a lot of drownings.

- It's a big lift for a relatively small team.

- You know, I think I only have really about 16 full-time staff members and the rest are either part-time or PRN.

So we kind of plug it, plug them into our schedule as the best we can.

- Is that sustainable to you?

- It is not.

That's not sustainable.

That's very hard.

It's, it's hard on me and this administrator and it's hard on our staff as well.

It leads to burnout and I think that's a lot of what we're seeing through entire, throughout the entire state.

Because this isn't just singular to Rose, but - What, what do you see the bottlenecks as being for, for bringing on full-time staff?

- The pay, you know, our reimbursement in South Dakota from specifically for Medicaid is so low that if we were to have to fully be supported by Medicaid, we would close our doors.

It would, it's impossible.

Medicare, the same token, you know, Medicare is about 60% reimbursement of cost.

You know, you pair the two you, you might be able to get by.

Because we have such a huge response area, a lot of our cost goes to fuel and mileage and maintenance of our vehicles - Adequately staffing and financing EMS is a complex and widespread challenge a couple hundred miles away.

Spearfish Ambulance Executive Director, Brian Hambeck faces similar struggles.

- Alright, so this is our office in a sense.

We have most of the same capabilities for first for initial care of a trauma or medical patient as an ER does, especially with our paramedics.

The advantage to the hospital is they have well lit rooms and physicians and nurses there.

So, and they aren't bouncing down the road at 80 miles an hour in some cases.

So people wonder about the costs and just to give a little bit of an idea here.

AEDs out on the streets or on the markets or in businesses or whatever, average in price, about $1,500 to $2,000.

Our monitor there is $36,000 just for one monitor.

That's the cost of a car, you know, so the cots are power lift and it'll lift up to 700 pounds with the push of a button.

These cots are about $18,000 a piece.

The truck alone was $200,000.

Just the truck.

You start adding up this bag of stuff and the cot and the defibrillator, you're talking in probably another 80 to $90,000 of equipment that goes into this.

- Three years ago, his operations submitted data for a federal cost study.

- And they found out that Medicare is reimbursing about 55% of what it costs us to run an ambulance.

55%.

You know, no wonder agencies are closing.

They can't make it, you know, and as our population grows older, they rely more on that Medicare funding and if the funding isn't there, then what do we do?

And if you think of COVID happening, the cost of supplies, a box of gloves used to cost me $8.

When COVID hit, it was 24 bucks.

So my cost tripled in some cases on supplies.

The cost of crews went up.

A lot of our volunteer staff said, you know what, I don't want to take the risk of bringing this home.

And they quit.

So I had to hire all full-time at that point.

So there goes my wages up and the insurances to include Medicare, Medicaid, and the private insurances did not compensate.

They did not go up with it.

So that's why you're seeing nationwide financial drain on EMS.

- Hambeck has nearly 45 years of experience in emergency medicine.

He's also president of the South Dakota Ambulance Association like Eric Emery in Rosebud.

He's worried about the future of emergency medical services.

If something doesn't change.

- EMS nationwide is in a death spiral.

We just are, without people, without being able to pay people appropriately, there's no way we can keep our lights on and the doors open.

So then what happens?

Well then we go back to the days before an ambulance service and the coroner taking the call.

Is that what our public wants?

Is that what our public needs?

People want an ambulance available, but they don't want to pay for it.

- Many people assume their taxes support ambulance services in the same way they do law enforcement and firefighters.

That's not necessarily true.

Counties are not required to provide an ambulance service under state law and there is no statewide funding mechanism for ambulances either.

Each service operates a little bit differently, but almost all of them are struggling.

- Well, it all started with the way we were put together.

- Maynard Konechne is the Kimball Ambulance Director.

He's in his 51st year as an emergency medical technician or EMT.

He represents South Dakota in the National EMT Association and lobbies for the industry part-time in the state capitol in Pierre.

- Before ambulances were in South Dakota here, basically the ambulance was the local mortician and he would pick up the patient and maybe do a little patient care, but if they didn't make it, they went right to the hos... , to the morgue.

If they made it, they went to the hospital.

They finally decided they weren't going to do that anymore.

They didn't like the blood and guts in their new hearses.

- By the mid 1960s, the federal government standardized training for EMTs.

- EMS started as a grassroots type of thing through communities, nationwide.

Small groups of people within the community decided they'd get first aid trained and EMT trained and start an ambulance service.

But there was no set funding mechanism back in the sixties and seventies for that.

- And communities just stepped up, begged, borrowed, and stole to get where we are today.

But with the way things are today, we can't do that anymore.

We have 638 square miles, which consists of a corner of Gerald County, little bit of Buffalo County and part of the reservation by Fort Thompson and most of the eastern part of Brule County.

All the way to the Charles Mix County line.

- How roughly how big is your staff?

- 10 plus my fire department are all trained to drive our ambulance.

So we have drivers, we just have 10 EMTs and four of the four of them live at least 10 to 20 miles from town.

- And those 10 EMTs are all volunteers.

A 2023 report from the Department of Health found most South Dakota Ambulance services are essentially staffed by volunteers who receive some reimbursement for each call.

Volunteering was the foundation of emergency medical services, but that foundation has started to crumble.

- Back in the eighties and early nineties, I had 60 people on my staff as volunteers.

They were paid so much per call and people actually enjoyed volunteering and doing the job.

But our call volume was also four or five, 600 calls a year.

Now we're closing in this year on 3000 a year.

People can't volunteer for that.

- More rural ambulance services with fewer calls are still stretched too thin to survive on a volunteer workforce alone.

Sherry Hocking is the Newell Ambulance Director, an all volunteer service in a sparsely populated area of Northwestern South Dakota.

- So we have a huge range.

We're about, I wanna say 12 to 1400 square miles.

We go up to Harding County going north.

We cover a little bit into Mead County East on two 12.

We go south to the Meade Butte County line and then we go over to Ormand Dam - Hawking says 10 years ago they averaged fewer than 90 calls a year.

Now they respond to around 250 calls a year, scattered across a thousand square miles of remote country.

And it's not uncommon for her team to spread out even when other services close their doors, - People burn out of what we're doing.

And so like with Enning and Bison, they just got down to just a couple of staff members.

Those staff members got burned out because you have to cover 24 hours a day, seven days a week, 365 days a year.

And they couldn't leave.

They couldn't go do anything.

They had no life and they just are like, we're done.

And so they closed their doors, thank goodness, through holding classes and doing what they needed to do.

Both of them were able to open back up.

But I think we covered for Enning for almost three years, trying to get them back where they were on firmer footing and could open their doors back up.

So it's a huge loss to a community to lose your ambulance service.

But people like, it's one of those things like people don't really care until you need an ambulance.

- It's a catch 22, EMS staff numbers are dwindling largely because they're underpaid, assuming they're paid at all.

But the overhead costs of running an ambulance service make it impossible to raise wages.

It's become increasingly clear that this isn't only a financial issue, it's a policy issue.

That's a big reason Eric Emery decided to run for office a few years ago.

- I never really was into the state politics, but in recent years following COVID, I really took an interest to it and I seen that we, we needed to do something here in District 26 and specifically in for EMS in the entire state of South Dakota.

I was on the national EMS Advisory Council to the Department of Transportation from 2015 till 2021.

And one of the things that I've seen was the innovation of making EMS an essential service.

- There's no uniform approach to making emergency medical services essential, but a handful of states around the country have passed some sort of legislation.

The idea is that state legislatures can decide to make somebody responsible for supporting EMS.

In the 2025 legislative session, Representative Emory brought House Bill 1043.

It required counties and municipalities to provide EMS in their jurisdictions and directed some money from court fees toward a grant fund.

- Initially it was gonna cost upwards of around $50 million to get it off the ground.

I knew that was an unrealistic ask from the taxpayers of South Dakota.

So working with the LRC, you know, we were able to get it down to a million dollar seed fund that the Department of Health would give out in form of grants to the various EMS agencies throughout the state.

- But any new funding was a hard sell in this legislative session.

Local government groups opposed what they saw as an unfunded mandate to provide a service.

The bill failed, but it succeeded in bringing broader attention to the issue.

- So it opened those eyes and it brought a summer study.

- An interim or summer study brings lawmakers together to learn more about an issue and propose solutions.

Emory is one of nine members of the emergency medical services interim committee.

The group is tasked with addressing several issues around ambulance services from staffing and reaching remote areas to identifying resources, operations need to continue.

And they have three meetings to do it.

During the first two meetings, lawmakers stepped inside an ambulance with telemedicine capabilities.

Longtime first responders like Brian Hambeck and Maynard Konechne offered their testimonies along with other healthcare experts.

One county commissioner from Yankton joined remotely to share the financial burden their county run ambulance has become.

Representative Jana Hunt and Senator Tim Reed are co-chairs of the committee.

Midway through the second meeting in July, they led a discussion with other members.

- The whole idea of being essential to me is where we say somebody has to be responsible for it.

And I believe in local is the best.

But now I don't know if we should do it all the way down to the, literally down to the ambulance.

- But the idea of legally requiring ambulance services becomes a non-starter.

- Cause you've got two counties within that district that don't even have ambulance services to date.

Two, two, I live in one of those.

My county commissioners would skin me alive.

- They don't want to be forced to have an ambulance or they don't want to be forced to be responsible.

Or do you think the issues would be with them?

- I think the geographic location the ambulance calls for, say Stanley, you get a lot of people come over from Hughes County, you get a lot of people that come up from Midland and and Pierre.

And then you get a lot of people that live in the boondocks that have kind of accepted life.

If they have an accident, they pray.

And that at least that's kind of the makeup of my county commission board in, in Ziebach County.

Not that it's not worth the fight, but it will be a fight from, from some of these western counties if you're gonna start telling them unfunded mandates.

I'm on the property tax committee too, that's all of these county commissioners are coming to the property tax task force and saying we are sick and tired of unfunded mandates.

Quit giving us unfunded mandates.

So we're, we're listening to this in one committee and then we're gonna come from another committee and say, here's another unfunded mandate.

The the big issue in this committee is funding.

- There's some discussion of funneling money from DUI and other fees toward EMS before the committee adjourns.

Representative Emery had taken a similar approach in his bill to create a grant fund.

- And I think that's still a good starting point to go off of.

And I think that's a lot of what our services throughout the state need when it come, when we talk about ambulances.

But the biggest issue is recruitment and retention.

Just getting, whether that's a paid service of volunteer services, just getting those people in the seats of ambulances and to take care of a citizens when we talk about EMS.

That's gonna be the biggest hurdle to, to really tackle.

And then how do we keep those services their doors open?

- I think one of the major things that came out in, in the discussion was, well this is a tough year to be talking about any kind of property taxes right.

We do have ambulance districts.

It's basically a property tax and, and people are saying they're so tired of property taxes.

And we got a committee that's looking at how to reduce 'em.

And then we got another committee that's talking about increasing them.

I think everybody agreed that they, that you know, people want this service to be available.

But there's just so much kind of political around so much politics around property taxes that we weren't real comfortable with using property taxes.

It's still there.

Ambulance districts can be used.

I'm a big proponent of letting counties or, or the districts kind of decide how best to operate.

But the whole funding aspect, we had to start looking at different sources than property taxes.

- Ambulance districts are a way for communities to create a tax base for EMS through a special election process.

That process is outlined in state law.

The Mitchell Fire and EMS department recently led the charge to create an ambulance district for Davison and Hanson counties.

Dan Pollreiz is the Mitchell Fire chief.

He says this was the only way to continue serving communities outside Mitchell City limits.

- So we have minimum staffing here.

So we have to keep a minimum staffing of six people here at all times.

So if we're at minimum staffing and we send an ambulance out of town, that means now we only have four people here.

So now we're calling in off-duty people and people have lives outside of work, you know, so what was happening is the station is you getting left empty.

The town is unprotected because we'll run a call out of town and then we will catch a call in town.

Now we're down to two people now we caught another call.

Now we don't have anybody here and the station's completely empty.

So what do you do?

What do you, you know who doesn't get the ambulance?

At the end of the day?

Last year, the longest wait time for somebody due to multiple calls, somebody in town to get an ambulance was 34 minutes.

Something has to change.

We either have to hire more people to continue to service 750 square miles and, you know, 8,000 population outside the city limits that's receiving these services or we're gonna have to stop doing it and focus on the city because it's a city service - That didn't sit well with him.

Especially because he and his family live outside the city limits.

The same is true of Amy Storm, who works part-time as an EMT for both Mitchell and Ethan.

She and Dan got to work rallying support for a new ambulance district to fund additional staffing.

They invited county commissioners, city councilmen, firefighters and others to a meeting.

- So that very first meeting we brainstormed quite a bit, how can we get word out?

I think it was a general consensus of, yeah, we need to do it.

I didn't feel like it was any opposition in the room.

I felt like more like it was just explain it to us again.

How does this work sometimes, let me wrap my head around this.

The whole concept of not any essential service.

I did not even realize that until we started this whole process.

So when we started talking about that side of it and that process, then you get the word out a little bit.

And I'll be honest, there'll be a lot of people that were saying, oh, come on, you really can't not come out there.

Like, yeah, unfortunately there is no law that's doing that.

- You can either do a resolution to move this forward or we have to do petitions.

And Davison and Hansen Counties both did resolutions saying, yep, let's move this forward.

We, we see the need for it.

And that's where it all started.

- And another common question was, we already do all of our business in the town of Mitchell or the city of Mitchell, so now I have to pay more and they're getting all my business.

And I, I understand those concerns 'cause it's legitimate questions.

But once you kind of explain the trickle down of your tax dollars and how much sales tax comes and then the trickle down of how much actually comes to fire, EMS, you know, it is a sliver of the budget that the city has to work with.

And so once we explained that, it was a little more swallowable if you wanna call it that.

But then the other side was that is not, they're not asking for new ambulances, they're not asking for new buildings, they're not asking for anything.

They are asking, help us hire six more people so we can keep going outside the city limits for the calls that come in with it.

- After six months of informational meetings and spreading the word, the counties held a special election, it was up to the public to say yes or no to the ambulance district.

A yes vote would pave the way for another election of board members who would have just a few weeks to decide on a budget and funding process.

Chief Pollreiz and Amy Storm were anxious.

They understood the stakes.

If the public said no, - The services around us are already maxed out to their limits, they're not able to come and help us.

And so in Ethan, we truly talked about we will not take medical calls anymore.

I'm like, we can't, I can't handle that.

I go, I can't handle holding my neighbor's hand every time and seeing the things that they do without an ambulance coming - Through the town halls and through the questions and the phone calls and people stopping by it, it was difficult to hand that over knowing that I only get to vote the same as everybody else and I don't get to necessarily make the call.

And that's, that's tough because in our profession and especially me as the chief, it's my job to solve those problems.

It was a very stressful day to begin with.

And then as we meet and we're waiting around and we're eating pizza or trying to eat a slice of pizza, yeah, it was difficult.

And then, you know, my wife stopped, she's on the town board and Ethan and she stopped and she said after they counted and said, are we close?

And it was a blowout.

- The yays had it by 94%.

- The very next day I was getting texts and phone calls from people first congratulating us and second saying, we need some help here.

Can we get the information?

Can you help us figure out how we can start this process?

And it's been from small services to big cities.

- People said that, well you did a great job because you know, you got it out there with a 95%.

And I said, you guys, this is something I'm passionate about as far as like it's an ambulance service.

I'm not out here selling peanut butter jelly sandwiches.

I'm here to get an ambulance for my neighbors.

Honestly, for us out there, when we get the calls on our service, I said, when we get the fire calls out, Ethan, I need an ambulance.

- The tax dollars raised from the new ambulance district will support salaries for six additional EMTs.

Chief Pollreiz expects them to be on board by January.

The ambulance district process worked out for them, but he doesn't think it's the answer to saving EMS across the board.

- Obviously I think it needs to be essential.

I can't imagine you call 9-1-1 and they say, sorry, no one's coming.

And it, and it's happened.

I've seen body camera footage, not from our state, but from police officers going, no one's coming.

So let's help grandma get grandpa in the car so she can get into the hospital.

And I can't imagine being on the other end of that line, right?

I can't imagine being the dispatcher to take a 9-1-1 call and say, sorry the ambulance service is closed today.

It's Carthage is just up the road.

And they made national news saying if we don't get help, we're shutting the doors.

Lyman County said, if we can't get people to take the EMT course and pass the certification, you might not have an ambulance between Chamberlain and Murdo.

You know, I mean it's just, it's unthinkable.

The majority, the vast majority of what we do, 87% of what we do out of this building is EMS.

It's not fire.

We've done a good job on the fire side of putting ourselves out of business.

We educate people all the time on fire prevention and on the EMS side, I can't make you any healthier.

I can't decide what you get to eat.

I can't tell you to put your phone down and don't text while you're driving 80 miles an hour down interstate.

I can't do those things.

We can only respond to 'em.

So ambulance calls are gonna continue to go up.

- Pollreiz knows the ambulance district hasn't solved all their problems, but it's a start.

- We lose over a million dollars a year operating our ambulance service alone.

And we'll the city will continue to lose that money because the district's not making up for that.

It's to hire more people.

95% of the people in in this district were saying yeah, let's spend a little extra money and help ourselves, help our families, help our friends, help our neighbors and, help the strangers that we're never gonna meet.

But hopefully it'll help save a life at some point.

- As for broader policy solutions, the Emergency Medical Services interim committee meets for a third and final time in October.

The group will approve a final report on the issue to share with legislative leadership.

- Hopefully that'll give us some ways of here's how we should go forward in the future.

You know, maybe some recommendations for Department of Health or the or or the, the Board of Medicine.

And, but also after we're working through that, then we should have some legislative bills and such that we think we can maybe can pass.

And so that third meeting, we're gonna be working through those.

There might be some on the fly editing so we can actually, you know, carry those forward to the executive board and see if those are ones that we're gonna put forth in the next session.

- Time will tell what those bills might be, but Eric Emery is confident some help is coming from the State House.

- There will be some solution that will come from this committee.

I think that we have a good group of legislators that are committed to coming up with some answers.

Will they solve everything next year in session?

Most likely not, but I think this is a good stepping stone to continuing the discussion for years to come to really hone in what we need here in South Dakota.