Sarah Lewin parked a Ford Explorer with medical equipment outside her home even after she got off work. As one of only four paramedics covering the vast five counties of eastern Montana, she knows someone who has had a heart attack, serious car accident or needs life support and is more than 100 miles from the nearest hospital. Come anytime.

“I put in as many as 100 hours of overtime in two weeks,” said Lewin, the battalion commander for the Myers City Fire and Rescue Department. “Others eat more.”

Paramedics are often the most skilled medical providers among emergency responders, and their presence can make a life-saving change in rural areas where medical services are scarce. Nursing staff are trained in the field of skilled nursing, such as placing breathing tubes in blocked airways or decompressing collapsed lungs. Such procedures are beyond the training of emergency medical technicians.

But healthcare workers are hard to find, and the turnover and resignations associated with pandemic burnout have exacerbated chronic labor shortages.

Larger departments are trying to lure healthcare workers by raising wages and offering huge signing bonuses. But small teams in underserved counties across the U.S. don’t have the budget to compete. Instead, some rural workers are trying to train existing emergency responders for these roles, with mixed results.

Miles City is one of the few communities in rural eastern Montana that offers paramedic-level services, but the department doesn’t have enough paramedics to provide 24/7 care, which is why medical staff like Lewin Will answer the phone while on vacation. The team received federal grants so four staff members could become paramedics, but only two vacancies could be filled. Some potential clients turn down training because they can’t balance intense schedules with day-to-day work. Others don’t want the extra workload that comes with being a caregiver.

“If you’re the only paramedic, you end up taking more calls,” Lewin said.

What happened in Miles City is also happening nationwide. Those who work in emergency medical care have long given the problem a name: the paradox of the paramedic.

“Patients who need paramedics most are in rural areas,” said Dia Gaynor, executive director of the National Association of Emergency Medical Services Officers. But healthcare workers are often drawn to dense urban areas, where response times are faster, the drive to hospitals is shorter, and health systems are more advanced.

“Across the country, throwing darts on the map, it’s likely that any rural area is struggling with staffing, income, and access to training and education,” Gaynor said. “The list goes on.”

The Michigan Ambulance Service Association called the paramedic and EMT shortage a “full-blown emergency” and called on the state legislature to spend $20 million this year to cover the cost of recruiting and training 1,000 new paramedics and EMTs.

Earlier this year, Colorado reintroduced its standard of crisis care for understaffed emergency medical services workers who have had a growing need for ambulances amid a surge in COVID cases. The shortage is so severe that in Denver, a medical center and high school teamed up to offer classes through a nursing school to spark student interest.

In Montana, 691 licensed paramedics are treating patients in emergency situations, said Jon Ebelt, a spokesman for the Montana Department of Public Health and Human Services. More than half are in the state’s five most populous counties — Yellowstone, Gallatin, Missoula, Flathead and Cascade — covering 11 percent of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties do not have a licensed EMS paramedic.

One major issue is funding, said Andy Gienapp, deputy executive director of the National Association of Emergency Medical Services Officers. Medicaid and Medicare reimbursement for urgent care is generally lower than the cost of running an ambulance service. Most local teams rely on a patchwork of volunteers and staff, while the most remote places often live on volunteers alone and don’t have the funds to hire highly skilled carers.

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If these rural groups do find or train paramedics in-house, they are often poached by larger stations. “Health care workers are being pumped because once they have these skills, there is a market for them,” Genap said.

Gienapp would like to see more states consider urgent care an essential service, so its existence is guaranteed and taxes contribute. So far, only about a dozen states have done so.

But state-level action doesn’t always guarantee the budget EMS workers say they need. Last year, Utah lawmakers passed a law requiring cities and counties to ensure at least a “minimum level” of ambulance service. But lawmakers haven’t allocated any money to comply with the law, and the added cost — estimated to be as high as $41 per resident a year — is left to local governments to calculate.

Andy Smith, a paramedic and executive director of Grand County Emergency Medical Services in Moab, Utah, said at least one town his staff serves would not contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said finding and keeping crews to cover the land is an ongoing struggle.

Smith said his team was lucky – it had several paramedics, partly because of the interest in the nearby national park, and because the ambulance service helped staff pay for paramedic certification. But even those perks haven’t attracted enough candidates, and he knows some will be lured away. He recently saw a nursing job in nearby Colorado with a starting salary of $70,000, which he said he couldn’t match.

“There is an expectation from the public that if something happens, we always have an ambulance available, we’ll be there in a few minutes, and we have trained people,” Smith said. “The reality is that when funding is scarce and it’s hard to find and retain talent, that’s not always the case.”

Despite staffing and budget constraints, state leaders often see first responders as filling gaps in basic health care in rural areas. Montana is one of the states trying to expand EMS work to non-urgent and preventive care, such as having medical technicians meet with patients at home for wound treatment.

A private ambulance provider in Pod River County, Montana, agreed to provide these community services in 2019. But the owner has retired and the company has closed. The county began providing emergency services last year, and Magistrate Lee Randall said providing essential health care has been put on hold. The immediate priority is to hire a paramedic.

It is possible to advance care that EMT staff can perform without a caregiver. Montana’s EMS systems manager Shari Graham said the state has created certifications for basic EMT to provide higher levels of care, such as initiating IV lines. The state has also increased training for rural communities so volunteers can avoid traveling there. But these steps still leave a gap in advanced life support.

“You don’t actually have paramedics in those rural areas where there is no income,” Graham said.

Back in Miles City, Lewin said her department may extend the training of more paramedics next year. But she wasn’t sure she could fill the void. She had several new EMT employees, but by then they weren’t ready to be certified as a paramedic.

“I’m not interested in anyone,” Lewin said. Now, she will have first aid equipment in her driveway and be ready to go.

Kaiser Health News is a national health policy news service. It is an independent editorial project of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.