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GROVETON — Among the tall pine trees of Davy Crockett National Forest sits a stretch of road David Robison calls “the dead zone.”
There is no cellphone service for miles, and there are few signs of civilization on this remote section of highway. It lacks safety precautions like shoulders or guardrails that are ubiquitous on more urban highways.
So when Robison receives a dispatch from the sheriff’s office about a car wreck in the dead zone, he hops in his ambulance and prepares for a challenge.
“A lot of times we try to call a hospital but we can’t reach them,” said Robison, who operates Groveton Emergency Medical Services, one of two EMS providers in Trinity County in deep East Texas. “Then we get there, and they’re scrambling to get their trauma team ready.”
Spotty cellphone coverage is just one obstacle Robison and other rural emergency service providers face when they respond to traffic accidents. And it’s one of the factors — along with high speeds and low seatbelt usage — that contribute to a stark disparity between rural and urban highway traffic fatalities.
Crashes in rural areas accounted for 51% of Texas’ 4,489 traffic fatalities in 2021, but only about 10% of the state’s population lives in rural areas, according to data from the state’s Department of Transportation.
The pattern exists nationwide. Nearly half of fatal crashes in the United States occur on rural roads even though only 19% of the population lives in rural areas.
“We’re the worst of all industrialized nations, and it’s clearly not inevitable since other nations have cut their fatalities,” said Robert Wunderlich, director of the Center for Transportation Safety at the Texas A&M Transportation Institute. “We’ve really got to question where we’re headed.”
High speeds, low seatbelt usage
The combination of high speeds on Texas highways and low compliance with seatbelt laws contributes to rural highway fatalities.
A small change in speed can greatly affect a person’s chance of survival since the speed of a vehicle determines how much kinetic energy is transferred upon impact. And Texas has relatively high speed limits compared with other states, including at least one state highway with a speed limit of 85 mph, the highest in the country.
On roads in rural areas, where police departments tend to be small and under-resourced, a lack of enforcement means drivers go even faster, Wunderlich said.
“We sort of take the speed limit as our minimum entitlement,” he said. “People are not conscious of the ramifications of that.”
Texas has lost at least one person every day on Texas roads since November 7, 2000, a statistic that prompted the state’s department of transportation to launch a public awareness campaign, #EndTheStreakTX, to decrease the number of traffic fatalities. The streak still continues, according to the latest data from the Department of Transportation.
Low compliance with seatbelt laws also contributes to rural fatalities.
Between 2016 and 2020, more than half of motor vehicle occupants who died in rural road crashes were not wearing seatbelts, one report found.
“Some of that is cultural, and some of that is a lack of enforcement in rural areas,” said Pam Shadel Fischer of the Governors Highway Safety Association. Wearing a seatbelt, Fischer added, is “the most effective and simplest thing we can do to bring down fatalities. We really need to think about that.”
EMS response times
When Robison receives a dispatch about a major collision, one of his first moves is to call the closest air rescue team, about 30 miles away in Crockett. If he waits to make that call when he arrives at the scene of the accident, it may be too late.
“I already know it’s a long distance to the trauma center,” Robison said. “So I’ll tell them, ‘Hey, we haven’t made patient contact, but we’re told there’s serious injury.’”
The hour following a traumatic injury, known as the golden hour, is critical for patients. The likelihood of survival depends largely on the care a patient gets immediately after sustaining the injury. Even seconds can matter.
In sparsely populated areas, EMS providers are often far away from trauma centers that can provide appropriate care.
Texas has 305 trauma centers, each with a designated level, 1 through 4. Level 1 centers provide the most comprehensive services. These centers are clustered in urban areas, while outlying areas tend to have Level 4 centers, which provide the least amount of service.
A handful of counties in rural Texas have no such centers.
“If you’re unfortunate enough to have an injury far from a hospital, it could take you time to get there,” said Dudley Wait, who serves on the Governor’s EMS and Trauma Advisory Council. “We can do a lot, but we can’t overcome the time-space continuum.”
Statewide, the median amount of time it takes for an EMS unit to respond to an emergency call and transport a patient to the hospital is 36 minutes. In a 19-county region of deep East Texas, the median amount of time is 44 minutes.
Part of the time difference stems from the difference in coverage area. Rural EMS providers serve huge territories with limited resources. Trinity County, part of that 19-county region in the Piney Woods, has two EMS services. Robison’s service covers 535 square miles with only one ambulance mostly staffed by a team of volunteers.
Robison averages one phone call a day and said he does not even pay himself a salary. He lives off savings and the income of his wife, an emergency medical technician who also works for the EMS service.
“I don’t make a lot of money, but it’s worthwhile,” Robison said. “This is a calling.”
Rural areas also tend to have a higher uninsured population and more people who rely on Medicaid, which offers lower reimbursement rates than private insurance companies.
“We provide a lot of free transports and free care,” Robison said. “And that’s OK, it’s just that it gets tough sometimes.”
Ambulances are also required to keep certain drugs on hand, but drug prices have gone up, and Robison sometimes has to throw away drugs because they expire.
“Everything has gotten absolutely crazy,” Robison said. “Financially it’s a rough slog, but we will hang in there.”
Robison and other rural EMS providers said the state should take a larger role in helping staff rural ambulances.
Anyone who works on an ambulance in Texas must be licensed by the state. Licensed EMS workers say that burnout and opportunities for higher salaries in hospitals are dissuading them from working in ambulance services.
According to data from the Department of Health and Human Services, more than 70% of licensed Texas EMS professionals did not work on ambulances during the first eight months of 2021. Put another way: Seven out every 10 Texans who could work on an ambulance did not.
The state has already taken one step. In 2021, the Legislature passed a $21.7 million EMS education and recruitment initiative as part of the American Rescue Plan Act.
The Texas EMS Alliance recently distributed the money across the state, with 60% going toward rural Texas to fund scholarships for students entering emergency medical technician or paramedic training programs. Next year, the alliance plans to launch a campaign encouraging people to consider emergency services as a career.
Dudley said he hopes to show the Legislature that with financial support, they can produce results.
“We’ve never had a plethora of EMS personnel just standing around looking for a job,” Dudley said. “Our goal is to show that we can produce a bunch of EMS personnel and then try to have a training fund from the state of Texas going forward.”
Disclosure: The Texas A&M Transportation Institute has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.
Correction, Dec. 21, 2022: A previous version of this article incorrectly reported a Texas Tribune analysis of state data found that 39 counties had no licensed EMS provider firms. The analysis was based on mailing addresses for a provider's licenses. It did not include additional stations that some providers serve. The charts have been removed.