Lyn Medinger has received calls in the middle of the night from friends and neighbors with heart pains asking him whether they need to go to the hospital.
He'll listen to the descriptions of their symptoms, advise them, and, if necessary, pick them up and take them to the hospital.
It's a simple reality of heading an ambulance service in a small town where everyone knows you - and your phone number.
"It comes down to dedication and commitment," said Medinger, who is accustomed to his pager going off at all hours after 20 years with the volunteer Bellevue Ambulance Service.
It's also a reality that could be changing in Bellevue, in Iowa, and across the nation where volunteer paramedic teams serving small towns and rural areas are being hit by rapidly increasing certification requirements, growing coverage areas created by shifting populations and an aging volunteer force.
"Every (volunteer) ambulance service is probably having problems right now," Medinger said.
With a team of 34 members who mostly have out-of-town careers and a district that spans 172 square miles, Bellevue is struggling to find the manpower to cover daytime calls.
"This story is wherever you look," said Ric Jones, the public policy chairman of the Iowa Emergency Medical Services Association and a retired Dubuque firefighter.
"The reality is the volunteers are just getting stretched thinner and thinner," said Jones, who estimated that 90 percent of Iowa's geography is covered by volunteer ambulance services.
While they don't serve the majority of people in the state, that doesn't undermine the importance of what volunteer services do.
"If it's your relative, it's the most important call in the world," said Bellevue City Administrator Loras Herrig.
Expectations have changed from the days of the first volunteer forces, when Jones said they typically adhered to the motto: "you fall, you call, we haul, that's all."
"That's kind of what ambulance services were all about," Jones said. "(Now) there's a great deal more demanded of them."
Many volunteer services were born in the 1970s; succeeding the traditional model of ambulance services provided by funeral homes.
"It was kind of a natural offshoot," said Jones, who said for years hearses were the only size vehicles that could accommodate people for emergency transports.
Bellevue joined the trend and started its volunteer ambulance service in 1972.
"Just like a lot of other towns, funeral homes were getting out of ambulance services," said Max Reed, one of the original Bellevue volunteers who is still on the force today.
By the 1980s, paramedics were required to do more than give rides, they also needed to provide patient care.
The standards have continued rising since then, and the demands are making it increasingly difficult to scout out new volunteers when larger urban departments offer paid positions.
Medinger works in a paid position for the Clinton Fire Department and as Bellevue's director of emergency services during his free time, but he is the exception rather than the norm.
Considering the training involved in being a paramedic, it isn't surprising that not everyone has the luxury of time to share.
To become certified, today's volunteers need to undergo hours of EMT training, meet increased driving requirements and learn a litany of OSHA rules.
There's finicky regulations about handling various pathogens and bioterrorism training - not to mention becoming adept at completing detailed medical reports.
"Back in 1970 if you filled out a little ticket for your call, that was probably all that happened," said Jones, noting the lengthy computer reports that now have to be filed.
Reed, certified in Iowa and Illinois and is planning on getting his Wisconsin certification, said he will keep volunteering for Bellevue as long as he's able.
Valuable as volunteers like Reed are, leaders like Medinger worry there aren't enough people waiting in the wings to replace them.
"Part of it is cultural," said Jones, who said sitting in meetings, helping with fund raising, constantly needing additional training and being on call at inconvenient times often sound unappealing.
Sheldon Keyser, president of the Illinois Rural Health Association, also pointed to the current culture and increase in technology as an interference, but he said it's because it complicates people's lives.
"(Technology) is designed to make us more productive but it's creating a lot more pressure. When people get off work they're just pressured out," he said.
"I don't think people lack the goodness in their hearts."
In a series of town hall meetings across Illinois, Keyser and others found that the difficulty in keeping volunteer organizations viable is a statewide dilemma.
"It has become abundantly clear as a result of these community forums that many of Illinois' EMS providers literally are hanging on by their fingernails," the rural health association concluded in its report.
Small towns are shrinking and younger people are moving to larger cities, said Keyser, citing data matching figures released by the U.S. Census Bureau earlier this year.
"Towns are smaller and we have an aging population; people less capable of caring for themselves and more in need of services," Keyser said.
Bellevue's ambulance service fits the profile of other rural departments looking for volunteers but differs because it is a community that is growing quickly.
The city of about 2,300 people is experiencing a host of new development, including condos, residential lots in six new subdivisions and investors "looking into the area," according to Herrig.
The pressure on the ambulance team is growing because the booming population is creating more demand and also is transforming Bellevue into a bedroom community.
"We need some daytime help, it's hard to get people that can leave their jobs," Medinger said.
He is relying on a handful of volunteers who still have jobs in town or have flexible managers who allow them to respond to daytime calls.
But even that's difficult when calls run two hours or more thanks to the large size of the district.
The average time to the hospital is 22 minutes, followed by waiting at the Emergency Room door, restocking medications, setting up the cot, driving back and filling out the detailed medical report.
By the time the call is done, the paramedic might have lost as much as half of his day, according to Medinger.
He and others on the Bellevue force worry the state will have to come in to provide services like it has in some Iowa communities if they don't respond quickly enough to their calls.
"If we can't respond in adequate time, then we fall under state control," Reed said.
While a few southern Iowa communities have had the state take over to provide services when they were unable to respond to all of their calls, other struggling volunteer departments have taken several routes - one in Anamosa teamed up with the local hospital while another in Eldridge created a shared agreement and schedule with the Davenport service.
Still, Bellevue is a lot better off then many other places, with a larger roster of volunteers and a new building built in 2002 for half the original estimate thanks to the community members who pitched in.
Finding the daytime volunteers that Bellevue needs is doable, according to Don Hunjadi, executive director of the Milwaukee-based Wisconsin EMS Association.
"Clearly this is a challenge, but we think its a challenge that they can meet," Hunjadi said. "Times have changed and you have to change with it."
Hunjadi, who has given lectures to volunteer departments throughout the Midwest, points to turnarounds in several communities including Whitewater, Wis., as evidence of what the power of marketing can do for recruitment.
"They were at the point where they almost had to hire people during the day," he said.
After their marketing campaign, Whitewater had enlisted 30 new volunteers and even had too many paramedics responding to calls.
Wisconsin EMS just finished a statewide recruitment drive, complete with billboard advertisements and teaching sessions for local providers on how to recruit volunteers.
The solution is simple, according to Hunjadi: Tell people about the positives of the job and think outside of the box when looking for recruits, whether it's stay-at-home moms, retirees or high school grads who are still in town.
Marketing is the name of the game in Pennsylvania, where a "Roll With It" Web site and advertisements at movie theaters are targeting younger generations across the state.
Flanked by dramatic lettering and dark backgrounds, the Web site encourages future volunteers with this message: "When you're EMS, you've got lives in the palm of your hand. When it gets crazy, you stay cool. You're always on. You've got to be tough enough. And you've got to have badass in your blood."
Along with aggressive marketing, Hunjadi said the other key to success is solid leadership.
That's good news for Bellevue, because Medinger has been a strong leader, according to Jones.
"He knows the challenges," he said.
While sharing stories of the family atmosphere of the Bellevue team and facility, Medinger and Reed also are honest with new members about the challenges.
One of the hardest things is in towns the size of Bellevue, paramedics usually respond to calls from people they know, if not close friends and family members.
"This takes a toll on a lot of people," Reed said quietly, pausing for a moment.
"We've lost members right after tragic calls."
Medinger realizes it is asking a lot of people to join the team when they have such busy lifestyles, but he is confident the support of city businesses and the general nature of the town will produce a new generation of volunteers in Bellevue.
"We've always been able to work it out and we will."
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