The Anza-Borrego Desert Natural History Association’s (ABDNHA) second community webinar, “Desert Living – Desert Health Webinar 2, Providing Health Care in Remote and Rural Communities,” on January 20, presented a local panel of Borrego Springs’ healthcare providers, discussing a range of services from primary care to paramedic care, and emergency air evacuation.

Free of charge, ABDNHA offered two webinars on healthcare to educate the community on what is available and for what medical situation. A third event on January 22 was an invitation for people to visit and view a paramedic vehicle and the Mercy Air helicopter.

The second webinar panel included, Dr. Laura Goetz from the Borrego Health Clinic, Eric Castro, firefighter/paramedic from the Borrego Fire Protection and Paramedics District (BSFPD), and Cameron Hershey, flight nurse, and Ryan Morgan, pilot, representing Mercy Air.

Dr. Goetz opened the conversation, saying that the first thing the Clinic needs is to build a trusting relationship with the community.

Her overview of services offered by the Clinic included monthly appointments for pediatric care; bi-monthly schedules for women’s health; obstetrics, Mammography; on site x-rays, and full scope laboratory blood draws, reviewed by Quest Diagnostics and LabCorp. Urgent care assessments for allergies, insect bites, minor fractures and sprains, infections, cuts and bronchial infections are other services.The Clinic team can also manage a plan and provide limited support for acute diseases for patients under the care of a specialist not located in the clinic.

A full range of vaccinations are available, including shots for COVID-19 and its derivatives. COVID tests are also available, however, they only have the type with a three-day turn around. Dr. Goetz pointed out while these are slower than other tests, they are more accurate.

She also pointed to the fact that the Clinic has immediate access to full pharmacy services, and immediate referral to Mercy Air Transport for medical conditions, requiring hospital or trauma care professionals and equipment. The Mercy Air medical helicopter is conveniently located on the Clinic grounds.

Dr. Goetz announced that Mercy Air is in the process of replacing the mobile vehicle housing with a permanent structure for the air flight medical staff, pilots, and helicopter. Cameron Hershey of Mercy Air confirmed they are stuck in the permitting processes at the county, but are moving forward with building the permanent complex.

In terms of managing more acute diseases such as diabetes and cardiac diseases, the Clinic refers patients to specialists, the same for bone breakage and other traumatic injuries. Dr. Goetz, a surgeon noted, “If the clinic had a doctor of internal medicine on staff, the clinic could handle a higher level of intervention with less need for referrals.”

She pointed out other limitations or limited services such as mental health, and advised, “if someone has a broken bone, it’s best to head for a specialist.” Answering a question from a webinar participant about liver dialysis, she noted that there was not enough demand in Borrego to warrant the cost of equipment and staff.

The clinic hours are 8 a.m. to 5 p.m., with a call-in number for weekends and after hours. Dr. Goetz suggested, “expanding the evening hours and adding some hours on Saturday would make the Clinic services available to working clients.”

She also is working on something that is part teleconference, part clinic visit. A patient comes to the Clinic to teleconference with a specialist, offering services beyond the Clinic’s capabilities.

“By sharing the teleconference call with the patient and their health care specialist, we are better equipped to understand and supplement the patient’s needs, because we are getting information first hand,” Dr. Goetz said. “Also, by using this simple, part teleconferencing, and, part onsite-visit program, the Clinic staff can lower the patient’s anxieties and fear by assisting with the computer use, as well as answering questions the patient may have after the call.”

Hershey introduced Mercy Air, saying the helicopter is available 24/7, and staffed with a pilot, paramedic, and nurse.

“There is an alternate team on the ground. The only way to access air evacuation is by calling 911, or the Borrego Fire District paramedics, or other first responders, like the Sheriff’s,” Hershey said.

The paramedics, according to Eric Castro, Borrego paramedic, will evaluate a ground situation and determine if the flight to a hospital or trauma center is required. Castro cautioned, the decision for flight requires an experienced paramedic to make that call.

“The paramedics will deliver the patient to the Mercy flight complex, or request emergency air at a site, specifically in the case of a car accident or other trauma related incidents,” he said. “The big question people always ask, even before a flight is, ‘What is this going to cost?’”

Hershey added, “Costs are related to overhead, time and distance, plus the degree of on-board medical treatment required.”

Mercy Air supplies blood transfusions, treats cardiac emergencies, heat stroke, snake bite, and intermediate trauma care until the patient can reach the nearest facility, with the appropriate specialties.

“While Palomar Pomerado is nearby, other San Diego County facilities may be more appropriate. UCSD, for example, has the largest supply of poisonous snake bite anti-venom,” Hershey noted.

“Patients that use Eisenhower, or JFK, in Riverside County, may request transportation to their hospital, even though the air service is located in San Diego County. Palomar is 22 minutes away; Eisenhower is 18 minutes by flight. Transport by paramedics is around two hours on average to the same medical facilities.”

Castro advised that, “Sometimes things are fluid,” acknowledging that the closest hospital for ground transport is Pioneer Hospital in Brawley. “However, if Pioneer’s emergency is overflowing with Covid virus patients, or the patient needs blood transfusions, and the hospital is low on blood, we search around for the best ER to treat a specific injury or illness.”

Hershey agreed, saying, “the same is true of air flights.”

However, there’s one caveat about air transport, according to Hershey. “The weather can have a big impact on which emergency facility is chosen.”

“Mercy Air is sort of a flying ICU unit,” Castro said, who portrayed the paramedics as a complementary emergency unit. “Working together with the Clinic and Mercy Air, we form a team that meets the spectrum of health and emergency services.”

According to Hershey, Mercy Air flight medical crews are required to have a considerable scope of practice and extensive training, with 7 – 8 years of experience.

“Recognizing that we are delivering a patient with need for specific specialists and hospital equipment, we make contact with the providers at the emergency drop point so that they are prepared to act immediately; and we can also give the patient the advantage of their expertise during the flight.”

Responding to a question about costs in real dollars, Hershey replied, “The average out of pocket cost is $114 – that’s for Medicare ‘in network. That’s pretty good, considering most of Borrego’s flights involve older individuals with Medicare insurance.”

He also pointed out what he calls, “A very generous gift for residents.” The gift, Hershey referred to, is the fact that the Borrego Valley Endowment Fund (BVEF) has an agreement with Mercy to cover out-of-pocket expenses in most cases.

A complaint of the air emergency industry is that Medicare, specifically, and other insurers do not cover true costs of the service.

“Out-of-pocket” refers to the balance due after all the insurance reimbursement has been claimed. However, Hershey states that Mercy does not bill “balance due” or “surprise bills” that are the bane of the industry and that shock patients with large bills of unexpected costs. Rather, Mercy has a staff to work with each client to negotiate costs with medical insurers.

Costs are made more complex because of issues like “in” and “out-of-network” terms. These are applied when it comes to insurance and whether one’s insurance plan covers the particular hospital or medical staff treating the patient. “In-network” means there’s insurance coverage that can be negotiated. “Out-of-network” is another issue entirely.

“We are always ready to go. Mercy has carriers in Escondido, Oceanside and Thermal that we contact if we’re already on a call, down for some reason, or if there’s an emergency requiring more than one helicopter,” explained Hershey.

Castro chimed in stating that paramedics can also utilize other air emergency companies, like REACH, which also services the Borrego area, if Mercy is unavailable, or additional air evacuation capacity is needed.

Both Hershey and Castro addressed the question of whether a patient may be accompanied by a family member. “With the new hospital ER rules, prohibiting accompanying individuals into treatment facilities due to COVID, the answer is no.”

“Concerned individuals need to identify the facility to which a patient has been transported; and contact that hospital to discuss the patient’s status and visitation privileges. There may be some exceptions such as when the patient is an infant or very young child,” Hershey added.

Castro outlined the district’s paramedic services, beginning with people that show up at the fire station with problems like allergies, simple cuts and bruises, scorpion bites, and cactus infections. The paramedics can provide immediate help with respiratory problems, heat strokes and cardiac concerns. They make an evaluation of the persons’ medical condition, and whether an air lift is needed. Then they contact Mercy Air, or another carrier if Mercy is not available.

“We typically know within seconds whether an air lift is needed,” he noted. “We welcome people to come to the station and are happy to help them. However, they should call first to make sure the trucks are at the facility. Calling 911 is the best solution for critical events, like mental health breakdowns and drug overdoses. These are very serious, even life-threatening medical conditions that require immediate intervention; and transport to a hospital with mental health and addiction capabilities.”

The BSFPD has a contingency of 12 firefighter paramedics, including two EMTs, all of which will hike or drive up trails and canyons for rescues. Castro assured, “The district has four-wheel vehicles for just that purpose.”

Asked about rumors that the district has trouble recruiting and maintaining qualified personnel, Castro replied, “It’s true, the department’s budget is behind the times. It’s a small district and we are lowest on the pay scales. Then there’s the fact the department is in the desert, which adds some extra complications.” he said. “However, I believe the community and the fire district will be able to solve this problem.”

All the panelists, from Dr. Goetz to Castro, and Hershey agreed about the level of cooperation and trust between the clinic, paramedics and Mercy Air.

“We are partners and when dealing with sick or injured patients, the right hand always knows what the left hand is doing. Something that does not occur in all communities,” acknowledged Castro. “For a small rural community, Borrego is fortunate to have health services that range from primary care, to emergency care through the paramedics, and intensive support care from Mercy Air.”