Ruth von Minden's life revolves around family, church, and the Springfield Ambulance Corps.
At age 66, von Minden proudly shows off a "Dinosaur of EMS" T-shirt she wears under a comfortable blue long-sleeved overshirt. She started in the Delaware County community 41 years ago as a "swoop and scoop," when medics would grab the patient and rush to the hospital for any care, and through 4,000 runs, she's seen childbirths, deadly car crashes, heart attacks, and life-altering burns.
Now she's a veteran of the last all-volunteer ambulance company in Delaware County. Fewer stations than ever rely on volunteers such as von Minden.
For decades, volunteer ambulance companies were part of the fabric of community life. Generations of good Samaritans stepped up to donate their time, money, and skills to help their sick or injured neighbors. But the emergency-services landscape has changed, across the region and the country.
Volunteers have dwindled as training costs and requirements have risen. The pay for professionals lags, while calls have surged and stations fight to recoup insurance reimbursements. Mergers are up - 25 in Pennsylvania between 2008 and 2014, and four more this year. In New Jersey, 120 volunteer ambulance companies have folded since the mid-1990s.
If new business models aren't found, supporters say, more services could disappear, straining the remaining ones and leaving some communities at risk.
"The entire system is just about to collapse," said Scott Phelps, professor of ambulance science at the Emergency Management Academy in New York. "There is not enough money to run the system the way it operates."
In better times, the way it operated was simple: Often an outgrowth of local fire companies, ambulance corps relied largely on donations to train, equip and staff local paramedics and emergency medical techs. At any hour of the day or night, they dashed to reports of accidents, calamities, even heart attacks, to deliver immediate treatment or hospital transport.
Some were paid, but many - such as von Minden - were not.
These days, the data on volunteers is elusive; as the National Association of State EMS Officials points out, even the very definition of volunteerism is unclear.
But the signs of change are everywhere. On the outer edges of Chester County, two longtime corps merged. In Newtown Township, Delaware County, officials turned over their services to Riddle Hospital. On the Main Line, four fire and ambulance companies have allied with municipal officials to address money issues.
Eamon Brazunas, the Berwyn Fire Company chief, says that without a funding solution, the volunteer system will all but disappear in a decade.
"We can't just keep kicking the can down the road," he said.
The Elverson ambulance company had struggled financially. In 2009, it narrowly avoided bankruptcy. Twice in the last three years, it ran five-figure deficits.
So when another Chester County company - this one from Honey Brook Borough - approached it about a merger two years ago, Elverson jumped on board.
"It was the right thing to do," said Stephen Bobella, executive director of the Schuylkill Valley EMS and paramedic brought in to oversee the transition and manage the finances.
The new company will share about 60 paid and 10 volunteer members and cover 13 municipalities in Chester, Berks, and Lancaster Counties that pay $65,000 a year, combined.
Twenty years ago, 25 or so volunteers ran the ambulances. "It's been a gradual decline," said Joe Carmen, director of operations, echoing what's happened in other spots. Howard Meyer, president of the EMS Council of New Jersey, which represents about 80 percent of that state's volunteer squads, estimates it would take more than $500 million to replace the ones that have folded.
Pennsylvania officials have seen a decline in license applications for emergency medical responders and technicians, the lowest levels of medical workers in the field, according to the Department of Health.
One reason could be cost: The price tags - and total hours required for certifications or degrees - have increased dramatically since the days when only a basic first-aid class was required.
A 12-credit EMT certificate costs $3,000, and a 70-credit, six-semester associate of applied science degree to become a paramedic at Delaware County Community College, $7,500. Non-county residents pay more.
EMTs make between $16,000 and $19,000 a year; paramedics, who have higher certification, take in $25,000 to $33,000, according to the U.S. Department of Labor. To make ends meet at home, those incomes must be supplemented.
"Everyone works a part-time job," said Bill Downey, of the Marple Township Ambulance Corps.
Part of the funding quandary stems from a constant battle over insurance reimbursement, EMS supporters say. Often, insurance companies send payments directly to patients, who fail to pass them on to the ambulance crews that served them.
"Well over 30 percent" of the patients keep the funds, said State Rep. Bernie O'Neill (R., Bucks), who has sponsored a bill to force insurers to send reimbursements directly to ambulance companies.
Reimbursement was one of the issues that moved Newtown Township to take a second look at its emergency services this year. It had been budgeting $655,000 a year to maintain an ambulance and to contract with Riddle Hospital for staffing and a backup ambulance.
But given the cost, the reporting requirements, privacy regulations, and billing issues, township officials thought they might do better by getting out of the EMS business entirely.
"No one on staff is versed enough in the responsibilities of EMS," said Stephen Nease, the township manager.
So the township sought proposals in the winter, netting two bids. One, from the Volunteer Medical Service Corps in Narberth, offered to provide the service for $407,000. A second proposal, from Riddle Hospital, offered an ambulance and staff to take over billing and other services for the 12,300 residents in the 10-square-mile municipality.
It would cost the township about $50,000 - but the hospital sought to operate a resident-subscription service.
Nease had reservations about the idea of having residents - or anyone who needed an ambulance while in the township - pay a fee to a for-profit company to receive emergency services.
If they didn't subscribe, they could be billed by the hospital for the entire amount. An emergency-room trip could cost $1,500.
In the end, the supervisors voted to retain Riddle Hospital, which took over operations in August; however, a decision on subscription fees has been deferred, he said.
The township will still house the ambulance. The cost of the service is about $10,000 to cover fuel and housekeeping, Nease said.
"This is going to be a challenge for municipalities going forward," Nease said.
Amid the changes, some successful models have emerged. One is the 71-year-old Volunteer Medical Service Corps in Narberth, which has maintained a stream of paid staffers and volunteers.
The company now serves Lower Merion Township and Narberth, Conshohocken, and West Conshohocken Boroughs and responds to more than 6,000 calls a year.
With an annual budget of about $2.6 million, it employs a paid administrative staff of four that helps recoup more than $2 million in insurance claims. Fund-raising - including a subscription drive - and grants cover the rest of the expenses, along with $24,000 from Lower Merion, said Patrick Doyle, executive director.
"The success of this place, in a word, is the people," medical director Ben Usatch said. They "bleed maroon," the color of the corps, he said.
Usatch, who is also an emergency-room physician at Lankenau Hospital, is one of four doctors in the company who respond along with crews on certain calls. Narberth has about 92 active volunteers who work alongside 37 EMTs and paramedics.
A rigorous application and acceptance program ensures that new members are a good fit with the group, he said. Not everyone is accepted.
The equipment is state of the art, including seven ambulances, three command vehicles, and a large mobile bus and a smaller one for mass-casualty events. All have WiFi and act as mobile intensive-care units.
Inside the more than 10,000-square-foot, two-story station is a study room, pool table, full kitchen, workout rooms, and sleeping quarters for male and female volunteers and staff. In-house training is also a draw for members - many of whom go on to careers in the medical field, said Chief Christopher Flanagan.
"Training is absolutely a team effort," said Joe Sobol, 23, an EMT and nursing graduate of Villanova University, who during one recent session showed the crews how to properly deliver Narcan, an antidote used in heroin overdoses. "It is a great way to bring the squad together."
Von Minden knows the feeling. That closeness is what has kept her coming back to Springfield's volunteer crew for four decades, nearly all of them as a crew chief.
"I wouldn't be here if I didn't have fun," she said.
When she started, the 50 or so men and women who volunteered all lived in the township and came from every walk of life; two-income households were the exception.
Volunteers would often congregate at one home with portable cribs and sleeping infants in tow, leaving behind a spouse to baby-sit as the others responded to calls.
Now they are dispatched from the same building that houses Springfield Fire Company 44 on Saxer Avenue.
The company has had its share of problems. In 2013, the township voiced concerns about whether volunteers could continue to maintain staffing levels needed and debated bringing in medics from Crozer Chester Medical Center during the day, said Kelly Sweeney, president. A big training push helped boost their numbers up to 92 volunteers, resulting in a new contract with the township, she said.
Over the years, von Minden has seen the transformations in the field - and in the volunteer community.
She remembers the tragic calls she'd prefer to forget, but smiles when she talks about the five babies she helped deliver and the time a former patient ran up to her in a parade and gave her a hug.
"It became a part of my life - every Saturday night was my night," von Minden said. "This place is a family."
A few years back, she renewed her EMT certification.
Probably, she said, for the last time.