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EMT: State Exploits Volunteers, Neglects Funding for Ambulance Services

On Tuesday, Governor Kristi Noem said South Dakota needs to spend money to recruit and support more volunteer emergency medical technicians:

Unfortunately, our emergency responders are getting fewer and fewer. Many have gotten older, and less people are stepping up to volunteer. We must reverse this trend. We need to recruit more volunteer firefighters and emergency responders. And we need to support them with modern tools – my budget does that. I look forward to working with all of you to get these wonderful folks the equipment and training that they need [Gov. Kristi Noem, State of the State Address, Pierre, SD, 2022.01.11].

Emergency medical technician Cully Williams, who has held his EMT license for nine years, says Noem’s focus on volunteer emergency services only perpetuates decades of neglect by the State of South Dakota.

Around 1966, the DOT discovered people were dying on highways, so they formed NHTSA and started using it to dump money into ambulances in rural areas. This is why most ambulances in SD (as well as the Office of EMS, and Board of Medicine) were formed +/- 1972.

For the next 30-40yrs, everything remained remarkably unchanged. In 1994, NHTSA came in for an Assessment for a nationwide report, and again in 2002. I’d like to take a quote from this 2002 report:

“On revisit, however, the absence of clear statutory authority for a lead agency consistently and predictably funded, and bureaucratically positioned to plan, implement and coordinate a comprehensive EMS system is evident…. Particularly disturbing is the continued lack of a State EMS Medical Director, the current absence of a State EMS Advisory Council, and distribution of authority over EMS issues and personnel among Department of Health offices and other state agencies.”

In reaction to this, nothing happened. Ambulance crews ticked along. Some crews couldn’t keep 2 EMT, so they would take a hardship exemption from the state and run with 1 EMT + 1 driver. By 2013, that was around 15% according to this Needs Assessment.

The 2013 report looked at the 2002 one and asked what got done. Out of 71 action items, only ten were done. Nine were the development of a statewide trauma system, and the other was a state DNR form. Come 2015, Safetech released their data.

In SD, 73% of services used volunteers, 94% said workforce recruitment was their greatest need, and 32% of services missed a call due to volunteer staffing. It became clear s[*] was about to hit the fan. I’d argue it hit sooner than expected, *then* COVID happened.

Safetech identified only 1 in 3 as sustainable in the coming 3-10 years. The next year, the leg[islature] lowered the minimum staffing reqs down to one EMT and one driver. Too many on hardship exemption. In 2018, townships were given authority to impose a tax levy for EMS.

Safetech returned 2019 saying: “In the past decade, this informal network of services has begun to show signs of strain. Volunteerism has declined, and the demand for services has risen. Pressure on the system now threatens the reliability and sustainability of EMS in rural SD.”

They also calculated how subsidized EMS is by volunteer labor, and returned a $36 Million/yr figure. Every year, volunteers contribute $36M to keep our ambulances afloat. That’s admirable, but very much not a smart/sustainable business model [Cully Williams, Twitter thread, 2022.01.11].

South Dakota’s model of praying for/preying on the kindness of its people’s hearts is running up against the reality of low wages, higher costs of living, and demographics. The Blue State Refugees the Governor claims are coming to South Dakota for Freedom™ aren’t volunteering to drive our ambulances. (They probably include a lot of older folks and risk takers who are going to need more ambulance calls.)

Williams thus proposes paid, full-time ambulance services facilitated by the state with an opt-in ambulance district plan and $37 million a year to cover operating expenses. According to an April 2021 South Dakota News Watch report, the state of South Dakota currently allocates enough each year to staff just one rural ambulance:

The EMS program within the South Dakota Department of Health Office of Rural Health received about $422,000 from the state general fund, EMS agency licensure fees and EMS professional licensing fees, according to a 2020 report from the National Association of EMS Officials. The state received about $115,000 in federal funding, according to the same report. The health department did not respond to follow-up questions about state funding for EMS and a spokesman said the director for EMS was not available for an interview.

The estimated cost of operating and staffing a single rural ambulance in South Dakota is about $484,000 each year, according to SafeTech Solutions survey. About $384,000 of that is estimated to be volunteer work [Danielle Ferguson, “Viability of Rural Ambulance Services in S.D. at Risk Due to Staffing and Funding Shortages,” South Dakota News Watch, 2021.04.29].

$37 million a year—is South Dakota willing to spend that money on ambulance services? Or will South Dakotans continue to cling to their low-wage/low-tax lifestyle and just hope someone volunteers to stop their bleeding and drive them to the hospital when they crash their electric ATVs?


  1. larry kurtz 2022-01-13 07:38

    The grassland fire danger index will be in the very high category again tomorrow for much of Mrs. Noem’s failed red state. This isn’t national forest being blocked from fuel treatments by radical environmentalists; it’s Republican ranch land decimated by a century of poor management practices. If livestock grazing is the key to preventing wildfires why is ranch country still suffering from near daily high even extreme grassland fire danger indices? Because Republicans are evil.

    91% of fire departments in my home state are staffed by volunteers in a state where old white Republicans are giving up the ghost yet Mrs. Noem is boasting she has recruited some 600 white supremacists to be cops but won’t commit to prescribing burns or bolstering fire departments.

  2. Dana P 2022-01-13 07:53

    How can we afford to pay EMT’s when we are subsidizing gun owners? Ok, that was major sarcasm

    Yep. The state definitely exploits these folks. Her word salad teleprompter ‘speeches’ are ridiculous. About all topics. But this one was way out there.

  3. Amy B. 2022-01-13 08:17

    I bet if one of her kids was an EMT, she would be all over this like an appraiser on a house.

  4. Medic 2022-01-13 09:20

    As an EMT I have asked the state for more money and they have ignored me. The one person I talked with said have local businesses give EMT discounts to give people an incentive to join the ambulance. I told him that’s who the volunteers are is the local business owners!! They truly don’t get it.

    But it’s not just a state problem. CMS(Medicare/Medicaid) refuses to pay for some services but we still respond. They also don’t pay enough to cover expenses in most cases which obviously doesn’t help.

  5. Scott Ehrisman 2022-01-13 10:49

    In SF our wonderful for profit ambulance service requires our Fire Rescue EMTs to show up also (we pay for thru taxes with NO reimbursement from the company) They usually show up 10-15 minutes before the private ambulance, treat the patient and release or prepare the patient for transport. The only thing our for profit ambulance does is pickup the patient, take them to an ER and collect the insurance money and don’t reimburse the taxpayers of SF for our mutual service. It’s pathetic. I have begged the council for years to just have a public ambulance service (we kind of do) and hire a 3rd party company to handle the billing and collections for a commission. We are already providing the service, the only thing is that the taxpayers are NOT being reimbursed.

  6. Guy 2022-01-13 12:06

    Well Cory, at least we’re planning on spending millions of our tax dollars to build one of the world’s largest shooting ranges…who needs EMT”s, right?

  7. Guy 2022-01-13 12:29

    Larry, she doesn’t seen to make it a priority to propose more funding for EMT’s, wildland fire suppression/mitigation. Her top priorities are: funding an ongoing lawsuit to ensure we have fireworks next summer at Mount Rushmore, funding our G, F & P to build one of the world’s largest shooting ranges and her new proposal that the taxpayers fund all firearm permits and background checks.

  8. Guy 2022-01-13 12:33

    People have screamed for years that Washington, DC is out of touch….well, what about Pierre???

  9. Guy 2022-01-13 13:58

    John where are the immigrants going to live with the affordable housing shortage in South Dakota?

  10. jerry 2022-01-13 14:30

    Slum lords will always stack them in. One of the problems with covid is that it spread so quickly in the immigrant housing projects of Sioux Falls and in all the urban areas because of overcrowding. Employers simply don’t get it or don’t want to get it. They want the government to do something, but they don’t want to pay taxes to help solve their problem.

    Capitalism depends on this kind of logic or lack of vision.

    Affordable housing is a myth and pretty much has always been a myth.

  11. Guy 2022-01-13 15:19

    Affordable housing is NOT a myth. I and many others live in affordable housing where I do not pay over 30% of my income for rent. Affordable housing should be viewed as a basic human right like healthcare. Good mental and physical health depend on access to affordable housing.

  12. cibvet 2022-01-13 16:06

    Guy– sounds like government subsidized housing. Not all can get that.

  13. Guy 2022-01-13 17:07

    Cibvet, we should ensure more workers CAN get affordable housing. Like healthcare it should be the new “human right” for a stable healthy society. I’m surprised it hasn’t become a political movement, YET. But. with the Millennial Generation this might be the next big political movement.

  14. W R Old Guy 2022-01-13 17:33

    The issue with volunteer ambulance services has been simmering for years. New Underwood closed in 2011 because they did not have enough volunteers to provide 24/7 service. The Meade County Ambulance based in Enning is apparently closed for the same reason. The SD Dept of Health has a map showing the currently licensed ambulances. There are areas with sparse coverage and not enough population to provide ambulance coverage.

    Money is part of the problem. Volunteers are hard to recruit and retain. Basic EMT requires 165 hours of training and continuing education to retain your certificate. I started my career in fire/medical first response in 1965. Medical training consisted learning the American Red Cross Advanced First Aid Book. Ambulances were built on the same chassis as hearses. Funeral homes sometimes ran the ambulance service. They did not carry Oxygen, Defibs or other equipment we consider essential today. People expect EMTs and Paramedics on the ambulances nowadays.
    People “burn out” after responding to calls involving trauma, medical emergencies, suicides, domestic violence, mental health issues, drugs and other medical issues. Some volunteer ambulance services are now paying staff for “on call” time in order to meet the 24/7 staffing.

    Rapid City used to have private ambulance services. The last one folded and the RC Fire Dept. now operates the ambulance.

    State law allows the formation of ambulance districts to provide funding for ambulance service. Several areas outside the city limits of Sturgis formed an ambulance district and contracts with Sturgis for service. Sturgis was going to cut service to areas outside the city limits because the rural areas were not providing enough funding to cover expenses.

    There may come a time when we have to go with a county run service with full time paid staff.

  15. Porter Lansing 2022-01-13 17:59

    Mortuaries running the ambulances? #HolyBusinessOpportunitiesBatman

  16. jerry 2022-01-13 18:22

    22.7% rent increase in a year! Someone please define affordable housing. Would it be something like this?

    “Rent Trends. As of January 2022, the average apartment rent in Rapid City, SD is $622 for a studio, $1,162 for one bedroom, $1,467 for two bedrooms, and $1,633 for three bedrooms. Apartment rent in Rapid City has increased by 22.7% in the past year.

  17. Porter Lansing 2022-01-13 18:37

    @Jerry – add $350 to each of those in my little town. My photo studio is a grand a month.

  18. Guy 2022-01-13 21:33

    Porter & Jerry, yes and we need more government subsidized apartments for workers. This is NOT right. Affordable SHOULD BE a basic human right in our state and in our country. I recently watched an educational documentary on SDPB (PBS World) about the negative influence a lack of affordable housing had on families in this nation. I was having coffee in my income adjusted apartment (government-subsidized) of 2 years, before going to work and I watched the show entitled: “Tightrope: Americans Reaching for Hope,” hosted by journalists Nicholas Kristof and Sheryl Wu Dun. They followed several families who lived in hotel rooms because there was no affordable or subsidized housing. Most of them worked full-time jobs and trying to make ends meet. I could relate to this show and the stories told. There is something VERY WRONG in our society where families have to live in old hotels that have been converted into apartments because there is a lack of affordable housing in their communities and they still work to make ends meet. I stand by my view that there needs to be a political movement for more affordable housing and LESS TAXPAYER money spent on corrupt projects to build shooting ranges and projects for wealthy special interests running things in Washington, D.C. and Pierre. This is such a SAD INDICTMENT on the affairs of our current society.

  19. Guy 2022-01-13 22:08

    Ronald Reagan and Congress dramatically cut the budget for affordable housing in the early 1980’s according to the show: “Tightrope: Americans Reaching for Hope.” Since then, we’ve destroyed many, many, many affordable housing projects. We are still living with this legacy from the 1980’s of destroying affordable housing.

  20. Arlo Blundt 2022-01-13 22:51

    Decades of neglect, and now we are at a tipping point. The Governor doesn’t offer much to solve the recruitment problem. EMT’s are dedicated bur aging out as our demographics, particularly in rural counties is gray and grim. Don’t look for the Republicans to come up with a solution as it is a real world problem.

  21. jerry 2022-01-13 23:08

    Each city should be required to set aside quality land building sites, with decent access to grocery and other amenities such as school access, public transportation (that would schedule runs 24/7 to worksites) and good roads. These should be funded by a contractors excise tax that would include developers in a big way. The TIF’s that are handed out, should also have money for these projects, included.

    Housing would have a requirement of super insulation, sound insulated and have solar panels and a set amount for electric power per month by demand controllers. Tenants would be required to maintain there usage and be taught how to utilize the controller. 2 story buildings would be used with the bottom floor for disabled workers or workers with disabled family members as a priority.

    The rent could not go above $350.00 per month. The utilities would be $100.00 for a family and $25.00 for a single or couple married or not.

    We have the money to do this to support our economy and our employers. No more penalizing people with the 30% of their income, that’s not fair.

  22. Guy 2022-01-13 23:27

    Jerry, NOT just disabled…ALL WORKERS.

  23. Guy 2022-01-13 23:29

    Jerry, there are lots of workers who are NOT disabled and can NOT make ends meet…do not forget them.

  24. jerry 2022-01-13 23:42

    They should be given the help and the housing they need. For such a great, powerful and most importantly wealthy country, surely we can do better for all our people. Homelessness and hunger, should not be allowed, period.

  25. ABC 2022-01-13 23:50

    I agree with the last 2 writers.

    Not spending money on housing (money sitting in the state treasury, unspent) is an impeachable offense.

    Why aren’t the Democrats talking about Impeachment of Noem? They are too busy chasing crumbs on the floor.

  26. jerry 2022-01-13 23:53

    Make some offers that make sense sense equals cents in the pocket. Get off the dumb wagon and find a way to pay for what you want. The state government sits on millions of rainy day money, and for what, we are in a drought in all magnitudes. Demand the help you need from a state government that is totally out of this planet. If they won’t do it, ya just might elect someone who will go to bat for you… or just die waiting for something to happen.

  27. ABC 2022-01-13 23:56

    We WILL Scandanavian-ize this State, housing is a Basic Human right ! It will happen, sooner or later, I vote for SOONER.

    Capitalism and Trumpian Republican Party here is FAILING humanity, by letting the Covid Housing Money SITTING
    in Pierre, unspent!

    The State of SD Constitution does NOT enshrine Capitalism or Trump or republican Party. The Constitution will change,
    as We the people will vote to change it!

  28. Guy 2022-01-13 23:57

    ABC, “Abuse of Power” in the Sherry Bren case, ALONE, should have launched an impeachment trial.

  29. ABC 2022-01-14 00:01

    The idea that the Constitution makes Capitalism sacred is so untrue, another lie.

    Does the Constiitution say, here we are in 1889, nothing will ever change, your stuck with whatever we have now? Of course not.

    Hating paying taxes is a dumb American thing to do. Without taxes, we would all suffer. Try driving Sioux Falls to Rapid
    with no highway money fixing the roads.

    Believe it or not, the meek and the SMART and the compassionate inherit the earth (and enjoy it while we’re here).

  30. Guy 2022-01-14 00:05

    ABC, when you suggest “Scandanavian-ize this state,” I am surprised that hasn’t already happened?!? I lived in East River for 5 years, where there is more Scandinavian descent and more population and I have to say, I am SURPRISED that hasn’t rubbed off in a little more socialization to benefit the citizens of this state?!? I guess the ancestry is where that stopped? It’s just not “Scandinavian” either, I had Belgian relatives and had first visited Belgium as a kid and was impressed by their responsible socialist system and could not understand why we, in America, couldn’t adopt some of that reasonable and responsible socialism to help our fellow citizens. But, I guess that today, you and I would be called “communists” and should either be deported or executed for such beliefs and called “un-American bastards”. I’m so sick of the greed and corruption for the few here I want to puke.

  31. ABC 2022-01-14 00:08

    The fact that we haven’t ever had an impeachment moved by legislature until 2021 shows how baCKWARDS THE
    State and the Republican Party is.

    This leads to an Executive Branch that is UNCHECKED by Legislative Power.

    A leader of a Party (be it Democratic, Libertarian, Librarian or Progressive) should DRUM THIS into the head of every candidate:

    When you get elected and SERVE in the Legislature, every day, you SHOULD KNOW, your Branch, YOU and 104 others, are co-equal with
    the Governor and the Supreme Court. Equal. Co-equal. Act like it!

  32. ABC 2022-01-14 00:16

    Scandanavian-ize is what all the countries of the world have to move towards, if we want to treat people like Human Beings.

    Thune is from Norwegian ancestors. He certainly, if he was a Senator in Norway, would NOT rail against all the social benefits
    that Norwegians enjoy.

    Ethics Law BUSTER Dennis Daugaard comes from Danish ancestry. Denmark is quite enlightened to honoring 100% of its people
    for higher wages, universal health care, paid parental leave, FREE College and University. Daugaaard is the opposite of his
    family tree.

    The love of guns and mindless individualism has led USA away from honoring every person. Unfortunately too many
    Americans love their ignorance, and say the C word if you propose a new idea or say the N word if you are born nonWhite.

    What will save us is always, new ideas and new Immigrants.

  33. Guy 2022-01-14 00:17

    …And speaking of Jesus Christ Principles…Didn’t Jesus teach about loving and helping one another in need and NOT passing judgement? You know, I keep reading that in the New Testament, but, the so-called “Christians” who run this state and country and profess capitalism while chasing money & power…sure do not act like what Jesus Christ professed in the New Testament?!? Once again, it’s like I live in a Twilight Zone. . .I’ve read the New Testament over and over and over again and Jesus sounds like the ultimate Socialist to me.

  34. ABC 2022-01-14 00:22

    I know the New Testament is a powerful story.

    Yes, the Twilight Zone is what this State has turned into.

    Mainly because Capitalism and Money and Power is NOT what the
    SD Constitution is about. Christianity does not deify it either. But Christians here fall into the trap of wanting to be liked by the
    crowd. The crowd says Capitalism and “those people” and their need to be one of the crowd overtakes their real human
    need to be loved and honored and taken care of by their fellow man and woman.

  35. Guy 2022-01-14 00:24

    ABC, well, I think if we had not fallen for Kristi Noem in 2010, Stephanie would have eventually come home and run for Governor and it would have been, in my belief, an entirely different circumstance. I truly believe Herseth would have followed in her Grandfather’s footsteps, as Governor, and put the state ahead of her own interests. I believe Stephanie would have brought us more socialism to benefit us all instead of parading around like Kristi – all for herself. You can disagree, but, I watched Stephanie in Congress and she was more about SERVING than promoting herself like Noem.

  36. Guy 2022-01-14 00:29

    If you ask for example, it was Stephanie Herseth who voted for President Barack Obama’s Stimulus (Socialism) that kept our state afloat and the budget BALANCED that Kristi Noem later used against Steph, but, was proud to take credit that the Obama Stimulus balanced our budget. I know people hate that I keep bringing that up…but it’s the truth and CONGRESSIONAL RECORD. Stephanie’s support of the Obama Stimulus SAVED OUR STATE after that Great Recession of 2008 and I have yet to hear Kristi and Mike Rounds THANK Stephanie.

  37. ABC 2022-01-14 01:17

    Herseth did good things.

    It’s the socialism, which is really the government, saying, here we are helping you. Even Norway is predominantly capitalist (except for the State Oil Co.)

    Socialism vs. 1820’s hardnose capitalism

    We will be thankful for all the good things, and the Good people will get elected to State Government. (not the flag, church and gun crowd).

    I think its always been Vision vs. Fear. That’s what the 1972 election was about. McGovern’s peaceful prosperous vision of America vs. Nixon’s.

  38. M 2022-01-14 05:13

    Have you seen what they charge to ride in an ambulance, less than one mile to the hospital? I’m sorry but if the workers are volunteers, who is getting the money?

    As I’ve said before, life is not worth much in this country and less in this state.

    All the billions we spend on defense for “just in case” scenarios however we have real issues we need to deal with in our own back yard NOW.

  39. Cory Allen Heidelberger Post author | 2022-01-14 06:55

    What did Stephanie Herseth Sandlin do to improve ambulance service in South Dakota? What has Kristi Noem done?

    Capitalism certainly isn’t providing ambulance service to rural South Dakota. Where the market cannot produce things the community needs, we must work together to meet those needs. When small communities lack the resources to meet those needs, they must combine their efforts and work through a larger community—the state or the nation—to meet those needs.

    The lack of volunteers for ambulance services is one more challenge to sustaining the rural lifestyle. lack of ambulance service, difficulty keeping teachers and other workers—is the rural lifestyle sustainable? Are we willing as a state to subsidize ambulance service for folks who choose to live in tiny, remote places?

  40. Guy 2022-01-14 08:36

    M and ABC, both of you have very good points. Our priorities to help our own citizens seem to take a back seat to special interests for a few and ridiculous war spending.

  41. Guy 2022-01-14 09:06

    Cory, I would rather subsidized ambulance service for people who really need it then to subsidize a 12 million dollar, 400 acres shooting range than a wealthy few want to build in a tiny remote place.

  42. jerry 2022-01-14 10:23

    There is a way for ambulance service for even ranches and farms themselves, MedeVac’s with a flight team to take the patients to a central care place, where they will probably end up after a triage at the local clinic.

  43. W R Old Guy 2022-01-14 11:17

    Please do not use the “Where does the money go, they’re volunteers?” to decry the cost of a transport. Ambulances are required to meet state standards in equipment they carry. A new ambulance can easily exceed $100,000.00 dollars. The service expenses for the building (maintenance, repairs, insurance, utilities, etc.) have to paid for. The ambulance has to be insured, maintenance and fuel, oil, and medical supplies carried have to be funded. The EMT’s have to be trained (165 hrs for basic EMT) and have recurring training as required by the state to retain their rating. The costs go up if there is an advanced EMT or Paramedic on the crew because of the additional training, equipment and medications carried. The ambulance service pays for this training.

    Medicare/Medicaid allowance for ambulance transport dos not cover the expenses incurred. The ambulance transport allowance is less in rural areas than in a larger city. You can thank Congress for deciding it’s cheaper to provide service in a rural area than the city.

  44. Cully Williams 2022-01-14 20:12

    $37M/yr is gross costs, before insurance reimbursements. Admittedly, it’s a very crudely calculated number.

    I love seeing Scott Ehrisman show up in a comments section, always here to remind me how blindly misinformed the public is on most issues. I worked for P+ for years, and I have a special place in Hell for that company, but let’s not pretend SFFR beats P+ to calls, or that P+ is a transport only service. I can give you the stations I wouldn’t trust to provide care of you want? Probably not, too busy ragging on P+ to work on real solutions.

    Rural areas are shutting down. Tax districts exist but clearly aren’t being implemented functionally, if at all. The plan I’m holding would effectively allow for a statewide entity that covers the patchwork holes that appear. This allows for uniform staffing standards, billing practices, medical guidelines, central supplies, etc. Hell, it even facilitates having volunteers act as first responders similar to how they do now, just without transport. It’s a decent solution to a complex problem, and it deserves at least a pilot of 3-5 services.

  45. MD 2022-01-16 20:06

    Im a bit late to the game.
    One of the drivers of the governor’s discussion on EMS is the situation in Webster. The ambulance in Webster has been privately owned for 30+ years, with the ambulance getting a $30-50k subsidy per year. 2-3 years ago, the county commission decided to pull that funding since the ambulance wouldn’t open their books.
    Now, the ambulance owner is retiring and the company is closing. They gave two years notice.
    One year in, they cannot “figure out a solution” despite hiring an outside consultant. The outside consultant is telling them what they already know – they need to develop a funding stream to make it happen – most likely through increasing taxes. Increasing taxes through an ambulance district feels off the table because they “don’t want to stick the cost on the farmers” – per the Day County Reporter and Farmer
    It is disheartening to see the lack of interest in making such a vital basic infrastructure investment out of the continued excuse of placing tax burden on farmers.
    In North Dakota, I am served by a self-sufficient EMS provider, yet I pay $40 in property taxes per year to subsidize the ambulance coverage for the county as a whole. We have to do our part to maintain that level of service.
    The nature of EMS as a public service has always had this awkward second fiddle feel – since it is tied to reimbursable medical services. In communities with a hospital, an ambulance service is hard pressed to survive solely on volunteer labor as interfacility transfers are very time consuming and hard to expect working volunteers to take that much time out of their day.

    It is true, South Dakota needs a SIGNIFICANT investment in EMS. It could start with as simple of policy decisions as requiring each ambulance service to have a call schedule and will eventually require many communities to start bringing on paid labor as we can’t keep putting this on volunteers.

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