Our colleagues in pediatrics often remind us that children “are not just little adults.” In much the same way, rural EMS is not just “little” EMS. Rural EMS departments not only face the same issues as their urban counterparts, but also must cope with challenges specific to rural areas, such as limited local resources and geographic isolation.¹ Because of these differences, rural EMS requires more than just downsizing an urban system to be successful. This chapter will highlight some of the challenges unique to rural EMS systems, and allow the reader to begin to develop an approach to rural medical direction.

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  Describe the unique challenges to providing emergency response and EMS care in rural locations.

  
  
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  Describe differences in volunteer/paid status, provider certification, experience level, and burnout rates when compared to urban EMS.

  
  
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  Discuss how resource utilization may be different in rural areas.

  
  
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  Discuss unique injury types and safety concerns in rural areas.

  
  
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  Describe challenges in EMS agency finance.

The term rural brings to mind low population density, few resources spread over a large area, and perhaps a harsh or austere natural environment. The US Census defines “rural” as all areas that are not urban, with “urban” defined as areas having at least 2500 people.² Based on this definition, about 72% of land in the United States is considered rural, and about 14s% of the US population, or around 46.2 million people, live there.³ The term frontier has also been used to classify locations of even smaller population density, and is generally defined as a population of six or fewer people per square mile, and a certain traveling distance from key services such as hospitals.^4,5 According to this definition, about 56% of total land area in the United States is frontier, and about 3% of the population resides there.⁶ For this chapter, unless specifically stated, the term rural will serve to represent both rural and frontier areas (Figure 17-1).

As difficult as it is to define rural areas, it is also difficult to make generalizations about the characteristics of rural populations in the United States. Sometimes, there is more variation between rural areas in different regions of the country than between rural and urban areas in the same region. Looking at census data from across the United States, a greater proportion of the rural population is older than 65 and white, fewer have graduated from college, and there is a lower mean household income as well as a higher poverty rate. In terms of health-related measures, there is no significant difference in health insurance coverage between rural and urban areas, although this varies by region. On a self-reported survey, more rural adults are current smokers, are obese, and more have hypertension, heart disease, cancer, or have had a stroke. Disparities exist in many areas of health care as well. There are proportionately fewer primary care physicians, with about 5 to 6 per 10,000 population in rural areas versus 9 per 10,000 in urban areas as well as far fewer specialists.⁷

Despite a general decline of age-adjusted mortality over the years in both rural and urban areas across the country, the rate of decline has become less in rural areas, leading to a rural “mortality penalty.” The cause of this remains unclear, but is present in cardiac disease, cancer, and stroke, the three leading causes of death in adults in the United States.8,9 Theories include difficulty initiating appropriate interventions in a timely manner for patients with time-sensitive medical conditions, such as acute myocardial infarction or stroke, and the difficulty of small hospitals in implementing advances in medical care. Although not specifically studied, it stands to reason that a lack of robust EMS systems in many rural parts of the country may contribute to this mortality penalty for rural residents. This highlights the need for improvements in all aspects of rural health care, including EMS, and the importance of active medical direction.

The challenges for rural EMS systems to help combat the mortality penalty are highlighted in some of the major medical emergencies faced by EMS on a daily basis. ST-elevation myocardial infarction (STEMI) is well established as a time-sensitive medical condition with the traditional goal of PCI being achieved within 90 minutes from arrival at the hospital (“door-to-balloon” time). However, since many patients have the diagnosis of STEMI first made on initial evaluation by EMS, emphasis is now being placed on EMS-to-balloon time, with the same goal of 90 minutes.¹⁰ However, it is estimated that 43.6 million adults in the United States live more than 60 minutes from a PCI-capable facility.¹¹ This makes early recognition of STEMI by rural EMS providers especially important through symptom recognition and early prehospital ECG acquisition.^12–14 Combined with prearrival notification of the cardiac catheterization lab team, and development of protocols to bypass closer but non-PCI capable facilities, rural EMS can help reduce delays and improve outcomes.^10–15

Studies also suggest worse outcomes for stroke patients presenting to rural hospitals. Barriers to stroke care include lack of neurology specialists and designated stroke teams, lack of 24-hour CT access, and decreased comfort of providers in giving thrombolytics. Furthermore, standards of stroke care tend to be developed at large urban medical centers with extensive resources; implementation of the same standards in small rural hospitals may be impractical.¹⁶ Prehospital care of the stroke patient begins with recognition of the signs and symptoms of an acute stroke, determination of the time of onset of symptoms, and prearrival notification of the nearest appropriate facility.¹⁷ Unfortunately, it has been shown that EMS can have difficulty in stroke assessment. In response to some deficiencies in rural stroke care, the Montana Stroke Initiative sought to provide stroke education to communities, prehospital care providers, and rural hospitals.¹⁸ This and similar training programs are available to EMS providers and may help improve rural stroke care.

In addition to the challenges of rural cardiac and stroke care, multiple studies have shown a higher rate of mortality for rural versus urban trauma victims, for all causes of trauma.^19–22 The cause of this disparity is still unclear, but factors specific to rural environments, such as distance from the scene to definitive medical care, higher speed limits on rural roads, decreased seat belt use, alcohol intoxication, and transport to local hospitals versus trauma centers may all play a role. Studies have reached conflicting conclusions as to the role EMS time intervals (activation, on scene, and transport times) play in mortality in trauma. ^19,20,22 Intuitively, shortening the time it takes to reach a hospital would improve survival; studies show IV placement en route rather than on scene achieves a shorter time, while demonstrating a higher success rate.^23,24 However, other studies have shown improved survival for patients with longer EMS contact time, possibly due, in part, to transporting directly to a trauma center and bypassing smaller, less equipped hospitals.²² Providers may be uncomfortable transporting potentially critical patients past a local hospital to a regional stroke, cardiac or trauma center; however, medical directors should work with EMS agencies and the local and regional health care systems to develop the most appropriate approach for the area.

In addition to the everyday call types of all EMS agencies, there are some illnesses and injuries unique to rural areas. Farm equipment such as tractors, augers, corn huskers, combines, and thrashers all have multiple dangerous moving parts capable of trapping, crushing, or amputating body parts. In addition, typical EMS rescue tools may not be effective on farming equipment and their use may inflict further injury to the victim.²⁵ Although most new farming implements come with warning labels and safety mechanisms to help prevent injuries, older equipment may not have these, or workers may intentionally disable safety features to ease access for maintenance. Farm workers may also routinely come into contact with various fuels, solvents, pesticides, and herbicides, which can result in life-threatening exposures and potential exposure to responders. Furthermore, many locations, such as grain silos and livestock pens can pose unique challenges for patient access. Programs, such as the FARMEDIC program begun in the early 1980s in New York State, can help train rural EMS providers to deal with these unique situations, and may be a valuable addition to standard EMS training.²⁵

In addition to chemical exposures on farms, large agribusiness or other industrial plants may pose significant HAZMAT risks for the surrounding area. It should not be assumed that the facility’s response plan to an event is adequate or accurately estimates the capability of the local EMS agencies. Frank and open discussions with facility safety personnel by local EMS agency staff, including the medical director, can help both sides understand the potential risks and develop response plans for any possible event. In addition to fixed sites, rural EMS agencies and systems must prepare for potential HAZMAT events occurring while dangerous materials are in transit through the area. There may be particular hazards for a specific region based on rail lines and transport routes. Familiarity with HAZMAT procedures as they pertain to EMS response is important for medical directors, and is covered in detail in other chapters.

Rural areas are home to many unique and sometimes socially independent populations. Native American reservations are found in many rural areas, and may have independent medical care, but also utilize local EMS. Other unique populations include isolated religious groups, such as the Amish, and other independent-minded individuals, who may have nontraditional attitudes toward modern medicine. For example, the Amish do not object to modern medical care; however, vaccination and prenatal care may not be routine, and they often do not purchase health insurance.²⁶ Therefore, the cost of medical services is paid out-of-pocket from the entire community, and is a consideration when outside medical care is sought. This can result in more serious presentations of disease not routinely seen by EMS personnel, particularly with trauma, obstetrical, and pediatric emergencies.²⁷

Beyond the atypical patient presentations, rural EMS agencies may also face wide variation in the size of the population being served. The population surge may be over days to weeks in the case of county fairs, rodeos, and sporting events, or over weeks to months in the case of seasonal attractions, such as ski resorts and national parks. Seasonal migrant workers may also expand the population at various times of the year. In some cases, the population surges are impressive.²⁸ The Black Hills Motorcycle Rally in Sturgis, South Dakota, adds 500,000 to 750,000 additional motorcyclists to the usual population of around 6000 almost overnight. Yellowstone National Park attracts about 3 million visitors each year, above the state population of 493,000. These massive surges are particularly challenging in rural areas where resources are already very limited. Defined events such as festivals may require weeks of ­planning, and may require coordination between multiple agencies, and possibly contracting with additional commercial ground and air medical services to fully prepare. When EMS agencies are working together, it may be necessary to modify protocols or grant temporary credentials for providers working under a different system. In addition, providers and medical directors should plan for the demographics of the expected population surge, and the expected illness or injury patterns. Trauma is to be expected at ski resorts and motorcycle rallies. In addition, however, visitors to parks and festivals may have multiple comorbidities, leading to complicated presentations to EMS.

Many of the challenges with rural EMS medical direction rise from the unique characteristics and differences in both providers and agencies compared to urban systems. Rural providers are more likely to be volunteers, older, EMT-B level providers, and often have less access to training programs and continuing education opportunities. ^29–31 Recruitment and retention is especially difficult in rural areas. Many rural EMS providers choose to volunteer; however, demands of work, family, and other activities, coupled with the significant time commitment of EMS and lack of appropriate pay, mean that rural agencies have a harder time filling vacancies. Rural agencies have attempted to solve these problems in unique ways. One volunteer BLS agency encourages members with a $20 per shift stipend. Another rural area uses a paid ALS agency to cover a large area, and maintains a volunteer BLS agency as backup. After their local ER closed, one hospital provided and staffed an ALS intercept vehicle to help rural BLS agencies. Unfortunately, not every rural EMS agency has this ability and recruitment and retention remains a major issue.³²

Even if an individual is willing and able to serve, becoming certified and maintaining that certification can be very challenging. EMS students may have to travel long distances several times a week for EMT classes and clinical rotations, making it even more difficult for rural providers to attain advanced certification. In addition, once certified, maintaining certification and skills retention can be daunting in many areas due to lack of education resources. Some of this can be accomplished through computer programs and distance learning programs, and/or teleconferencing to provide training and continuing education to EMS personnel who live far from education centers.³³ In addition, a rural EMS medical director must take the time to hold regular training sessions to ensure continued competency of the providers operating under his or her license.³⁴ This can be difficult if the medical director does not live or work locally or provides direction for multiple agencies. However, creative solutions such as meeting with multiple small agencies at once or utilizing regional resources to provide some educational materials and supplies may help.