Rural Emergency Medical Services

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Most EMS literature has been developed by urban and suburban systems, with little emphasis on rural EMS care. However, rural EMS systems are an integral part of health care for the ill and injured rural patient. The rural environment provides a number of unique challenges to providers of emergency care. 17 Long distances over which to reach and transport patients are a central issue. Specialized search and rescue capabilities may be needed for off-road and wilderness emergencies. Because of the low population density of rural areas, there is a decreased likelihood that an emergency will be witnessed and emergency aid summoned. Compared to urban and suburban populations, the population in rural areas tends to be less affluent, older, and less likely to request emergency aid unless it is truly needed.

The implementation of a 911 system has not occurred in many rural communities. Enhanced 911 services, which provide automatic location identifiers, may not be as useful in rural as in urban locations because there may not be addresses to guide emergency providers. The infrastructure for basic radio communications may not be as well developed or supported. The contraction of the health care system in the United States has caused the closure of a number of hospitals, most of them in rural areas. If an emergency facility exists, it may not have specialty or critical care services. Therefore, patients must have access to air or ground interfacility transport service. Fortunately, large tertiary care facilities can facilitate these transfers, and most rural facilities are able to prospectively develop the necessary relationships and transfer agreements.

The key component of any EMS system is its personnel. Rural EMS systems face particular challenges in maintaining a cadre of EMS personnel. The volume of EMS responses in most rural communities is too low to allow for the employment of full-time EMS providers; thus, rural EMS services often use volunteers or on-call part-time personnel who are paid only when called out. Volunteer and part-time personnel have limited time for initial training and continuing education and limited experience necessary for skill maintenance. Most, but not all, rural EMS services are provided at the EMT-B level. The recent revision of the model DOT EMT curriculum allows for an increased level of service by EMT-Bs that would be useful in rural areas. They can now assist patients with self-administration of some medications (e.g., nitroglycerin for angina or bronchodilators for asthma), use AEDs for cardiac arrest, and, with the optional 10-h training module, utilize advanced airway techniques. These modifications allow a higher level of basic EMT service without having to commit rural providers to the much longer time required to obtain a higher level of certification. Innovative approaches to continuing education are also needed, particularly in isolated areas. Distance learning approaches, often in collaboration with local schools, are invaluable. Videotape conferences, satellite transmission of lectures, and computer- and Internet-based education programs are all valuable adjuncts to rural EMS continuing education.

The provision of lifesaving services on a volunteer basis entails particular obstacles. Daytime coverage for service is a challenge because most volunteers or part-time personnel have other full-time employment. As a result, many services hire a cadre of full-time providers to respond during business hours. Dispatching volunteers from home or work directly to the scene may be one method of providing daytime coverage and reducing response times.18 Recruitment and retention of providers is an ongoing problem. To address it, volunteer services may be able to provide incentives, such as retirement benefits, death benefits, and scholarships for volunteers and their children. Undoubtedly, the most powerful incentive for EMS volunteers is the fellowship bonds that develop within volunteer EMS agencies.

Medical leadership of any EMS system is crucial. Identification of a physician who is knowledgeable and experienced in emergency care and willing to take time away from his or her family and practice is a difficult problem for rural systems. Many systems depend on nonemergency physicians, such as family physicians with an interest in community health or general surgeons with an interest in acute surgical care, to provide medical leadership.

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