Rural Patients Deserve the Same EMS Care As Urban Ones

In June’s issue of EMS World, I wrote an article describing what communities deserve from their EMS system.   My position is that every call should have someone capable of administering a 12-lead EKG, CPAP, nebulized bronchodilators, pain medication, and chemical sedation.  This requires an ALS provider on every call, which sparked some discussion about responses in rural areas.  Here is an except of a conversation I had with @RVaMedic over Twitter about this:

In a paid system, every truck should have an EMT and a medic. Many rural areas still have volly squads & it’s asking a lot…

Do patients in rural areas, who are furthest from hospitals, deserve less care than patients in urban areas where hospitals are closer?  Patients in rural areas usually wait longer for EMS to arrive.   That is inevitable.  They also spend more time with the EMS practitioners after arrive, which is why I believe they deserve the same treatment arsenal.

Consider STEMI patients.  Mortality increases with each 30 minute delay in getting to the cath lab.  Unless EKG’s can be transmitted by BLS providers, one won’t be done until the patient arrives at the closest hospital.  This may be several hours after the initial 911 call was made.  If that hospital is not a PCI center, hours may pass before they can be transferred to one.  These patients deserve better things from us.

If supplemental oxygen (which does nothing to make it easier to breathe) and a bag-valve-mask are the only tools available to manage difficulty breathing, patients in rural areas will feel like they are breathing through a straw for hours before getting relief with CPAP and/or albuterol at the hospital.  Bringing these to the patient’s side will help them feel better, and often avoids an intubation in the hospital.  They deserve us to bring it to them.

Most patients are in some type of pain.  Peter Canning pointed out that untreated acute pain causes permanent nerve damage that causes chornic pain.  Medicating even minor injuries can improve a patient’s quality of life long after we drop them off.  Even when transport times are short, patients wait for an hour or more to receive pain medication in the hospital.

Now consider the experience of a patient in pain in a rural area.  They wait longer for help to arrive.  They may spend an hour or more in an ambulance, perhaps on a hard board.  Then they wait for an hour or more in the hospital to receive medication that they could have been brought to their side.  What is our excuse not to?

What’s better: BLS-only response or no response at all?

Why do we tolerate this as the only options?  How important are these interventions?  We expect the same level of  service from rural police departments, hospitals, and schools, why not EMS?  The “volunteer BLS or nothing” box is one we have built – not the communities we serve.  Other countries get these interventions to rural areas.  Knowing what we know about how effective they are,we have a responsibility to get them to our patients.

Who’s going to pay for volunteers’ tuition to medic school and pay compensation for the work they’ll miss?

Communities are willing to pay for police officers, nurses, teachers, football coaches, and parks workers, but for some reason we expect people to drop what they are doing to answer EMS calls for free.  I am not against volunteers in EMS – in fact I used to volunteer in a community not far from @RVaMedic.  However, I do believe that the depth and breadth of EMS education needs to be much higher than it is today, and that it is unreasonable for communities to rely on volunteers to obtain it.  It is even more unreasonable for volunteer organizations to be nimble and adapt when new evidence emerges.

In Australia, volunteers supplement well organized paid systems where the minimum education requirement is a bachelor’s degree.  Paramedics rotate between urban and rural areas, and deliver similar treatment in both settings.  They have a model we can learn from.

I’ve written before that it is time to draw a line in the sand between good clinical care and excuses.  There are good excuses for not delivering evidence-based care to patients in rural areas, but they are still excuses.  We seem to get stuck in “this is all we’ve done, and this is all we can do” boxes that we can’t see outside of.  Instead communities should take the latest evidence about what treatment helps patients, look outside the boxes that have been built, and figure out how to deliver it.

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  1. I am not sure there needs to be an “ALS provider on every call” but an ALS provider available for every call.

    Someday we will look back at this quaint notion of people providing essential out of hospital healthcare for severely ill and injured people for free and chuckle.

    I think it is both possible and inevitable that communities will have EMS without having volunteers.

    I am going to hand the saw back to you because this limb isn’t as big as I thought it was …

    • emspatientperspective says:

      Thanks Greg. I can think of a lot of things that I hope we look back at and chuckle. One of them is that we allow people with a high school diploma and a 200 hour class, which does not require the demonstration of any skill on live patients in a supervised clinical setting or a field internship before certification, to be the highest medical authority delivering that essential out of hospital healthcare to severely injured people. That’s one reason I believe that an ALS provider should be on every call.

  2. Lisa M. says:

    Like Greg said, ALS should be available on every call; but everything works in theory and in our utopian version of EMS that make for good blog posts. But we don’t live in a utopia with infinite tax dollars to pour into emergency services, at least I don’t. I grew up in a very wealthy suburb of DC with a fire station and fully equipped ER within a mile of my house; I was totally flabbergasted when I found out that most EMS and fire in Virginia is volunteer, and most counties have one or two sheriffs available at any one time. But once I got over the culture shock and “this isn’t right!” thoughts, and looked at reality, my opinion changed. A BLS response with transport to a small community hospital with limited resources is absolutely 100% better than no response at all. Your example STEMI patient is sure to die without treatment, but he has a chance if he has a BLS provider to administer aspirin and oxygen, and transport to an ER. So, is “BLS is better than nothing” so wrong if it gives a patient a chance?

    Is it ideal? Is it fair? No, but it’s reality. Do the rural patients deserve less than their urban or suburban counterparts? Of course not; but again, it’s reality. Each time this topic comes up on Twitter, I ask “where is the money going to come from?” and no one has been able to satisfactorily answer it within the confines of reality. Plenty of “shoulds” but nothing realistic. I’ve worked in urban, suburban and rural communities, volunteer and paid, 911 and non-emergent transport services, BLS-only (sometimes, *gasp* driver-only with an EMT) and ALS/BLS teams, so I have a more complete perspective than a lot of people. Much of Virginia (and the south) is conservative, rural and struggling to make ends meet–a combination that doesn’t make increasing taxes easy. With little money in a county’s coffers and no hope of socialized healthcare that could bring paid EMS to every community, we have to be realistic and do what we can with what we have to help people.

    • emspatientperspective says:

      Gee Lisa, so that is it? We’re just going to give up? Knowing the benefits of pain medication, CPAP, 12-leads, and all the other good things EMS can do, we’re okay huge sections of the country not getting them? I would consider those the standard of care, not utopian care. As alleged professionals, why are we okay with people who wear the same patch and carry the same cards hold our standards so low?

      I’ve worked in the same variety of systems you have, and in one not far from you. I am well aware of what the reality is and choose not to accept it. In addition to writing blog posts, I’m the Delaware’s state advococy coordinator for NAEMT. NAEMT just released a position statement calling for shared goverment funding – local, state, and especially federal – to make EMS an essential public function. You can read the statement here. That would take care of the “no response at all” part of your equations. BTW, Delaware has a largely state funded EMS system that gets paid paramedics to rural areas that support Tea Party candidates.

      BLS may be better than nothing, but I don’t think we should accept that it is good enough.

  3. Andy Johnson says:

    Most all rural and many suburban areas don’t have the call volume and thereby the reimbursement monies to sustain an ALS provider on every ambulance. We would love to be able to provide every patient in every communitty on every street the best EMS care there is, but we need to realize that the current system of funding and copious number of agencies in the same area needs to change. There needs to be consilidation of resources to achieve a more equal level of care to a larger area.

    In New York State, we are still very lucky to have the funding to reimburse agencies for certification training. Although, it has not increased in years and does not cover the entire cost of a course, it is better than nothing.

    We are seeing smaller agencies dissolving because of lack of staff and lack of funds. Municipalities seldom step up to assist these agencies and thereby leaving their constituants with sub-par or no EMS coverage. Until EMS is on the same level as law enforcement and fire with funding and legislation, I don’t see much of a change.

    • emspatientperspective says:

      Thanks Andy. Gary Wingrove and Chris Monteral have thought way outside of the box with community paramedic programs that get ALS into rural areas. Under Obamacare, funding for EMS is about to turn upside down. I think there will be a lot of consolidation, which I also believe is a good thing.

  4. As Winston Churchill once said, “Never! Ever! Give up! Many of the advances that we have in EMS today are as a result of a group of people who didn’t take “No” for an answer. It is true that, financially, we live in an entirely different world than that of ten years ago. However, society has always faced challenges. The question to ask is “How will we overcome this one?”

    I agree that the concept of providing medical care as a volunteer is probably one whose time has passed. It is nearly impossible to maintain skill proficiency with only sporadic responses. This is one ara that hospitals should step up and step in. I am not, necessarily advocating for EMS responders to be saddled with in hospital assignments and run responses between (that brings a host of problems in and of itself), but let’s face it. Healthcare begins outside the confines of the hospital walls. Shouldn’t EMS in the rural areas foster partnerships with them?

    • emspatientperspective says:

      Amen, Bill. Why should hospital clinical time stop after paramedic school? There are always issues like you describe, but they are not insurmountable.


  1. […] Sullivan follows-up his June EMS World article on rural patients deserving ALS care. Many communities choose to remain at the basic level and the decision is relatively easy when […]

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