The following post is the result of a classroom writing assignment by Dr. Erika Martin at the University at Albany-SUNY who required students to write a commentary on a health-related topic of interest, explaining some of the complexities of solving the problem and offering recommendations. Three commentaries have been selected for publication on JPHMP Direct this year. Here, student Alexa Brooks looks at emergency medical responses in rural communities.   

THE SITUATION

In October of 2017, while I was away at school, I received a call that my elderly grandmother had fallen outside her home and completely shattered her ankle. She needed surgery the very next day to keep one of the bone fragments from breaking through the skin. Hearing that news and being too far away to help was upsetting, but what was more upsetting was the fact that it took two different ambulance crews to get her to the hospital more than three hours after an emergency response was called. My grandparents live in a very rural area, so about an hour from response to hospital admission is expected. But three hours and two crews? I found myself feeling angry at the inadequacy of her care, but grateful that it was a broken ankle rather than something more serious. What would have happened if she had had internal bleeding, or if it was cardiac arrest or a stroke?

This was not an unusual case, as there are known disparities between rural and urban emergency medical services (EMS) response. In urban areas, the response time for 90% of EMS calls is 8 minutes 59 seconds or less, while in rural areas the response time for 90% of calls jumps to 14 minutes 59 seconds or less. This doesn’t include the amount of time spent on scene or transit time to the hospital, as transit time for 90% of EMS calls was found to be 42 minutes in more remote areas as opposed to 28 minutes in more urban areas. Additionally, Mueller et al found that additional delays in response time, on-scene time, and transit were more common in remote areas. Not surprisingly, mortality on scene for patients with signs of stroke and/or trauma was also reported to be higher in remote areas. What causes these disparities and what can be done to fix the issues?

BARRIERS AND INTERVENTIONS

One of the largest barriers to effective and adequate EMS response in rural areas is location of both hospitals and EMS stations. In an analysis of healthcare access in New England, Li found that in rural areas with a sparse population there are fewer hospitals available. Thus, rural EMS teams have further distances to transport their patients to a hospital, which lengthens the time before a patient receives the medical care they need. Li concluded that understanding geographical area is important, and therefore crucial in advocating for new policies to address the lack of hospitals in rural areas. Similarly, Sunarin, Mayorga, and McLay analyze the locations of EMS stations in rural areas in relation to the areas they serve using a bi-objective covering model in which the first objective aims to maximize the number of calls a station can respond to within a standard time, and the second objective addresses reducing the disparity in coverage between rural and urban areas. Their study found that minimizing the distance between areas lacking coverage and the closest open EMS station provides the best solution in reducing response times in rural areas. Under this recommendation, EMS stations should be strategically located to decrease the distance between the station and areas that lack timely EMS response in order to decrease such response times and provide more rapid care in emergency situations.

Another barrier to providing effective EMS response in rural areas is the lack of paid staff. Due to the dynamics of rural areas, the EMS available tend to be volunteer and therefore lack paid staff. However, new paramedic roles have evolved to better serve rural communities, such as community paramedics that intervene in care both before and after emergency service is needed, as well as in emergency situations. Mathiesen et al found that patients had increased rates of survival in rural areas when an EMS physician was present. Thus, the inclusion of paid staff, such as the community paramedics, in rural EMS would positively impact the quality of the EMS response and lead to better patient outcomes.

Volunteer EMS face additional challenges outside of the lack of paid staff as well. These challenges, such as lack of funding and training, also directly affect patient care  (Adamshick & Barishansky, 2005). Without proper training and adequate funding, volunteer EMS simply cannot provide the best care possible to their patients. However, while finances may be an issue, states such as North Carolina found an $8 million surplus in their Volunteer Rescue/ EMS fund. Upon close analysis of budgets, many more states could find surplus funds which can aid in remedying the financial issues of volunteer squads, funding additional training, and supplying salaries for paid staffing in rural EMS.

While addressing geographical barriers and the lack of paid staff directly remedy specific barriers to adequate EMS response in rural areas, a third intervention could also aid in the improvement of the EMS response. In their study, Nordberg et al show that dispatching firefighters and police officers trained in basic life support and equipped with automated external defibrillators (AEDs) in cases of cardiac arrest significantly increased patient survival. They also found that in 54% of rural emergency cases, firefighters were first on the scene, reducing the time between the initial call and the response to the patient. Schneider et al also found that dispatching trained community members known as Community First Responders in rural areas of Scotland also reduced response times and expedited patient care. These CFRs are responsible for assessing the scene, recording vital signs such as heart and respiratory rates, and providing basic life support until the arrival of EMS. Then they hand over care to the EMS and report their assessments and the vital signs to the EMS crew so they can quickly begin to provide the necessary care to the patient. Such systems, known as dual-dispatch systems, show significant promise in increasing the quality and decreasing the response times of rural EMS.

CALL TO ACTION

Ideally, all three of these interventions are recommended and should be implemented to allow for the best EMS response possible for rural areas. However, this is not reasonable or practical. Therefore, efforts and funding should be allocated to establishing a dual-dispatch system in rural areas. This system addresses both response time and quality of care by allowing a trained person quicker access to the scene to assess and provide preliminary care to the patient while the ambulance is on its way. With the implementation of a dual-dispatch system, addressing the geographical barriers, or remedying the lack of paid staff, funds, and training in rural areas, other families will be able to avoid the stress of hearing that their elderly grandmother did not receive the EMS response that she deserves.

Acknowledgements: Thanks to Dr. Erica Martin for her constructive feedback and continuous support throughout this process.

Additional References

Adamshick, L., & Barishansky, R. (2005). Oh Brother/Sister, Where Art Thou? The Decline in EMS/Fire Service Volunteerism. Journal of Volunteer Administration, 23(4), 48-51.

You May Also Enjoy These Articles in the Journal of Public Health Management and Practice: 

• Effectiveness of the Dual Dispatch to Cardiac Arrest Policy in Houston, Texas
• Recruitment and Retention in Rural and Urban EMS: Results from a National Survey of Local EMS Directors
• Mississippi Medical Reserve Corps: Moving Mississippi From Emergency Planning to Response Ready

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