Racing Against the Clock: Improving Speed and Effectiveness of Emergency Medical Service Response in Rural Areas
by Alexa Brooks
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.
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.
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.
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Alexa Brooks is a sophomore in the Honors College at the University at Albany, majoring in human biology with a minor in Spanish. She is studying to become a licensed Physician Assistant specializing in Orthopedic Surgery.
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I have a handful of issues with this article and would like to know the extent of experience the writer has in both rural and urban EMS. I ask this because there are a slew of factors here that are missing. Yes, rural response and transport times are normal, that is the nature of the beast, besides the difference in population per square mile, you also have terrain. This is one reason why you will see medevac helos used in rural calls. Let’s also take a look at 2 other factors.
1) Those who live in rural areas tend to wait until their health degrades further than those in urban environments. This leads to more severe and complicated treatment requirements on a medical call. Patients are also less likely to be in an easily accessible location in rural area for trauma calls, having to gain access to a snowmobile accident patient requires extraction from the woods to the ambulance.
2) Where is this data being pulled? It seems very NYS heavy in analysis. I ask because we can go into the discussion of training and standing orders differences. EMS has a track record of being the most progressive in Texas due to military medicine going civilian out of Fort Sam in San Antonio to behind the times when you end up in upstate New York. NYS you need a 70 on your exams to pass, down south, most places require an 80 or 85. NYS continues to reduce the treatments and on board drugs available to providers. Go south and you will see agencies that carry IV antibiotics, advanced hemostatic agents, hyper and hypo tonic IV solutions, some carry TPA and even whole blood. It’s the difference between bringing the ER to the patient and bringing the patient to the ER. I respect that the writer is interested in medicine and is going on to be a PA but I have a hard time standing behind articles like this that make too many assumptions and seem far more academic in nature than experience from being on the ground. And before anyone asks, yes, over 15 years experience on the ground as a medic in both states.
Thanks for reading my commentary, which was an assignment for a public health course I took last semester at the University at Albany. I am an undergraduate human biology student, so you’re correct in ascertaining that I don’t have direct experience in rural or urban EMS. My intention was to highlight a public health issue that sparked my interest and to suggest potential interventions to help address some (not all) of the barriers that exist in this complicated issue. As you point out, there are many barriers, including population per square mile, difficult terrain, health behaviors and status of rural community residents, and others. One of the interventions noted in my commentary calls for strategically locating EMS stations to help mitigate the challenges you identify.
I drew data from a variety of sources, which are linked throughout my commentary; however, as noted, there is a gap in research regarding rural EMS, volunteer EMS, and ideas for improvement across the country. And that’s part of what I find so compelling about this issue. Hopefully, highlighting some of the challenges presented to trained and experienced EMS staff such as yourself will lead to additional research that can then be implemented in the field to help close the gaps and remedy this issue across the country.
I appreciate your comments and the opportunity to talk about this important subject.
I have an issue tagging the “inadequacy of her care” as solely an EMS issue here. This story sounds like EMS transport to closest hospital with no ortho available, and transfer by another EMS to tertiary care. This unfortunately, is a reality not just of rural EMS, but most Critical Access Hospitals…..lack of specialty care.
Thank you for your input. You bring up a fair point. It appears I was not clear enough on the situation. The closest EMS service to my grandmother’s house did not have a driver at the time, so it was necessary to dispatch a crew much further away, from a different state entirely. Once that crew got to the scene, they realized they did not have whatever equipment necessary to stabilize my grandmother, remove her from her front deck, and get her to the hospital. Thus, the first crew was called again to bring the equipment that the other EMS crew did not have. Once they were able to find a driver and the equipment arrived, both crews worked together to get my grandmother to the hospital. Had one of the interventions I outlined in my commentary been available (ie, a more strategically located EMS station, paid staff, or dual dispatch services), the response time might have been much more in line with reasonable expectations
The closest hospital, the one my grandmother was taken to, has a reputation for excellence in orthopedics. I am an employee there and have worked very closely with the orthopedic department, so I personally know that there was not an issue with the lack of specialty care once she arrived at the hospital in this situation. However, I could see how this could be a common issue in many communities.