I grew up in Los Angeles so I am a city transplant like yourself. I have only worked in rural areas since I became a paramedic 3 years ago. Prior to that I worked in a large city for 6 years as an EMT so I have seen both worlds. Like the above posters said, in a small town everyone knows everyone so watch what you say. Chances the patient's family knows your supervisor. A patient is a patient no matter where you go. A CVA, MI or trauma is the same in a small down as it is in a big city. That being said, some of the things I wish I had known about working in a small town before I started were:
Depending on where your specialty centers (Trauma, STEMI, etc.) are, review whatever local policies are on air transport. In big cities, air transport is not a factor. Also, know the landing zones where the helo will actually go to and the ETA of a helicopter to them. Many air medical agencies have pre designated landing zones and it is up to the paramedic to pick the closest one.
Know your local resources and be prepared to do more with less. For example, in a large city, a MVA with 5 patients might get 3 ambulances. In a rural area, you might not have three ambulances in the entire county. Definitely do not be scared to call for the appropriate resources, but be aware they might be coming from a distance or not available at all. I was first on to a MVA with multiple ejections once and my 2nd in unit was coming from 15 miles away, and the 3rd in was even further out.
Country folk do not like calling 911 as a general rule. They are rugged and independent. Many times if they call you, they desperately need you. I have seen compound open fractures and arterial bleeds come into the ER via private vehicle because the patient said "ambulances are for emergencies only." (For a comparison, often country folk take about as long to call 911 as some SNFs do and usually wait until they are as sick as a SNF dos.) Be prepared to run some serious calls where the patient has been deteriorating for awhile.
Know your first in area, including local terminology for locations. Some locations are hard to find and mapping can be an issue in the small towns. Instead of 123 Main street you will hear "the patient is down a dirt road 1/2 mile north of the old railroad bridge near the old stage route." There is a definitely a learning curve when it comes to navigation. Hopefully your partner will be able to orient you to the area.
Maintain a high level of professionalism with your local hospital, fire department, law enforcement, etc. You will probably be on a first name basis with all of them fairly quickly. You do not want to develop a bad reputation because those are hard to shake in small towns. You can not simply lay low if you irritate someone like you can in larger cities.
You will be part of the community. People will wave at you. Children will come up and want to see the ambulance. People will come up to you and make conversation in the stores and on the street. At least where I work, EMS personnel are respected members of the community. Embrace that, even if it seems strange at first. A little PR goes a long way. When there are big public community events, if we do not have a dedicated standby unit, I will usually stay in service but attend the street fair, parade, graduation, etc. The public likes to see their local EMS being a part of the community, and simply being there and walking around gives a good impression.
Also, when you run a tragic call, be prepared for people in town to ask you about it. Word travels quickly and chances are the person all ready knows about it but wants to hear about it from someone who was there. If it was a fatality chances are they knew the person that died or their family from school, church, work, 4H, FFA, etc. Remember to keep yourself tight lipped and HIPPA compliant. You will know anything and everything that happens in the town. Every roadside memorial you will know the backstory to and will probably have been at that scene. That can trigger a wide range of emotions. It seems in small towns as if we feel the communities pain every time something bad happens.
I love rural EMS and would not trade it for anything. However, those are just some of the things I wish I had been told before I started. Good luck!!!!!
