Rural EMS

[Epi-do]

What can you tell me? I have been in EMS for 14 years, but all of it has been in an urban system, working for relatively well funded services. My new job is in a rural area. While I am excited about the new opportunity, I know there is going to be a learning curve.

I already know I am not going to have some of the equipment I am used to having. For instance, despite the crews wanting 12-leads, they do not have that capability. Also, they do not have capnography, and if I remember correctly, I didn't see CPAP on the trucks either.

I know that most of the departments we will be running with will be volunteer, instead of all paid departments (which is what I am used to). That means, less help on runs where extra hands would be nice. I will be going from being one of 2 or 3 medics on a scene to being the only medic. However, they do use advance EMTs who will be going through the bridge program to the newly defined Intermediate level. That means I basically will have someone that can get IVs for me while I attend to something else, if needed (at least until they complete the bridge).

I have also been told to expect sicker patients since a lot of the people "don't want to bother anyone" and will wait until they are totally sucking mud to call. I will get to become more familiar with HEMS, since they tend to fly critical trauma patients due to distance from the Level 1.

I think I am going to take a CCT class once I get settled in to the job, since they also do transfers from the community hospital to the bigger hospitals in Indy.

Beyond that, any words of advice or helpful tips from those that have been there/done that? I would love to hear anything from "this is what you should expect" to "I have found that doing xxxx works well in yyyy situation."

 

[ffemt8978]

Rural EMS is a completely different beast in some aspects. Initially, the hardest part will be learning where everybody is, since directions like "Turn left at the stump" are not uncommon.

You will end up spending more time with your patients, so you will develop better history taking skills and learn more how vital signs trends can become important.

You will probably see more disfiguring trauma, especially from farm equipment (depending upon the area). All in all, you will need to be ready to improvise, adapt, and overcome. I've taken more than one patient to the hospital using duct tape to stabilize the metal rod that penetrated their torso.

Waiting for law to secure a scene will become a long process, depending upon how far away the nearest deputy is.

These are just my experiences from working primarily in a rural environment with a year working an IFT ambulance in a large city.

 

[medic417]

Define rural. Are you really a long way to hospitals? The fact that you get helos on the ground indicates not being extreme rural.

 

[RocketMedic]

Learn to improvise 12-leads, brother, and agitate if it's possible to get one. LP-12s and the first-generation MRx are both readily available and cheap for a service to buy, especially with grants.

WhisperFlow CPAPs are fairly cheap, as are the first-generation machines that bigger services are phasing out. Perhaps you can point out that they're safer than furosimide and cheaper.

If your service is short staffed, you can often find a niche in education or grants. Often times, states will have grants available for rural services- it may take work and collaboration with the VFD, but it's a funding source.

 

[hogwiley]

I agree with the one who said finding patients is more difficult. A lot of these back country roads arent going to be on a GPS, and just seeing addresses, road signs and landmarks can be challenging on dark nights, especially with rain or heavy snowfall, as you arent going to have any artificial lighting around. Weve had to use thermal imaging to find patients lying in fields or brush a few times.

If you will be working in a northern climate deep snow and ice covered roads will be an issue as they arent going to be plowed right away, and you will obviously be driving in the same conditions that cause accidents. Also dont be surprised if you turn bambi into a hood ornament on occasion.

 

[ffemt8978]

Define rural. Are you really a long way to hospitals? The fact that you get helos on the ground indicates not being extreme rural.

Not true. We're rural by any definition (closest McDonald's is an hour away) and we do a lot with helos because of the reduced transport time.

 

[medic417]

Not true. We're rural by any definition (closest McDonald's is an hour away) and we do a lot with helos because of the reduced transport time.

My thought of rural is helo more than an hour away. But I forget I am frontier not rural. Carry on.

 

[RocketMedic]

Heck, Oklahoma City still has plenty of rural areas. 20 miles from OU-Presby is some of the backwoodiest places in the state.

 

[lightsandsirens5]

Having done very little Urban EMS I cannot provide a compare and contrast for you, but I'll do my best to explain what could be differences in my mind.

You have already hit a big one. Prepare to be the sole ALS provider on a patient. In many cases it'll be you and your partner with no backup available within a reasonable about of time. Do you know how long HEMS response is to the area's you cover? Sometimes for me it is almost an hour. This can make a huge difference in transport decisions. I don't know if I speak for all HEMS services, but MedStar NW and Lifeflight Network (who provide overlapping coverage for us) would rather get the call early than late. Ie. if it sounds bad enough for a bird, treat it like it is till proven otherwise.) If you get on scene and find something needs flight, but flight is an hour out, it's too late. So I guess that is my number 1 point: Be aggressive with the bird.

Second would be be aggressive with the patient. We probably see the same percentage of high acuity patients out here, but seeing as how we run fewer total calls, we see fewer high acuity pts. So while the true "life and death" pts are few and far between, they tend to be really bad, as opposed to just bad. One reason being sometimes it takes you an hour to get to them. (Hence being aggressive with the bird.) But if HEMS can't fly or isn't available, intervene early and often. If you have a true anaphalaxisis (spelling) you might have to give insane amounts of epi over the course of a 90 minute transport through the snow. Nothing truly life threatening "can wait" for an around the block trip to the ER. It has to be dealt with by you, right away or you might as well go to the morgue. Also, utilize AEMTs to their fullest. Someone who can start IVs for you when you are the only medic is worth their weight in gold.

Third, a higher percentage of people will be stubborn. (I think). They might not call for a long time, if they call at all. I have numerous times been sitting at the ER writing report when someone who is pretty bad off hobbles into the ER and collapses at the check in desk. One time we had the ER crew ask us for help getting a patient out of a vehicle. He had cut his leg off with a chainsaw and driven himself to the emergency room.

Forth, watch out for the deer! Not kidding at all on this one. In general traffic dynamics are totally different then in an urban environment. Don't be surprised at all if you come around a blind corner and there is a tractor hauling an implement that occupies 75% of the road surface.

Other stuff would be things such as law being farther from you than you were from the scene. In my county, between 0300 and 0700 there are no on duty officers, deputies or state troopers. Not saying that means you get to play recklessly, just keep it in mind. You begin to realize the real importance of trending vitals and such. I've been with patients in the back of my ambulance for three hours in heavy winter weather. That's a long stinking time, especially when they have been gored by a bull, driven a tractor over their leg, etc.

Comms can be tough. Repeaters are few and far between and cell service is spotty at best. Don't be surprised if you cant get a hold of OMC on many calls. Coupled with that then comes possibly more open protocols and more leeway as far as making aggressive decisions. Get to know the MPD if you can. It is great to be friends with the guy that writes the rule book, especially when sometimes all you have is what he wrote and no contact with an MD. Just seems to have helped me when I have questions regarding flowcharts and such to go right to the source and hammer it out in my mind before I need it. Cause when I do need it, there probably wont be any fall back if I am not 100% sure.

Lastly, directions. They will suck. Period. "Per RP take County Road 184943 three miles to the fork, take the left fork. Once you reach the old magnesium smelter take the second right. There will be a pink barn on the left, go right there. The driveway is across from an old rusty Studebaker on its side in the corner of a cornfield. There is a pine tree growing out of it." Literally had directions like that. My experience has been that unless it is in a RFPD, on one marks their address either, and if they do, it is on a piece of plywood, hung in a tree, painted in brown paint. You will also do a lot more rendezvous calls where the pt starts in pov and you meet up with them somewhere between their place and the ER. Get to know the roads. Memorize the county mapbook till you at least know which direction to head out of the station initially.

If you ask my honest opinion, rural EMS is far and away more enjoyable then urban EMS.

Oh yea, and one more thing. Be prepared. Don't be paranoid, jut be ready for anything. In the winter I carry a backpack with an extra set of warm clothes and enough stuff to survive in an upside-down ambulance for a few days. Never know what will happen on icy roads in the middle of a blizzard.

And above all, have fun. Rural EMS is amazing.

 

[Epi-do]

Thanks for all the input so far! You all have mentioned things I didn't even thing about, i.e. PD being further away. I am really excited about this new job. I have always thought working rural EMS would be fun and challenging, but never really thought I would get the chance.

I have been told the medical director is really cool, and pretty laid back. I am getting anxious to see my new protocols. I may see if I can get a copy of them to look over while I am out there on Monday, so I can start getting familiar with them before I start precepting.

 

[firetender]

You're also going to be immersed in whatever culture dominates the area. People will do things differently than you city folk and being the outsider, you get to adjust until you build enough trust with the community you serve.

Kiss your anonymity Goodbye! You'll be living under a microscope. It'll take you a while to find places you can hide.

And God forbid you may even find yourself caring more because these are your neighbors!

All in all, pace yourself for the long haul, don't be too City Big and what to you in EMS are SOP; to them they are huge innovations so step quietly into your role as an agent of change.

"Earn their trust", that is your mantra!

 

[CritterNurse]

I know that most of the departments we will be running with will be volunteer, instead of all paid departments (which is what I am used to). That means, less help on runs where extra hands would be nice.

I've been with a rural volunteer department for a few years. I spent a short amount of time with a professional ambulance company. From my experience with the professional company, you went to a call knowing you had x number of people showing up, and knew you could call for more help. From my experience with rural volunteer departments, the number of responders depended on the time of day, the day of the week, and other variables. You could have more people than you could possibly need, with several standing around just waiting for something to do, or you could be calling dispatch to tone the fire department so you could at least have a driver to drive the ambulance while you treat the patient on your own in the back.

 

[stairchair]

Never hesitate to request fire rescue as a rider or driver. Its a long trip and you might need the extra hands.

 

[Shishkabob]

I know that most of the departments we will be running with will be volunteer, instead of all paid departments (which is what I am used to). That means, less help on runs where extra hands would be nice.

While you will tend to have less hands on scene, you'll also get the people who are more willing to help / less egos showing up on scene. I prefer working with volunteer FFs than paid FFs. More willing to do what you ask without attitude, more willing to be useful, less trying to get off scene as fast as possible to get back to the station.

I will be going from being one of 2 or 3 medics on a scene to being the only medic.

Double edged sword. While you don't have another medic who you can bounce things off of or act as a second pair of ALS hands for those truly critical patients, you learn to trust yourself that much more and not rely on others bailing you out.

I have also been told to expect sicker patients since a lot of the people "don't want to bother anyone" and will wait until they are totally sucking mud to call.

You'll still get your share of "Why the hell did you call?" patients, but as a percentage, I'll agree you'll have more ALS worthy calls, even if not totally critical.

I will get to become more familiar with HEMS, since they tend to fly critical trauma patients due to distance from the Level 1.

Depends on yourself as a provider. In the year I did rural EMS, I never once utilized a helicopter, but then again I had aggressive protocols equal to our HEMS and saw no reason to wait 20 minutes for the helicopter to fly the distance when I could be nearly halfway to the hospital doing the same stuff.

But it also depends. I had a 22 minute takeoff to scene time for most locations with HEMS, followed by atleast 20 min on scene, and another 20 to the hospital, meaning an hour which is as long as it would take me to go myself, but your agency probably has a different time criteria. I know medics who called the helo every other week.

Beyond that, any words of advice or helpful tips from those that have been there/done that? I would love to hear anything from "this is what you should expect" to "I have found that doing xxxx works well in yyyy situation."

Have fun. You're going to learn to rely on yourself more than working in urban EMS as you truly are it. When I was working rural, I would be the only Paramedic on scene and potentially the only Paramedic within a 45 minute response time so backup was out of the question.


When you DO get the good critical patients, you get to actually see how your interventions work because you'll have them for the entire transport. You have time to work things out. Now that I'm urban, it's pretty much "If you can't do it in the 10 minutes you have to the hospital, it won't be done" while when I was rural it was "Hey, I have an hour to the hospital, I can get pretty much my whole drug box in to them if needed"

 

[mycrofft]

Boots to step out into mud or walk through barnyard muck would be good, and a set of gloves for handling wood, barbed wire, hay bales. Not common, but once is enough.Extra batteries is always a plus, you can "lend" them to your co-workers.


See what the others are carrying and mimic. They've been doing it longer than you.

 

[abckidsmom]

Depends on yourself as a provider. In the year I did rural EMS, I never once utilized a helicopter, but then again I had aggressive protocols equal to our HEMS and saw no reason to wait 20 minutes for the helicopter to fly the distance when I could be nearly halfway to the hospital doing the same stuff.

But it also depends. I had a 22 minute takeoff to scene time for most locations with HEMS, followed by atleast 20 min on scene, and another 20 to the hospital, meaning an hour which is as long as it would take me to go myself, but your agency probably has a different time criteria. I know medics who called the helo every other week.

This is a good point on the helicoptor. I very rarely call one because they spend so much time on scene. I have not ever seen them spend less than 15 minutes on scene, and if I wait 20 minutes for them to get there, they don't actually save time at all.

On a recent trauma about 45 miles from the hospital (65 minutes), we considered calling the helicopter, but there was no fire in the immediate area to do the LZ, and once you drive all the way there (30 minute response time) and load up, you just want to be moving toward the hospital.

Maybe a quicker helicoptor service would be better, but ours all tend to lollygag on scenes. They say that the train wreck factor of the patients I do call the helicopter for influences my experience, though.

 

[46Young]

This is a good point on the helicoptor. I very rarely call one because they spend so much time on scene. I have not ever seen them spend less than 15 minutes on scene, and if I wait 20 minutes for them to get there, they don't actually save time at all.

On a recent trauma about 45 miles from the hospital (65 minutes), we considered calling the helicopter, but there was no fire in the immediate area to do the LZ, and once you drive all the way there (30 minute response time) and load up, you just want to be moving toward the hospital.

Maybe a quicker helicoptor service would be better, but ours all tend to lollygag on scenes. They say that the train wreck factor of the patients I do call the helicopter for influences my experience, though.

No kidding! Same here - a few minutes to drive to the LZ, upwards of ten minutes for the flight medics to work and then txp the pt to the helo, then the trip to the hospital. The time difference is negligible if any time is saved at all! Unless the pt needs a crich or RSI (which we do not have), it's virtually worthless to call for the bird. We always have at least two medics on every ALs call, by virtue of our close proximity to the cerner of the universe (D.C.) and the large budget that comes with.

I could see the benefit of calling the flight crew just to have an extra medic or two to help you. Cowboy medicine with long txp times is cool, but it's still dangerous for the pt if you're doing everything by yourself or even with a basic in the back with you. I would request an intercept by flight crews on ground if they can't fly due to weather. Got to think outside the box sometimes. I wouldn't want to be alone with a post arrest pt with a tube, or a STEMI that could code at any moment. Hospitals have entire teams to handle these types of patients. Going it alone is inappropriate, I feel, if there are other options.

 

[abckidsmom]

No kidding! Same here - a few minutes to drive to the LZ, upwards of ten minutes for the flight medics to work and then txp the pt to the helo, then the trip to the hospital. The time difference is negligible if any time is saved at all! Unless the pt needs a crich or RSI (which we do not have), it's virtually worthless to call for the bird. We always have at least two medics on every ALs call, by virtue of our close proximity to the cerner of the universe (D.C.) and the large budget that comes with.

I could see the benefit of calling the flight crew just to have an extra medic or two to help you. Cowboy medicine with long txp times is cool, but it's still dangerous for the pt if you're doing everything by yourself or even with a basic in the back with you. I would request an intercept by flight crews on ground if they can't fly due to weather. Got to think outside the box sometimes. I wouldn't want to be alone with a post arrest pt with a tube, or a STEMI that could code at any moment. Hospitals have entire teams to handle these types of patients. Going it alone is inappropriate, I feel, if there are other options.

Definitely. We loaded up and drove back to town and picked up one of the engine crews. (We staff that big time engine crew of 1.)

Before EZIO, I called the helicopter if I needed access and couldn't get it, they could do femoral lines. And now I'm with you, they come for most airway manager and prolonged extrication.

They are based on the opposite side of town about 15 mins from the trauma center in clear weather, so they aren't much use to call them for ground help either, although it has happened.

 

[lightsandsirens5]

Good grief people! I don't think I have ever had a helo on the ground longer than 15 minutes. And usually when I call them we are so for by ground to a good number of calls that they set down about the time that I make patient contact.

I am also blessed to have RFPDs cover most of my response area and so I always have an LZ crew. And for the vast majority of my calls, the LZ has been the scene itself or within, at the very most, a 2 minute drive.

 

[emschick1985]

What can you tell me? I have been in EMS for 14 years, but all of it has been in an urban system, working for relatively well funded services. My new job is in a rural area. While I am excited about the new opportunity, I know there is going to be a learning curve.

I already know I am not going to have some of the equipment I am used to having. For instance, despite the crews wanting 12-leads, they do not have that capability. Also, they do not have capnography, and if I remember correctly, I didn't see CPAP on the trucks either.

I know that most of the departments we will be running with will be volunteer, instead of all paid departments (which is what I am used to). That means, less help on runs where extra hands would be nice. I will be going from being one of 2 or 3 medics on a scene to being the only medic. However, they do use advance EMTs who will be going through the bridge program to the newly defined Intermediate level. That means I basically will have someone that can get IVs for me while I attend to something else, if needed (at least until they complete the bridge).

I have also been told to expect sicker patients since a lot of the people "don't want to bother anyone" and will wait until they are totally sucking mud to call. I will get to become more familiar with HEMS, since they tend to fly critical trauma patients due to distance from the Level 1.

I think I am going to take a CCT class once I get settled in to the job, since they also do transfers from the community hospital to the bigger hospitals in Indy.

Beyond that, any words of advice or helpful tips from those that have been there/done that? I would love to hear anything from "this is what you should expect" to "I have found that doing xxxx works well in yyyy situation."

I can't compare because I've always worked rural, well a city of 10,000 and the surrounding small towns. I can tell you that what I've experienced is for the most part there are always an abundance of volunteer first responders that show up and know the area. They have helped us find locations more times than I can count! Sometimes I wonder how we would have found the place without them on some
Of the locations.