In a general sense, I think we can all agree that:
1. You must do the best thing for the most number of people with the money that you have. To improve services, either you get more money (not the subject of this discussion), accept poor service to particular demographics (undesirable) or you look at improved models of service provision (see bellow).
2. Rural response times will always be longer to some extent than in the city. If your rural property is larger than a number of metropolitan suburbs combined, you simply will not be able to get an ambulance quite as fast as the 10000 people in the equivalent sized metro areas serviced by X number of ambulances. This is just a fact. Rich or bankrupt, vollies or no vollies, first aid cert or PhD. You can't change that.
What I've talked about bellow are some of the ways we try to better organize and spend those resources and that money that you do have. What actually constitutes the
best for the most? How do you best spend your money so that the challenges of rural healthcare can be overcome?
A few thoughts:
Amalgamation
In terms of disaster planning, having multiple tiny agencies is a nightmare in every way. Resource balance, specialist equipment, communication, command and control, etc. If every county has its own air force, nobody could afford a $2 billion B2 bomber. But because they all get together and form the USA, they can. If you apply that idea to EMS and disaster management, there is no way every 2 ambulance rural volley company can afford emergency management communication infrastructure, mass casualty resource trucks, USAR, but 'Ambulance Service Missouri' can. If there is a mass casualty event in a remote area here, it is monitored by the emergency management division of our state ambulance service. There is then a standardized grid by which disasters are evaluated that dictates the levels of response and coordination. The entire state's resources of some 2500 paramedics can be readjusted not only to deal with the MCI, but to continue to provide everyday services to the rest of the state. Regional managers can be dispatched to control resources on the ground. Specialist vehicles from the capital city can be dispatched with CBR gear, USAR gear or support vehicles equipped with enough supplies for 200 pts to all around the state along with mobile communication centres. This is all controlled through the Ambulance Emergency Operation Centre which is a super awesome room with lots of NASA style mission control screens and tables and people who know stuff about stuff. This is ultimately part of an overall state emergency health plan coordinating Ambulance and hospital response to disasters. Its not just "the big one" that never happens either. MCIs of various kinds happen every day somewhere in the state and the escalation grid is relatively well tested. You cannot do this when EMS is so fragmented organisationally and with so many differences in training, scope, professionalism etc.
http://www.ambulance.vic.gov.au/Amb...nagement/Emergency-Management-Department.html
Not to be forgotten is the aftermath. The very successful peer support system and Victorian Ambulance Counselling Unit look after us all, and our families (because our spouses and children can suffer from our trauma as well). These simply aren't systems you can have as part of a smaller service.
Other Agencies
Police and fire should get involved in medical first response in rural areas. We don't have any of the territorial issues US EMS has with fire and police, simply because of our education standards. If EMS requires a 100 hour certificate, why not just cross train police and fire with an EMT cert? Kinda makes EMTs useless (as if they weren't already). But when it takes 4 years to become a qualified paramedic and 7, at an absolute minimum, to rise to Intensive Care, the fire brigade is welcome to get their 100 hour advanced first aid cert. They're no threat to us, in fact we train and oversee the MFR program. They don't wanna be paramedics, we don't wanna be firefighters and mostly everyone gets along.
Volunteers
We currently have a lot volunteer Community Emergency Response Teams (CERTS) in rural areas that fill the gaps in response times. We have none of the volly issues as in the US. Firstly CERT teams are only dispatched to life threatening emergencies when response times might actually matter and cannot transport (they drive SUVs) and are
always backed by ALS. Their job is to turn up early and apply a few basic modalities to keep people alive until ALS arrive. Embarrassingly for US EMTs, even our lowest level of volly FR, has more training, better clinical over-site and in many cases a greater scope of practice (AED, O2, Epipen, Albuterol, Glucose paste, Methoxyflurane analgesic, ASA, Nitro) than their US counterparts. Their training and ongoing clinical mentoring is overseen by the state service; no cowboy volly "rescue squads" here. The program seems to have been quite successful.
Just some food for thought. I'll post a little more if anything pops into my head. I also have a bit of literature about overcoming the challenges of rural prehospital care if you're interested
