Rural vs Urban EMS

Wolves

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Hey everyone,

I was just wondering if you guys have any insights as to the difference between working in a rural environment and an urban/suburban environment? I know that a lot of times in a rural environment, it can take much longer both to arrive at the scene and to get to a hospital because hospitals can be few and far between. Do you think this has a significant effect on the survival rate of patients? Is there anything else you can think of?

Thanks, and I appreciate any responses I get!
 

46Young

Level 25 EMS Wizard
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Hey everyone,

I was just wondering if you guys have any insights as to the difference between working in a rural environment and an urban/suburban environment? I know that a lot of times in a rural environment, it can take much longer both to arrive at the scene and to get to a hospital because hospitals can be few and far between. Do you think this has a significant effect on the survival rate of patients? Is there anything else you can think of?

Thanks, and I appreciate any responses I get!
Urban: use protocols with more frequency. Benefits - steep learning curve, your interview and skills will become very quick and accurate, and your "rolodex" of pts will be vast, so for each challenging pt or pt with an atypical presentation you can draw on your numerous pt contacts to draw familiarization to guide your treatment. Drawbacks: short txp times, so protocols can be restrictive, certain interventions can be deferred due to close proximity to the hospital, and you may not have enough time with the pt to see the outcome of your interventions.

Rural: opposite of the above.

Edit: Urban can also = more money, and rural can = less money, generally speaking.
 

mycrofft

Still crazy but elsewhere
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URBAN: the archetype .
RURAL: a badly underserved and somewhat more diverse practice.

I've long thought rural/frontier needs its own category. See SEARCH
 

Clare

Forum Asst. Chief
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It takes significantly longer to locate, treat, transport and return to station than in the urban setting. This means areas are often uncovered or covered from a more distant station as most rural stations only have one vehicle.

Because time is greater your patients are often sicker and you are reliant upon backup to come from farther away by either road or air.

People out in the county get themselves into some odd situations that urban paramedics probably never see such as high speed road crash, people getting squashed by tractors or farm equipment and such.

You really rely upon the Fire Service (who are all volunteers) and the locals are often really helpful especially at a road crash or when somebody is trapped under a rolled tractor because they are generally fit, strong and in good numbers so can be very helpful lifting or carrying or holding up fluid or something like that. People in the city are rude and sheltered away in their own lives and don't stop to help nearly as much as the country people.

The rural stations are often quite busy because the ambulance is the only resource available 24/7 as the local GP is often overworked and doesn't get much break from their work they are less willing to come out after hours, the rural hospitals have by-and-large been closed down meaning transport times are much longer and transport to a hospital is often the only option.

The country offers a lot of interesting challenges and I hate to say it but you will not find me at a rural station anytime soon.
 

mycrofft

Still crazy but elsewhere
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Canadian first aid laws account for distance to definitive care,, US doesn't.
 

MagicTyler

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My service is brand new interfacility/ ALS coverage for a very large rual native american reservation. The 911 service has BLS/ILS. Its kind of a learning curve to teach them when to call for ALS. They're so used to just doing it all on their own. The only back up they had was flight. In the 6 months my service has been in service we've ran about a dozen 911 ALS intercepts, and every one has been for major trauma with multiple patients. I think we have like 10 pre hospital intubations out of 12 ALS calls. The closest we could get a 911 call is aprox 30 minutes from a small rual hospital, and an hour from a trauma center. We could in theory have 3 hour+ transport times.

So even though we dont get quanity, we get quality calls.
 

Medic Tim

Forum Deputy Chief
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Canadian first aid laws account for distance to definitive care,, US doesn't.
since when?
Every Province is different and the only first aid laws (if there even are any) is the good Samaritan law. A first aider is a non professional or lay person who has no duty to act. Some courses are designed for rural jobsites or wilderness where you may have the only training and help is hours away. There is no different scope depending on how far away to my knowledge (back to the every province being different) .
The US has WEMT where the EMT may perform the extra skills they have if they are 2-3 hours from a hospital or care
 

Wolves

Forum Probie
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Every Province is different and the only first aid laws (if there even are any) is the good Samaritan law. A first aider is a non professional or lay person who has no duty to act. Some courses are designed for rural jobsites or wilderness where you may have the only training and help is hours away. There is no different scope depending on how far away to my knowledge (back to the every province being different) .
The US has WEMT where the EMT may perform the extra skills they have if they are 2-3 hours from a hospital or care
I've never heard of WEMT, just looked it up and it seems like a great idea. Do you know of how legal issues are handled for Rx though? Wikipedia says that in some cases there are standing orders for prescription-only drugs, including some narcotic drugs. Do these standing orders stop when a hospital is 2-3 hrs away? Just kind of an interesting aside.

It would be interesting to take a WEMT class, not particularly useful for me right now though. I'm currently living in the MA, working on a college degree, but I am just wondering what it would be like to live and work outside of an urban environment.
 

mycrofft

Still crazy but elsewhere
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In 2012 preparing for a conference to change California's first aid kit laws ( primarily industrial), we were sent a copy of Canadian first aid kit laws, which made distance to definitive care a factor in what you stock and the level of care available at the site.

As far as know, laws governing first aid kits and providence at worksites is pretty uniform as far as distance to definitive care is concerned, mostly because industrial reps do not want to incur higher support costs and increase potential liability for already expensive remote operating sites. That was evident at the conference I attended.

There have been specialized regulations drawn up for such as mining, fishing, and lumbering, and insurance companies can weigh in on their own, but otherwise a tire shop in Unalaska can have the same kit as one a block away from San Francisco General in California, or less.

So here if you are
 

AGill01

Forum Crew Member
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I work in a very rural area in AR and a lot of the time we can count on our volunteer fire dept first responders in an emergency to get there first get vitals, start O2 if needed and some times lead the ambulance in to the residence especially on the calls where the residence is way down a back dirt road with missing road signs. They will update us on pt condition andif other resources are needed ie. Air transfer.
 

Mike L

Forum Ride Along
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I personally LOVE rural EMS, I get so much time with my patients with anywhere from 20-55 miles per transport.

I get to see the results of the interventions I provide, as well as learn about the patient more, etc. Particularly in my county, we have an extremely high number of under privileged, and elderly so we deal with alot of death/near death due to the inability to get proper healthcare and low standard of living, as well as a very long stretch of the interstate and 2 major highways running through.

I interact with Air medical groups more often than i would like, and lets be honest working a code for 10 minutes on scene and during a 40 mile transport is a real pain on personnel as well as supplies.

Money is not an issue as we are a non-profit privately owned rural EMS system we don't have some owner biting at the heels to get every cent, we have very competitive pay, and great benefits.

Urban EMS you usually have help readily available on bad calls, and you only have to be with that "Critical patient" for a short period of time, BUT you certainly get the opportunity to see more patients and do more skills in the urban setting. And in alot of cases the fact that you ARE that close makes the patient outcomes much much better. IE A stroke patient in downtown Dallas have good chances of D2B<60 minutes but in some rural settings you may not even make patient contact until 30 minutes into that window (Here we try and keep D2B < 90, but that is rarely possible)

Its a real difficult situation to decide between, you want to get more experience, and go on more calls but you also want to have the opportunity to interact with your patients and see what YOU did to fix them, so it all boils down to personal preference. I personally dont ever see myself leaving rural EMS unless somehow the people in my area no longer require us to be here.
 

JDallas

Forum Probie
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Rural EMS- Trona, CA

My area (rural) is under San Bernardino County Fire jurisdiction. We have volunteer firefighters and EMTs running our ambulance service.

We have ALS (Liberty Ambulance) and a crappy hospital (Ridgecrest Regional) about half an hour away. We're not allowed to transport to different hospitals (obviously, the next closest is over 100 miles away), so whenever a patient needs critical care (stroke, heart attack, MVA) they get airlifted by Mercy Air.

Usually by the time we get the helicopter up here, landed, and the patient loaded up, the "Golden Hour" is gone, and its still an hour-long flight to Loma Linda or Arrowhead trauma centers.
 

RocketMedic

King of the Improbable
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My area (rural) is under San Bernardino County Fire jurisdiction. We have volunteer firefighters and EMTs running our ambulance service.

We have ALS (Liberty Ambulance) and a crappy hospital (Ridgecrest Regional) about half an hour away. We're not allowed to transport to different hospitals (obviously, the next closest is over 100 miles away), so whenever a patient needs critical care (stroke, heart attack, MVA) they get airlifted by Mercy Air.

Usually by the time we get the helicopter up here, landed, and the patient loaded up, the "Golden Hour" is gone, and its still an hour-long flight to Loma Linda or Arrowhead trauma centers.
You are in the best part of CA for EMS- Kern County is far more advanced than IECMA would let y'all be.
Liberty-Ridgecrest is one of the few companies in CA I'd move back for. (Grew up there, know a lot of people out there).

Ridgecrest Regional isn't bad, it's just not set up for the critical stuff. There's no shame in flying patients you can't take care of organically- that comes with living out there.
 
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JDallas

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You are in the best part of CA for EMS- Kern County is far more advanced than IECMA would let y'all be.
Liberty-Ridgecrest is one of the few companies in CA I'd move back for. (Grew up there, know a lot of people out there).

Ridgecrest Regional isn't bad, it's just not set up for the critical stuff. There's no shame in flying patients you can't take care of organically- that comes with living out there.
I agree with the point that Kern County EMS allows more than ICEMA for sure.

I also have had positive experiences with Liberty. I'm already guaranteed a job here in Trona after i finish my schooling (I know people) but I'm also going to apply for Liberty so I can get a local full time job.

Now on to RRH. I've found them to be a competent hospital for "normal" day-to-day EMS. When the :censored::censored::censored::censored: hits the fan though, they transfer out a lot. We like to just airship them out first- it will probably save our patient lots of money in the long run. "Not set up for the critical stuff" is completely accurate- but I hear rumors that they're trying to turn it into a Level 4 trauma center.. so I hear.

If you don't mind me asking, what agencies did you work for in this area?
 

mycrofft

Still crazy but elsewhere
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TRONA! Holly smokes. Prett uber-rural!
 

mycrofft

Still crazy but elsewhere
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One of my (long-deceased) grand-uncles devised how to put in the first water system out near there (might have been Jo-burgh). My grandfather in law was a mine worker in Trona long log ago.
 

WuLabsWuTecH

Forum Deputy Chief
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urban EMS is what everyone thinks of when they think EMS. I work for a small urban department and it's pretty typical. We have high run volumes (12 runs a day isn't unusual, and we average 6-8 depending on the time of year) but also quick runs. I can hit everything in our primary run district in 60 seconds, slightly more if it's raining. Transports take about 5 minutes for critical patients, if we let them choose a hospital, the most it'll take is 15 minutes. We usually spend more time at the hospital filling out reports than we do transporting.

Rural EMS is a whole 'nother beast. I am on a department that covers 200 square miles, but it is a rectangular run district and very long, lengthwise. Response times average 12 minutes, but there are corners of our district were a 35 minute response is necessary. Transport to the hospital for critical patients to the nearest ER is at least 15 minutes and averages 18 or so. Going to a trauma center or other definitive care is at least a half hour and averages 42 minutes. From the corners of our run district, the closest hospital can be 30 minutes away or more and a trauma center is an hour and 5 minutes. You get to use a lot more of your skills and critical thinking in the rural area, but it also means a lot of new challenges you have to face.
 

climberslacker

Forum Crew Member
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"I've never heard of WEMT, just looked it up and it seems like a great idea. Do you know of how legal issues are handled for Rx though? Wikipedia says that in some cases there are standing orders for prescription-only drugs, including some narcotic drugs. Do these standing orders stop when a hospital is 2-3 hrs away? Just kind of an interesting aside."

The WEMT program is, in my opinion, a great class to have. Not only do you go more into detail on pathophysiology (It seemed like we did, from what I hear) you also get to learn about how to deal with patients in REALLY long transport times (i.e. >24 hour) so you get some of the more "nursing" aspects of the profession down.

As far as Rx and such, that typically only will happen if you are with a large program that has a "medical advisor" positions. So programs like NOLS carry prescriptions and the instructors are allowed to administer them. One of the more surprising things that we learned was the administration of IM epi, commonly carried in wilderness first aid kits on the larger programs.

The other things that we can do are "Focused Spine Assessments"--basically clearing spinal injuries; Reducing dislocations of the shoulder, fingers, and patella; the ability to stop CPR without a doctor needing to be there; and wound irrigation/debridement and closure (Steristrips not sutures).

The biggest skill that we have really though are the ability to do almost everything we can do on the ambulance without the ambulance (Did you know you can improvise a tractions splint with just a few sticks?).

Great course, highly recommended. I went through WMI.
 
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