Introduction by Joseph A. Moore
There are many places in the United States and Canada where emergency medical services ( EMS ) are difficult to provide or non-existent. Some areas have overcome the huge obstacles to provide a basic life support level (BLS) of service. Most of these services are volunteer, and most of the agencies could not exist without the volunteers. Thankfully, most of the agencies have enough volunteers to provide the needed services for the emergencies that occur, but this is fast, unfortunately, becoming not true.
Once a rural EMS agency is established, it goes through a growth period that includes training, fundraising for equipment, and eventually licensing within a specific area of service. The biggest problem for all rural EMS agencies is funding. Without the adequate funding necessary to provide the equipment and supplies necessary to operate the agency and its vehicles, the agency is doomed to fail. The communities are very happy to have the volunteers give time and are very supportive of their local rural EMS service, but the honeymoon period seems to end when the volunteers want to improve the level of care that is provided. The major obstacle is usually money. Even if the agency is able to bill insurance companies or the patients for services provided, in the rural environment, there usually are not enough billable ambulance responses to support the costs of operations, let alone the money to provide pay for a manager or providers.
After volunteering for years and years, the donated time becomes overwhelming. The volunteer does not want to volunteer anymore. This is particularly true when the local governmental agency or the non-profit organization does not provide sufficient praise and thank-you's to the volunteer staff. The honeymoon is over immediately when the governing organization begins to question the need for the services provided. “We got along fine without the……” will immediately end the honeymoon. The volunteers need to feel needed and appreciated. If that feeling of being needed and appreciated disappears, then the agency is doomed to not only lose volunteers, but also lose management and desire to grow.
Every EMS agency needs to continue to grow. Either it grows in increasing levels of care, or it grows in finding more efficient ways to provide that care. Any EMS agency, particularly if made up of volunteers, needs to feel this growth and that each person is contributing toward that growth. As soon as a member does not feel as if (s)he is contributing toward the growth, that member is on his/her way away from providing volunteer service to his/her community.
So the recipe to maintenance of a healthy rural volunteer EMS agency is not really that difficult. You start with a few caring people willing to undergo extensive education and training. You motivate them to want to be able to help others in their community. You continue to motivate them by expressions of appreciation, opportunity to grow, and particularly by saying, “Thank you.” The community also needs to provide the funding for the agency.
The rural areas also provide special challenges that are not found in urban EMS agencies, yet the legislation is almost always written by, for, and about urban EMS . The entire model and curricula for EMS classes are built around an urban EMS model that cannot be duplicated in most rural areas. Here are a few examples.
Many of the states in this country are mainly rural. Any of these EMS stories may have occurred in any of these states, including, but not limited to, Texas , Oklahoma , Wyoming , Colorado , Michigan , Wisconsin , Nevada , North and South Dakota , and many others. Rural EMS is a strong force of mostly volunteers in all these states. There are some places that are more rural than others, even though many may be considered rural. Some examples follow.
Kotzebue , Alaska 's Maniilaq Association provides EMS services to eleven outlying villages. With no roads available to these villages or the closest city hospital or level one trauma center, the transportation here must be completed by aircraft. How do the ‘Platinum Ten Minutes” and the “Golden Hour” fit into a rural area that takes more than one hour to respond to an emergency? The medical control committee's four to eight minute response time in any city across North America means absolutely nothing to this association trying to do the best that can be done given the circumstances of geography. There are many other agencies and locations in the great State of Alaska that also demonstrate the differences between rural and urban EMS , and even may separate rural from geographically-challenged rural.
The Upper Peninsula of Michigan contains some of the most geographically-challenged and rural areas of the entire country after Alaska . The response times in these stories has purposely been left out. The times referred to in this book include patient assessment time, treatment time, and transport time as if the patient were in a rural area that is approximately 30 minutes away from the nearest hospital, but has a geographical challenge that can't be overcome. The use of an aircraft or a helicopter is used in these stories is to add some continuity, complete the dramatic effect, and to disguise the actual location of the emergencies than may seem familiar to the reader.
Geographically isolated rural EMS agencies have weather difficulties to overcome that mean nothing to an urban EMS agency manager. These what if's don't mean much in downtown Washington , D.C. , Lansing , Michigan , or any other city. What if the geographically isolated EMS agency cannot transport a patient due to thick fog that prevents the transport for three days or more? Where does this fall into the urban planning that dictates EMS rules and law throughout our nation?
Although using a snowmobile to transport a patient is a dramatic method of transport, the locations where this might be necessary would be limited to only a few, making the patient think that the story refers to him or her. Driving through the unplowed roads or taking a dogsled or a snowmobile to the scene of an emergency is pretty foreign to most urban services. In Kotzebue, for example, the time frames mentioned in this book may be even longer than presented here. The time to fly to the location of the emergency could not be included here to keep the locations as unknown as possible.
To separate and eliminate the exact locations of the emergencies, it was necessary to also leave out the specific language barriers also, even though urban services may need to communicate with patients who speak a different language. The actual languages that are encountered will not be the same between rural and urban services, but the concept of needed communication is absolutely the same.
The situation of being geographically-challenged and rural is true of an agency on an island in Lake Michigan in Charlevoix County . Beaver Island is about 85 square miles, but it is an island. There are no roads to drive the patient to the hospital, which is on the mainland of Michigan , and no bridge spanning the 32 miles of water that separate this island from the mainland of Michigan . Any island will have challenges that urban city dwellers will not be able to identify with as long as there is no road connecting it to the mainland. Mackinac Island , Michigan , and Washington Island , Wisconsin , even though close to the mainland, have challenges that will not be addressed by urban planners. How do you provide privacy for your patient when the only option is to take your patient aboard a ferry to transport him/her to a hospital?
There is similarity even to the Upper Peninsula EMS agencies of Michigan if the issue is long transport time or the level of care available in places like Paradise and Grand Marais. Snowy, drifted roads are not compatible with good patient care in a BLS ambulance or when ALS is needed. Some of these emergencies may have occurred in the UP of Michigan . These stories all need some disguise as well.
These examples demonstrate challenges that the urban planners and EMS designers do not take into consideration. The challenges are big enough with just BLS transportation issues. The needs are even greater in the rural areas for higher levels of care. Advanced life support (ALS) is needed for medical emergencies in the rural areas. This ALS level of care is even more essential in an area where four to twelve hours to the nearest hospital is the norm and not the exception. How will your father, mother, aunt, uncle, or other relative survive the medical emergency if there isn't any EMS response for more than an hour or the level of care is only BLS for more than an hour? Will oxygen and a somewhat smooth ride to the hospital be all that you would wish for your relatives, friends, and neighbors?
Where does straightening a pulseless, severely deformed, fractured arm fall into the training for a rural agency? Where does an IV drip cardiac drug needed by the cardiac patient fall into the training for a rural agency? How does defibrillation in the first four minutes of a cardiac arrest differ in a rural environment when your closest EMS agency response is more than that away? How do integrity, compassion, accountability, respect, and empathy fit a rural agency when the model does not emulate those aspects of patient care? Where does one go to find a model that can be emulated?
The answer is in this book. Rural EMS IS Different provides a model of caring patient care in a less than convenient rural environment. These stories are meant to give the reader an idea of what can be done if the pieces of the rural EMS puzzle are correctly aligned. Although these stories have one particularly recognizable setting, the original setting for the stories could have been anywhere in rural American EMS: Kotzebue , AK ; Grand Marais , MI ; or Mackinac Island , MI , or any other rural county in our states and our nation. Let's make certain that the urban planners understand the facts.
Rural EMS IS Different!
(These stories are fictional, for educational and entertainment purposes, and not meant to describe a particular person. The stories may have occurred in many different settings. The Rural EMS agency does not truly exist. This is fiction, but similar incidents actually occurred within the twenty years from 1987-2007. Any similarity of the depicted patients to real persons is purely coincidental. All information that may be somewhat recognizable has purposely gone through the HIPAA de-identified information procedure, 164.514 of 45 CFR Subtitle A, Subchapter C to the extent possible . )