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How one rural EMS agency shines at innovative patient care

Volunteer and paid EMTs in a remote area of Texas provide an expanded scope of practice through advanced prolonged critical care transport and community paramedince

In a remote area stretching nearly 2,000 square miles on both sides of the U.S. and Mexico border, a combination of paid and volunteer EMS providers at Presidio Emergency Services respond to an estimated 700 calls per year.

Many employees travel long distances to service the communities of Presidio, Texas, the neighboring community of Candelaria, Texas, and Ojinaga, Mexico, as well as rural highways and Big Bend Ranch state park. Crews often transport critical care patients over rugged terrain for easily three hours to the nearest hospital.

“I drive four hours, each way weekly, for the amazing experience of working here,” said Jonathan Farrow, Director of Emergency Services for the City of Presidio.

While many rural organizations are struggling to maintain volunteer membership and quality services, this agency strives to be an innovative leader in EMS, focusing on evidence-based care in a very remote area of southwest Texas.

“Over the last five years we have focused our care on providing services needed in our extremely remote location, examining the spectrum of care provided throughout a patient’s entire health care system experience, and not allowing the “dogmas” of EMS to guide our decisions,” Farrow said.

Prolonged care and transport

Of the 700 calls Presidio Emergency Services runs per year, many are prolonged care and transport of highly critical patients.

“Due to rugged, remote terrain and the nearest hospital being 88 miles north, our transports are usually two and a half to three hours,” Farrow said.

A Presidio ambulance is normally staffed with a paramedic and EMT.

“If an ambulance is staffed with two BLS providers a paramedic is available in an intercept truck,” Farrow said.

The actual transport distance and time to the hospital in Alpine, Texas depends on the specific location the patient is picked up from in the Presidio EMS district, he said.

Sprawling service area

Presidio EMS covers three other small areas, the furthest of which is Candelaria, Texas, which is 48 miles away.

“Because of the severe road conditions, it takes almost an hour for our ambulance to respond to Candelaria and another hour and a half to return to Presidio,” Farrow said. “We have to drive slowly on the rugged road. Once we are back to town with a patient it is another 100 miles to the hospital.”

The round trip is also long for the Presidio EMS crew. The call, from dispatch to return to quarters, might take between seven to eight hours and require almost 300 miles of driving.

Since the nearest hospital in Apline has limited capabilities, all severe trauma and medical patients are flown 270 miles to the El Paso University Medical Center.

“Our crews transport the patient to the airport in Presidio and continue care while waiting for the fixed wing air transport to El Paso,"Farrow said.

Community paramedics and expanded scope of practice

Yet working in such a remote location hasn’t deterred Presidio EMS from staying on the cutting edge of patient care.

Two years ago the agency began a community paramedic program to deliver home health services, as well as provide advanced treatments in the pre-hospital arena.

“We carry a wide variety of medications and diagnostic tools that allow us to perform additional treatments,” Farrow said. “We can perform field urinalysis, administer antibiotics, and have the ability to refer patients for follow up care.”

Presidio ambulances carry a full range of critical care tools and medications allowing paramedics to administer pain management, perform rapid sequence induction, insert a chest tube, and suture wounds in the field.

“Our medical director expects us to properly treat patients with our expanded scope,” Farrow said.

Rigorous education and training

This expanded scope is supported by a massive in-house continuing education program.

“In a typical year we conduct about 200 hours of hands-on EMS training, as well as a self-study program,” Farrow said. Most EMS personnel are also members of the Fire/Rescue branch and receive another 150 hours of annual rescue training.

The rigorous training program has allowed the creation of in-house clearance courses to expand the scope of EMT-basics. EMTs can start IV’s, administer intramuscular epinephrine, intravenous Benadryl, and Nebulizers for life threatening emergencies.

“In-house training and clearance courses can also authorize EMTs to administer Toradol and Zofran for patient comfort, as well pain medications, such as Nubain, and Ativan to control seizures.”

All hazards service provider

Presidio Emergency Services is also responsible for fire, technical rescue, search and rescue, and disaster relief. The department is affiliated with the American Red Cross so that following a disaster, such as a house fire, residents can be ensured of having safe housing, clothing, and food.

“We also work to establish bank accounts for donations and work with the local media to gain public support for rebuilding efforts,” Farrow said.

Success starts with personnel

Presidio Emergency Services is a combination department.

“We have paid EMS and volunteer fire, as well as volunteers that help with public outreach and fundraising,” Farrow said.

In addition to making a five to six hour drive to get to work, staff comes from a range of different experiences and backgrounds.

“One of our paramedics is a former semi-pro hockey player that works at Presidio full-time, as well as a flight paramedic for a large company,” Farrow said. “Another EMT that works for us has 20 years of experience in helicopter operations and is a forest service smoke jumper.

“I proudly tell anyone that the best EMTs in the country work in Presidio.”