Rural EMS is often viewed as being easier because it is slow. It is not easier because it is slower; it is harder because everything takes longer.
Not only must you manage your patient, but you must also manage distance, time and uncertainty in ways urban EMS does not have to. Patients wait longer to call, response times to the scene are longer, transport times are longer, and you have to manage a patient longer in the back of an ambulance.
|MORE: Rural EMS high-acuity calls average 97 minutes, study shows
The myth of the slow shift
I started as a new advanced EMT in a rural agency in 2024. Rural EMS is great; it got my feet wet part time without running me into the ground.
Rural EMS typically has a very low call volume compared to its urban counterpart. My agency averages 2.5 calls per day, or roughly 900 calls a year. Compare that to my clinicals in the big city where we ran 10 calls in 12 hours every shift. While that slow pace may sound great to some folks, it can easily lead to diminished skills, complacency, longer transport times and more work in the back of the ambulance, especially for new folks. The challenge is maintaining critical skills that you need in a moment’s notice, but not being able to practice them routinely.
Rural EMS may sound slow, and it generally is, but it has a higher percentage of high-acuity patients. Therea are many people in rural areas who do not visit a primary care physician. Do you know how many times I have heard, “I didn’t want to bother anyone.” We have all heard the stories of the farmer who sliced his neck and rode the ATV four miles back to his truck and drove 37 miles to the ER to get stitches … yes this really happens in the country.
According to Isabella Turcinovic, lead study author and a third-year medical student at Baylor College of Medicine, “Limited access to primary and preventive care can cause medical conditions to worsen before patients seek help. Rural communities also see higher injury rates due to work-related accidents, longer commutes and higher driving speeds.” According to Turcinovic’s research, 40% of the rural calls are high acuity, compared to just 27% nationally.
Complacency is the enemy
Complacency can be the biggest challenge in rural EMS, and I fight it every time. It is very easy, especially in a slow environment, to just stop taking the proper steps like maintaining equipment or performing rig checks, or maybe taking them every other shift. It’s easy to get into a mindset of “it will not happen here,” or “I just saw that piece of equipment on the truck last shift,” but “I don’t need to do a truck check off, because it didn’t roll the last two shifts” is the absolute wrong attitude.
This slower pace also leads to diminished skills because you may not start an IV for weeks or manage an advanced airway, only to find yourself needing to use these skills for a critically ill patient 30 minutes away from the nearest hospital.
The repetition is not there with a low-call volume department, and that’s why training is important. You have to keep your skills sharp. Every rural provider has felt the pull of complacency. The pull is real — coffee, the recliner, the TV. When critical calls are infrequent, it becomes easy to put off training or assume your skills will be there when you need them.
Most of the paramedics I work with have been doing this 15-20 years, yet they still recognize the importance of training because critical skills can go unused for long periods. Agencies with a low call volume have the time to train, and they should.
Go find the time to train; even if you run a high-volume workplace, find the time to train. Run through your ambulance, put hands on equipment and ask questions if you don’t know how it works or what it does. You also need to train with your partner to become proficient and efficient at what your roles are, and what needs to be done. They say BLS before ALS, and this is never truer than in rural EMS.
When patients finally call
EMS response times are longer, both to the scene and to definitive care. In the furthest reaches of our district and some mutual aid calls, our response time could be 20 minutes or more just to get to the scene. Some of my shortest transport times to the closest hospitals are 20 minutes. While that doesn’t sound like a long time, try doing CPR in the back of an ambulance down a pig trail dirt road for 20 minutes.
Our longest transports are upwards of 45 minutes to a level II trauma center. With such long travel times, you may think, why not just fly them via helicopter? We have four helicopters within 30 minutes flight time of our location. But helicopter availability depends on weather, base location and lift time. A 20-minute flight plus lift is a long time. Sometimes, by the time they get notified, even with a 5–10-minute plus lift time, a scene evaluation and a scene flight to our furthest hospital, we can beat them there by ground, and we have.
We had a case of a dual drowning. The helicopter took one patient and the ambulance crew took the second. The ambulance crew, leaving just minutes before the helicopter crew, arrived first at the hospital furthest. According to researchers, the average call time from dispatch to definitive care could be up to 40 minutes longer when transported to specialized trauma centers.
Most rural areas only have volunteer fire departments for fire and EMS. When you call for help, who is showing up? Sometimes no one. Sometimes it is just you and your partner, whereas in a large urban area, you can usually get fire quickly on scene to help.
Just getting to the emergency room doors isn’t definitive care either. Sometimes there could be two or three hour wait times “holding the wall.” Managing your patient doesn’t end when you cross the ED door threshold.
The regulars
We get to really know our patients in a small community, and that’s the best part about it. Yes, we go to the same people over and over, but this allows us to provide better patient care. We have sat in patients’ homes and cooked them breakfast or restocked their refrigerators when they couldn’t stand up long enough to do it. We have cleaned up messes from a fall and sat and talked with patients when all they wanted was someone to listen.
We have the luxury of sitting a few extra minutes with Ms. Betty and helping to calm her. We know almost immediately if something isn’t right with one of our regulars. Another plus to knowing everyone in your small community is you can see them progress and get to celebrate some of their wins when home health comes out and helps improve their health and situation.
The downside is we also see them as they decline and see them when they pass. As we go to these same routine lift-assist calls, they eventually become more serious.I have responded to several falls with a nose bleed to find the patient face down in a pool of blood. This was not what I was expecting to walk into.
Low volume, high stakes
Low call volume does not mean low responsibility. There is less margin of error because time and distance are not our friends. We spend more time on scene, more time in the back of the ambulance, and more time trying to get to definitive care. At the same time, we have fewer patient contacts to maintain critical skills those calls need. Rural EMS is not easier because it is slower. It is harder because everything takes longer.
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ABOUT THE AUTHOR
Brian Tannehill is an advanced EMT, TECC-certified provider and volunteer firefighter serving Alabama’s River Region, with experience in rural, low-frequency/high-acuity emergency response. He holds a master’s degree in emergency and disaster management, and is a retired U.S. Air Force Officer with over 15 years of experience supporting critical satellite communications systems. A Master Instructor, he has taught both technical training and graduate-level professional military education to U.S. and international officers and also teaches EMT Basic, CPR and Stop-the-Bleed courses.
