Country Musings: Thoughts on Rural EMS


 
 

Howard Rodenberg, MD | | Monday, November 26, 2007


"Gold is just a windy Kansas wheat field

Blue is just a Kansas summer sky."

John Denver, "Matthew"

Everyone has someplace to think of as home, and for me it s Kansas. Although I was born in the Chicago area and was later transplanted to Iowa and Indiana (my parents had something to do with that), I went to high school, college and medical school in Kansas City and did my residency in emergency medicine a stone s throw from Bryant s Barbecue and the Missouri River. And since I lived on the Kansas side of the KC area, I think I have a pretty good claim to be a Jayhawk.

(While there are many explanations of what a "Jayhawk" actually is, they all come from the era just before the Civil War. In the late 1850s, the eastern portion of the territory it was not yet a state was known as "Bloody Kansas" due to the bloodshed between slave owners and "free-soilers." Depending on what you believe, "Jayhawkers" were alternately border ruffians, vigilant citizens or simply people taking a wagon train west across the plains. So the Jayhawk is not a real bird, although there is a large stone statue of a Jayhawk on the campus of the University of Kansas in Lawrence. It is supposed to fly when an unsullied maiden graduates from KU. It s still there.)

Being from Kansas has certain advantages. I m able to pepper my conversation by telling people how I took Dorothy to prom and locked that annoying dog in the trunk, or how I didn t know that the world was in color until I crossed the line into Missouri. I could also explain that if you liked the beach, Kansas was ideal, because it was as close to both the Atlantic and the Pacific as you could get at one time. And when I d run into someone from either coast who had no clue about "flyover country, I d explain where Kansas City was by saying it was about an hour east of Topeka, and watch them nod in a knowing fashion.

The truth, however, is that I am not a child of the plains. I did not live on a ranch, attend a one-room schoolhouse or spend my summers in the fields. I lived in a conglomeration of suburbs of Kansas City known as Shawnee Mission, featuring rural enclaves like Mission Hills, where in 1999 the median household income was $189,000. And although we did have some gently sloping hills, corporate parks and subdivisions obscured the vast expanse of the prairies.

(Just to prove that my urban experience is not unique to Kansans, I checked the 2000 United States Census Report for the Sunflower State. Four counties in Kansas, home to the cities of Wichita, Shawnee Mission, Kansas City and Topeka, account for nearly 50% of the state s population. No data on the locations of scarecrows, tin men or lions)

This does not mean I am totally blind to the bucolic flatness of my claimed motherland. While I truly appreciate the beauty of an unfettered plain of wheat beneath an aquamarine Kansas sky, I do understand that it can be an acquired taste. And there is no doubt that parts of Kansas fit the textbook definition of rural.

I was thinking about my Kansas roots as I reviewed some columns I ve written in the previous year. On a number of occasions, I ve referred to the differences between EMS in rural and urban settings. As my thoughts on these differences have evolved, I ve become convinced that the future of EMS may lie in rural America.

The basis for my argument lies in the meaning of time. If you think about it, time is the major component that defines prehospital care, and it becomes the major dividing line between urban and rural EMS systems.

Let s begin this discussion by looking at those conditions most amenable to EMS care. We know that we can save people in ventricular fibrillation with the quick application of electricity and that the chances of successful resuscitation decrease as time elapses from the moment of arrest. It s to this end that we configure our EMS systems to minimize response times to these calls. We know that the brain tolerates hypoxia very poorly; therefore, we see airway management as a time-critical function. Trauma also operates within a designated time frame ("The Golden Hour"), and we know that one of the peaks of death from trauma occurs immediately after the insult.

In treating these immediately time-critical of cases, I think it s clear that urban EMS systems have the advantage. Limited and well-defined geographical boundaries and high population densities keep access and response times low. A funding base that supports professional staffing and training, the ready availability of hospitals and the ability of an EMS system to adopt a "true" system status management mode make it much easier for urban agencies to provide immediate life-saving care.

Rural EMS systems face a different slate of challenges. They cover large areas of low population density, using minimal resources to respond to the scene. Low call volumes mean that they cannot effectively use a system status management program without units sitting at junctions of rural roads for hours on end. The odds are stacked against them being at the patient s side within the "magic" four- to eight-minute window. This is not the fault of the rural system, but simply a function of the environment in which they work. Paramedics may be just as skilled in rural areas as those in the city; and given unlimited resources of money and staff, rural EMS would be more than happy to place an AED in every farmstead and hamlet, and to thickly sow units throughout the coverage area. But because rural systems don't benefit from such "wish fulfillment," it does seem that when it comes to saving lives from sudden and immediate death, urban systems will probably continue to carry the flag.

However, I d contend that it s in this urban group of cases where EMS has relatively less room for progress. We already have some pretty good strategies for managing these acute life threats. While these schemes and techniques may change over time, the short contact period between the EMS system and the patient means that there are a limited number of interventions that may be performed without compromising the time to hospital care.

If we focus on patients with critical illness or injury who survive their initial insult, it s here that rural EMS makes its impact known. One of the advantages of urban systems is that they can readily deposit the patient at a hospital for definitive care. Because of the short transport times, there is really very little an urban paramedic might do for the patient other than immediate care for life threats without prolonging the out-of-hospital intervals. In a rural system, however, long distances and poor infrastructure mean that there is a significant length of time for interaction between the paramedic and the patient. This time is especially important in the care of the patient with critical illness or injury who may be on the brink of collapse, but have not yet entered a preterminal phase. This prolonged patient contact time allows the paramedic the opportunity to perform additional critical care skills, use new pharmaceutical agents or conduct detailed diagnostic assessments without compromising the interval from arrival on scene to arrival at definitive care.

Let s take a very simple example. It s pretty well established that paramedics can interpret a 12-lead ECG for signs of acute myocardial infarction. The "real life" caveat to this intellectual exercise is that the acquisition of such data must not prolong scene or transport times. When one is but a few minutes from the hospital, the time to perform the procedure becomes a very real concern. However, when transport times are long, the issue of whether to do the ECG or not is a moot point. The time is there, and if time is also myocardium, then we must use that time to expedite the patient s care. We can make the same argument to demonstrate that rural settings pose the best applications for new technologies, such as non-invasive ventilatory techniques and "point-of-care" testing, and for advanced pharmaceutical agents like IV nitroglycerin or the prehospital use of thrombolytics.

If it s true that the rural setting offers more opportunities for advancements in patient care, why is most of the work with EMS new technologies and techniques done in urban areas? The answer is related to patient volume and statistical techniques. For example, it s been demonstrated that paramedics can interpret ECGs and administer thrombolytic therapy. The data acquisition, screening and decision-making, and drug administration required by the lytic process takes time. As patient contact times are prolonged in rural settings, one would expect these works to be conducted in less populated environments.

But if you re doing a formal study and hope to demonstrate statistical success, you need large numbers of cases to review. The smaller the anticipated differences between the study groups, the larger number of patients you need. If you re looking for large numbers of patients with acute MI, you need to look at places where the population density is high, so your numbers will climb at a rapid rate. That means you need to conduct your research in an urban area, regardless of whether the work is most relevant to this setting. And if you re selling a drug or device, you had better demonstrate its use in places that can afford to purchase large volumes of your product. There s nothing wrong with that it s simply playing the math and the market. The key is for the consumer to see behind this and make an appropriate call.

The sad paradox of our current EMS system is that those areas which might benefit the most from enhanced equipment, staffing and training are those which must often "make do" with the least. To some extent, I suppose that s the nature of providing a rural service; less money, less resources, less of everything (I ve heard some cynics note that a lack of emergency service is the price you pay when for choosing a rural life). While special grant programs can help, it remains an irony that those areas that need the most support often receive the least help. It would be my hope that, as an EMS community, we recognize the differences between urban and rural EMS, and use these differences as springboard to progress in patient care and to prioritize our political advocacy.

I d like to share one other thought about rural EMS. It may be a matter of perception, but I find that medics in rural areas have a different attitude about their job. It may be because while most of us talk about the possibility of caring for friends and family, these folks literally do. EMS for them is less a job than a way of contributing to the community. I ve often found rural medics more open to education and technology than some of their urban counterparts. I think that s because they re looking at way to care not just for people, but for people they know; their children s schoolmates, the families they see at church.

I almost forgot being from Kansas does have one other advantage. At any time I can don the ruby red slippers, click my heels three times and go home. Problem is that they don t make red slippers in my size, and even if they did red is just not my color. So I think I ll stay in Florida until someone makes me an offer I just can t refuse. Just when does the Director of the Kansas Department of Health retire?


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