Return of the Rural Paramedic

When Mikel A. Rothenberg, MD, delivered the opening keynote address at the 1990 EMS Today Conference in Tucson, Ariz., he mesmerized the thousands of EMS responders who were present as he commanded the stage in his bright Hawaiian shirt, sharing his vision of the paramedic of the future. In 10 years, he said, he foresaw paramedics arriving at the home and checking the patient out — by doing a 12-lead ECG, an X-ray, a blood chemistry panel, diagnosing congestive heart failure, starting a nitroprusside drip and scheduling a follow-up visit for the next day. They would then go on the next call and provide diabetes or alcoholism counseling, and maybe refer the patient to a local medical clinic or a physician’s office. “Yes, the mid-level paramedic would be arriving soon, by 2000,” he said.

It was an inspiring presentation, and a surge of pilot projects and studies soon followed. The most famous over the next decade was the “Red River Project” in Taos County, New Mexico. That project proved to be successful for five years, from 1995 through 2000, showing that the general public would accept care by paramedics working as mid-level primary care providers.

Despite the success the Red River Project had in demonstrating community acceptance, a number of concurrent studies in other cities, along with an evaluation of the Red River Project that was done by a team at the University of New Mexico School of Medicine Department of Emergency Medicine, raised a number of questions and concerns about paramedics filling the roles of mid-level providers.(1,2,3) These included issues about patients being lost to follow up, physicians prescribing antibiotics for patients they would never see, third-party billing, and issues with the quality and level of care provided. Many in health care then questioned the need for another mid-level provider, given the widespread successes and acceptance of physician assistants and nurse practitioners. Weren’t expanded-practice paramedics just another redundant care provider?

The shortage of rural health-care services today has answered that question with a hard dose of reality. Great expanses of the U.S. are rural and frontier (remote) communities, and some populations have EMTs as their only health professionals. Many remote rural communities, and most frontier communities, are unable to attract the physicians, nurses, dentists, pharmacists and other licensed health-care professionals that serve urban and affluent suburban communities. The community health paramedic has re-emerged to fill that critical gap in service.

A comprehensive national curriculum has been developed, worldwide conferences are being held, and pilot projects are in progress, including several in the U.S. and Canada. The experiences and lessons learned from past projects are being re-evaluated and addressed again in new ways.

The new curriculum has been modeled after the Red River Project, the U.S. military Corpsman (medic), the Alaskan Community Health Aide Practitioner (CHAP) Curriculum and others around the globe. The curriculum and scope of practice includes expanded responsibilities for long-term patient counseling for chronic illnesses, health and wellness, advanced roles in analyzing social services needs, making social services referrals for patients and community advocacy. The curriculum is also designed to include many of the advanced clinical skills that are practiced by U.S. military medics and that were included in the Red River Project. It also includes advanced skills currently included in the Alaskan CHAP program, such as suturing, Fluorescein Dye Examination, reduction of dislocations of joints and a greatly expanded drug formulary. (4,5,6).

Although EMS has been formalized into a national standard of care with defined roles and responsibilities, the primary and absolute guiding principle for all EMS may need to be reconsidered: Does the only acceptable EMS response include transport to a 24-hour licensed hospital? Is EMS a health-provider service or a transport service? These concepts are on the table, and EMS around the world may be about to change.

1.  Brown LH, Hubble MW, Cone DC et al. Paramedic Determinations of Medical Necessity: A Meta-Analysis. PEC. 2009: 13, No. 4: 516-527.

2. Hauswald M, Raynovich W & Brainard AH. Expanded Emergency Medical Services: The failure of an experimental community health program. PEC. 2005; 9:250 253.

3. Hauswald M, Brillman J, Raynovich W, et al., Training Paramedics to Determine Who Does Not Need Ambulance Transport: Validation of an educational program and protocol. Poster presentation at the Society of Academic Emergency Medicine. 1999.

4. Peabody, S. Alaska Community Health Aide/Practitioner Manual. Alaska Native Health Board and Alaska Native Tribal Health Consortium. 4 ed. ISBN 0-977241-3-4 (Vol. 4). 1998.

5. US AIR FORCE. The air force independent duty medical technician medical and dental treatment protocols. Air Force Manual 44-158. December 1, 1999.

6. University of New Mexico EMS Academy. Red River Protocols. 2000.

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