The Paramedic Intercept – Rural EMS

It may shock some of my more urban readers out there, but not everywhere is a city.

Why did I say that? It’s because there’s not much talk out there regarding rural EMS. I live rural EMS and I believe that someone who calls 911 in a rural area deserves just as good of service as someone who lives in the city. To further my goal of increasing the dialogue, I’m writing about some of the issues facing rural EMS and the techniques that we use. Hopefully it’s educational.

Here’s the first part in my series on Rural EMS: The ALS Intercept:

Not every 911 call for an ambulance brings forth a paramedic-staffed Advanced Life Support ambulance. There’s a lot of ground in this nation covered by dedicated volunteer EMT-Basics that answer the call for their communities day-in and day-out. In fact, I got my start at one of these all-volunteer 911 EMT-Basic squads. We covered 275sq miles of sparsely populated terrain in the rural Midwest and ran about 200 or so calls for service per year. I have to say that it made me a very good basic, because there wasn’t any back-up for our BLS skills. However the patient presented, they got treated with the best that our Basic Life Support ambulance had to offer.

Of course, back then we had an ace in the hole. The big-city hospitals that were 45 minutes away at a minimum laid in the service area of ambulances with paramedics in them that could be called to head out our way and meet up with us for an “ALS intercept”. It still happens that way in a lot of communities, in fact, I ride around in an “interceptor” while at one of my jobs, which is an SUV with lights, sirens, and a full complement of ALS gear in it. Working out of that vehicle I respond first-due in our own jurisdiction and upon call for some of the surrounding communities. We meet up either on scene or enroute, and I hop in to dazzle the crew with a stunning display of ALS-sy goodness.

I have to tell you, I remember that from the perspective of an EMT-basic racing to the meet-up point with an “Oh-My-God” critical patient, having the paramedic jump on board was such a feeling of relief. Now, from the perspective of the paramedic who jumps in, it’s sometimes a bit of a pucker factor… because now you’re working with an unfamiliar audience watching your every move.

ALS intercepts are a great tool in the arsenal of rural EMS systems. There are a lot of small communities out there that do not have the capabilities to staff and support full paramedic ambulances. Even if they have the money to pay for all of the equipment and training needed for paramedics, they may not have the call volume needed to keep the paramedics busy and their skills sharp. That’s why consolidating the paramedics and sharing them between multiple services makes sense to me. The community volunteers respond as an initial stabilization, and a faster, more mobile unit runs out to meet them with higher skills. It’s a truly tiered response system.

Rural paramedicine and rural EMS take a different mentality than does urban EMS. For instance, the distance that we must cover mandates long response times. At my previous all-BLS service, we covered the 275sq mile 911 area out of one station. We had under 5000 people in that jurisdiction and that made staffing more than one ambulance infeasible. To cover the gap, we had outfitted volunteer EMT-Bs as “Satellite” First Responders to augment the response. It worked… if they were home or in the area.  Nonetheless, the response times went up to and over 30 minutes in the most remote areas. “Call Early” and “Call First” were necessary philosophies for the community. In addition, the longer transport times made necessary some long protocols that had lots of tools in them to keep the patients stable for the long time we were with them.

Today, I respond to my calls with some of the most advanced EMS protocols that I know of in the region. For example our service and our resource hospital is committed to meeting the AHA’s goal of a 90minute symptom onset-to-balloon time for STEMIs (ST segment Elevation Myocardial Infarction or, the classic heart attack) this requires either ground-bypassing the closest community hospital ER by almost an hour to make it to a hospital equipped with a cath-lab. Most urban services that I’ve worked for carried Nitroglycerine, Aspirin, and Morphine for these cases. For our rural protocols, we add Nitro Paste, a bolus of Heparin, and IV Metoprolol. We also carry transport ventilators on the trucks to free-up a pair of hands from bagging during the long transports with minimal personnel. It takes a strong and independent paramedic to be able to handle anything that’s thrown at them as a single medic. It takes a very strong an independent medic to handle it with an unfamiliar team of EMT-Basics in unfamiliar circumstances.

The relationship between the ALS provider and the EMT-Basic services that they support must be strong in order to be effective. There has to be a high-level of trust between both organizations and the providers working within them to keep the service level high. Holding joint trainings and understanding that everyone has a role within the continuum of patient-care is necessary. Dispatch protocols that pre-deploy ALS resources make a difference as well and take the responsibility off of the BLS provider to make the decision on whether the ALS response is necessary. I personally subscribe to the idea that it is good to be proactive with ALS dispatch protocols and in addition to sending ALS to the obvious complaints, such as Unresponsive patients, Chest pains, and difficulty breathing calls; it is also a good idea to send them ALS to non-specific dispatches such as the unknown medical. BLS providers that arrive first can always cancel the responding ALS if they determine that they’re truly not needed.

And always, always, always… the ALS and BLS providers must check their egos at the door and realize that what’s best for the patient is the most important consideration.

The ALS intercept is a great tool that extends the reach of paramedics into areas where we can’t be effectively based from. It takes work, but it’s good for our patients and our communities. Rural EMS takes different strategies, and this is a good one.

What are your thoughts on this?

  • totwtytr

    I used to work part time for a hospital based intercept service. We responded to one city and about eight towns. 20 minute response times were the norm, as were intercepts from the towns and private services if they didn't have an ALS truck available.

    I came to appreciate how good the EMTs in my full time system are and how bad some EMTs that are out there are. A lot of the EMTs only called use because their protocols required it. Others used us to deal with patients that they didn't want to put up with. Ironically, there was one service staffed by cops and they treated us the best. Always glad to see us, assisted us as much as they could, never had attitudes. The full time staff told me that they never got a ticket from the cops in that town. :)

    You're right about checking egos. Some of the medics I worked with where not doubt the problem, but they had caused that before I came on board and I wasn't going to fix it.

    The pay wasn't good, but still I miss the shifts down there.

  • totwtytr

    I used to work part time for a hospital based intercept service. We responded to one city and about eight towns. 20 minute response times were the norm, as were intercepts from the towns and private services if they didn't have an ALS truck available.

    I came to appreciate how good the EMTs in my full time system are and how bad some EMTs that are out there are. A lot of the EMTs only called use because their protocols required it. Others used us to deal with patients that they didn't want to put up with. Ironically, there was one service staffed by cops and they treated us the best. Always glad to see us, assisted us as much as they could, never had attitudes. The full time staff told me that they never got a ticket from the cops in that town. :)

    You're right about checking egos. Some of the medics I worked with where not doubt the problem, but they had caused that before I came on board and I wasn't going to fix it.

    The pay wasn't good, but still I miss the shifts down there.

  • totwtytr

    I used to work part time for a hospital based intercept service. We responded to one city and about eight towns. 20 minute response times were the norm, as were intercepts from the towns and private services if they didn't have an ALS truck available.

    I came to appreciate how good the EMTs in my full time system are and how bad some EMTs that are out there are. A lot of the EMTs only called use because their protocols required it. Others used us to deal with patients that they didn't want to put up with. Ironically, there was one service staffed by cops and they treated us the best. Always glad to see us, assisted us as much as they could, never had attitudes. The full time staff told me that they never got a ticket from the cops in that town. :)

    You're right about checking egos. Some of the medics I worked with where not doubt the problem, but they had caused that before I came on board and I wasn't going to fix it.

    The pay wasn't good, but still I miss the shifts down there.

  • volliecc

    I staff lease to a volunteer service from a commercial agency so the taxed based ambulance customers do not pay for additional ALS services. I also volunteer to allow a volunteer agency to have ALS on overnight that otherwise would not have ALS in county. If it was not for the local fly-car or out of county ALS units, we would be in a very difficult position since out volunteer service only has 3 ALS techs.

  • volliecc

    I staff lease to a volunteer service from a commercial agency so the taxed based ambulance customers do not pay for additional ALS services. I also volunteer to allow a volunteer agency to have ALS on overnight that otherwise would not have ALS in county. If it was not for the local fly-car or out of county ALS units, we would be in a very difficult position since out volunteer service only has 3 ALS techs.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    Ckemtp
    I Got Attacked – A Paramedic Speaks About Public Trust
    I somewhat agree, though I assure you I didn't set out to waste your time. I probably should have broken this down into two separate points as the second point was the one I most wanted to emphasize. My bad on this one, I'll do better next time. Thanks for the feedback. If you'd like,…
    2014-12-16 20:25:00
    hawk4080
    I Got Attacked – A Paramedic Speaks About Public Trust
    Wow. That was a total waste to read.
    2014-12-16 19:20:00
    retired ems medic
    I Got Attacked – A Paramedic Speaks About Public Trust
    The radios should have had a trouble button to eliminate the need to key the Mike and talk. Maybe the dispatchers need to be rotated out to the streets to get out of the mode of just getting the calls out and only half listening to the radio.
    2014-12-16 14:50:00
    HybridMedic
    I Got Attacked – A Paramedic Speaks About Public Trust
    We use "Signal C" as a code to relay a crew in distress. Takes a second for the dispatchers to confirm it, but it sends the nearest engine, battalion chief, fire investigator (who are sworn LEO's) and makes an officer in distress call to Memphis Police. The arrival of all those resources is quite... Dramatic.
    2014-12-15 14:29:00
    exmedic
    Welcome to the Club
    Not me anymore
    2014-12-15 09:17:00

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