It may shock some of my more urban readers out there, but not everywhere is a city.
Why did I say that? Itís because thereís 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, Iím writing about some of the issues facing rural EMS and the techniques that we use. Hopefully itís educational.
Hereís 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. Thereís 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 wasnít 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 ďALS interceptĒ. It still happens that way in a lot of communities, in fact, I ride around in an ďinterceptorĒ 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 ďOh-My-GodĒ critical patient, having the paramedic jump on board was such a feeling of relief. Now, from the perspective of the paramedic who jumps in, itís sometimes a bit of a pucker factorÖ because now youíre 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. Thatís 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. Itís 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 ďSatelliteĒ First Responders to augment the response. It workedÖ if they were home or in the area.† Nonetheless, the response times went up to and over 30 minutes in the most remote areas. ďCall EarlyĒ and ďCall FirstĒ 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 AHAís 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 Iíve 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 thatís 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 theyíre truly not needed.
And always, always, alwaysÖ the ALS and BLS providers must check their egos at the door and realize that whatís 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 canít be effectively based from. It takes work, but itís good for our patients and our communities. Rural EMS takes different strategies, and this is a good one.
What are your thoughts on this?