Serving 30 years as a paramedic in rural Alabama has left John Reed, MPH, BSN, RN, with hard-earned insights concerning the difficulties faced in rural emergency medical service (EMS). "Even though we're all paramedics, being a rural paramedic is a different animal," says the Professional Nurse Development Specialist at UAB Center for Nursing Excellence.
Distance and call volume make the difference. "We deal with the same medical conditions as urban paramedics--a heart attack is still a heart attack-- but sometimes our patients are sicker because they may not have a community hospital in the county," Reed says. "Or they may only have one ambulance."
So not only does it take more time for rural paramedics to reach the patient, but the lack of access to healthcare means paramedics often face sicker patients with more untreated comorbidities.
One way to mitigate both these challenges would be to establish more-freestanding emergency clinics in rural areas. "There are whole counties that don't even have a hospital or a single physician," Reed says. As of 2017, seven Alabama counties were without a hospital according to the Alabama Rural Health Association: Cleburne, Coosa, Henry, Lamar, Lowndes, Macon, and Perry. And 81 percent of the state's counties are designated as rural.
In Blount County, where Reed has served as a volunteer paramedic for decades, it can take up to 30 minutes to reach the emergency scene and sometimes another hour to drive to the hospital. By comparison, Birmingham patients will usually arrive at the hospital in 10 to 15 minutes.
"The lengthy transports mean that rural EMTs have to be better at the job, but although they are trained, they don't get the real life exposure that urban paramedics get," Reed says. "A rural paramedic may only treat three heart attacks in a year versus a paramedic stationed in a city who might respond to 25 of those calls a month."
Most trauma calls in a city center around car wrecks and gunshot wounds, but in the country, trauma usually means something farming related and not always accessible. "You go to a grain mill, and someone's 100 feet up in the air who needs help," Reed says. "Once, we had a deer hunter who had an accident on an ATV a mile away from any roads. We had to get creative. We transported him out of the fields on a wagon pulled by a farmer's tractor. That kind of thing doesn't happen every day, but occasionally it's what we're up against."
That creativity must compensate for the lack of resources, from jaws of life and long truck ladders--which most every city fire department carries--to something as simple as a tow truck. "One time we sent someone to the farm down the road to get the tractor because a vehicle in a ditch had fallen on the man working on it," Reed says. The wrecker would have taken 45 minutes to reach the scene. The neighbor got there in minutes. "To lift that car in the city, they would have used a wrecker or specialized air bags. For us, the biggest resource is the farmer next door."
Rural paramedics are more likely to have to deal with an emergency alone, unlike urban areas where multiple paramedics staff each ambulance. Many rural areas have just one paramedic serving 20,000 to 40,000 people because most paramedics want the higher pay and benefits offered in cities.
With paramedics now scarce nationwide, especially since COVID-19 hit, a few Alabama cities have found a way to improve the efficiency of their emergency staff by initiating a concept called community paramedicine which engages the paramedics in resolving medically-related situations.
For instance, a woman in Birmingham had been sent to the ER as a result of not taking her medications correctly. "The paramedic visited her in her home as part of the program and realized that she was illiterate and unable to read the pharmacy label," Reed says. "With this program, we can see the patient in their home environment which makes a difference. This kind of untraditional role for paramedics as problem solvers could help draw some paramedics out of the cities and into rural communities. The bottom line there is so many challenges to rural healthcare, and hopefully we can find creative ways to improve things."