Online newsletter Volume 2, Number 2,  Summer 2004

Where Getting from Crash to Care Is Still a Challenge  

Geography and budgets create barriers for rural EMS
 

For reasons of geography and budgetary constraints, many rural areas still do not enjoy the fullest advances in emergency medical services (EMS) achieved in much of the U.S. over the last three decades, a disparity that contributes to the high rate of fatal crashes on rural roads. These improvements came about when EMS incorporated experiences in battlefield hospitals in Korea and Vietnam and theories such as the "golden hour," advanced by the late R. Adams Cowley, who argued that many victims could be saved if treated by trauma specialists within 60 minutes of their injuries. In fact, on average, rural-area EMS response times come dangerously close to exceeding that critical window of opportunity, beyond which mortality rates rise drastically.

According to a 1997 report for the National Transportation Safety Board advocating the importance of automatic crash notification systems (a technology that has yet to see widespread adoption), of the nearly 20,000 victims who died at the scene of the crash, "about 13,500" of them were injured in rural crashes, compared to "about 6,500" in urban crashes. "Of the 22,000 crash deaths that are taken to hospital, many die because they arrive too late to be saved. Thousands of crash deaths occur each year in which the victim did not arrive at a hospital—much less at a trauma center—within the 'Golden Hour,'" the authors wrote. (See sidebar for link to this report)

Long and Winding Roads  

The delay is due to a combination of factors. Rural-area EMS units typically travel longer distances to reach crash sites, and, on average, the lag time between the crash's occurrence and units receiving a call for help is also longer. According to the National Transportation Safety Board report, the average time lapse between a crash and an EMS arriving is 18 minutes, compared to 10 minutes in urban areas, and victims arrive at a hospital in an average of 52 minutes in rural areas, as opposed to 35 minutes in urban ones. That brings the time between crash and treatment by emergency medical personnel response dangerously close to the "golden hour." In addition, on the scene, the personnel who do arrive are, in many cases, lacking the training or resources of their urban counterparts.  

Lowering response times and providing more training for EMS staff and volunteers is a continuing challenge for many EMS providers in rural areas nationwide. This article will describe the situation in a large rural area of Northern California, a state project in rural North Carolina credited with cutting death rates, and a nationwide campaign, "First There, First Care," aimed at educating bystanders on what they can do to provide the crucial preliminary care that has been shown to significantly lower the death rate of crash victims.
 
Typical of the issues facing rural-area EMS operations are those facing the Northern California EMS (Nor-Cal EMS), a private, non-profit agency that oversees EMS in the northeastern part of the state. Its region is vast—some 22 percent of the state's territory—though only 2 percent of its population, comprising Butte, Colusa, Glenn, Lassen, Modoc, Plumas, Shasta, Sierra, Siskiyou, Tehama, and Trinity counties. The region's two most populous cities are Chico (approximately 82,500) and Redding (approximately 125,000), while the remainder of the population centers are small-to-medium size towns ranging in size from 1,000 to about 10,000 residents. Each county tends to be limited to one or two of those towns and has large isolated areas. Because of their rural nature, urban amenities such as publicly supported fire departments and EMS personnel are usually not available.

Kevin O'Loughlin, EMS Systems Director for Nor-Cal EMS, says that lags in EMS response time, inadequate training for paramedics and a high turnover rate among volunteers are among the problems faced by EMS providers in the region. "Huge area, few bodies. And we cover all of it," O'Loughlin says. "[Lags] in response times is a huge issue, but that's just the way it's laid out.  

"You make do with what you have and figure it out when you get there."  

Not only are many of the region's small towns located "in the middle of nowhere," as O'Loughlin says, but the roads that lead to them are often narrow, steep or (at higher elevations in the winter) icy.

A typical example of a remote location in the area is the town of Forks of Salmon in Siskiyou County. "There's one road in and one road out," O'Loughlin says. "And it's a one-lane road. There's a mountain on one side and a 100-foot drop-off on the other."

O'Loughlin adds, however, that the situation is not as bad as it might seem. If there is a serious crash in a remote, hard-to-reach location, an EMS unit will usually fly in by helicopter. Helicopters are used extensively to reach crash sites in the 11-county region. In addition, most of the serious crashes happen around Redding and Chico—areas that have "standard, 8-minute time frames" for EMS response, he says—rather than in rural areas.  

"We are fortunate that we haven't had a lot of wrecks in the hills. If it was somewhere like Cedarville [in Modoc County] in the winter, you have to go down a really steep, icy grade."  

The region's 11 counties are served by two trauma centers, five Emergency Departments Approved for Trauma (EDATs) and 15 hospitals. Most—75 percent—of the region's EMS providers are private agencies that bid for contracts and charge clients and insurers for their services, though they typically receive some funding from the county they serve. Even so, only one county, Butte, has an EMS provider with a full-time staff. Other counties in the region, by contrast, have "hospital-based" paramedics. Often, a single paramedic is on duty at that hospital. These paramedics, O'Loughlin says, work long hours and may even remain on call after their shift is over. If a call comes in, another person on staff at the hospital may ride along with the paramedic to provide some basic assistance, but that person will not necessarily be a medical professional.  

"It could be the janitor; it could be anybody," O'Loughlin says.  

Many EMS personnel in the region's rural areas are volunteers who double as firefighters and paramedics. Getting people to volunteer generally isn't a problem, O'Loughlin says, but keeping them often is.  

In Shasta County, where O'Loughlin volunteered, he said, "We used to turn people over like water. It gets to be too much. They reason, 'I work full time, I have a family, I'm in the military, something needs to go.'"  

Lack of adequate training is also a problem, O'Loughlin says. While some EMS providers train their volunteers extensively, "others don't train their [volunteers] at all. Nobody's there to watch them and hold their hand." 

O'Loughlin says that the region's EMS providers would benefit from more training materials and more free training classes. In addition, the fact that volunteers double as firefighters and paramedics presents problems. O'Loughlin says that some volunteers are more excited about the firefighting component of their work than the medical component. Some volunteer units, he said, do not as a practice go on non-emergency "medical calls" such as those for chest pains.  

"They just want to put the wet stuff on the red stuff," he says—an idiom for "putting out fires." "The more rural you get, it seems, the more you get that mentality."  

The low priority given to medical calls is starting to create a problem of conflicting expectations among the region's more recent arrivals, an increasing number of whom are newly retired from more urban areas, especially San Francisco. These retirees, O'Loughlin says, want the security of knowing that an ambulance will come quickly if they have a medical problem.   

"They still expect the same level of service as in downtown San Francisco," O'Loughlin says. "They call the ambulance in San Francisco; in four or five minutes it's there. Here, if it gets there in an hour you're doing pretty good."  

O'Loughlin says that perhaps the single most important factor in improving EMS in the region is "better coverage"—more trained professionals on duty at any given time. However, the barriers to providing comprehensive training to EMS personnel—and to retaining them—are significant. Lack of funds is a perennial issue, though O'Loughlin says that coverage could be improved if the region's emergency medical services were organized differently, and funds were channeled differently. According to O'Loughlin, the best solution would be for counties to pool their resources. Currently, each county has an exclusive contract with an EMS provider; no new provider can come into that "exclusive operating area." O'Loughlin has proposed an alternative arrangement to officials in the region: expand the "exclusive operating area" to four counties. If that were to happen, O'Loughlin says, the multi-county region could get bids from EMS providers that have more resources and more staff members.  

"There's ways to make it happen. The politics is difficult. It's getting counties to agree to it, the hospital, everybody and his brother. I've been preaching this for some years."

 
A North Carolina Success

Responding to a study that found excessive mortality rates for crash victims needing emergency services, a rural region of North Carolina embarked on a highly structured training and follow-up program that seems to have enjoyed considerable success.  

In a 1992 National Highway Traffic Safety Administration (NHTSA) study conducted in rural eastern North Carolina, researchers found that the region's preventable mortality rate for EMS responders (the deaths that could have been prevented with appropriate and timely medical care) was 29 percent. This same study found that 103 of 151 patients reviewed received some type of inappropriate care, with 72 patients receiving inappropriate care in the "prehospital" setting and 69 in the emergency department. The study results suggested that training EMS providers in airway management, techniques to resuscitate victims and keep them breathing on the trip to the hospital, was needed, and that the period of time to get them to "definitive care" needed to be reduced.

These findings prompted local officials to implement the Rural Enhancement of Access and Care for Trauma (REACT) project, a comprehensive, locally-based program to improve EMS response times.

The REACT project focused on training for EMS providers. Project leaders established guidelines for appropriate "prehospital" care, based on suggestions by hospital administrators, trauma surgeons, emergency physicians, prehospital personnel, and emergency department personnel. EMS providers then underwent in-depth training designed along those guidelines and, in a follow-up segment of the project, were informed how well they were complying with them. A follow-up NHTSA study found that the preventable mortality rate had dropped to 14.9 percent and credited REACT with helping to lower it.  

A project aimed at reducing the rate of preventable trauma deaths that has a different focus is NHTSA's "First There, First Care: Bystander Care for the Injured." Developed by NHTSA, along with the Health Resources and Service Administration and the American Trauma Society, it is a campaign aimed at giving ordinary motorists "information, training and confidence to provide life-saving bystander care at the scene of a crash," according to project materials. It is based on the theory that in many cases passing motorists could help keep crash victims alive long enough to receive life-saving trauma care by delivering basic emergency care, such as CPR. Indeed, many crash fatalities result from blocked breathing passages or blood loss, conditions which bystanders can easily treat, provided they have the proper training to do so.  

Community members interested in holding First There, First Care training sessions in their area can approach a medical professional such as a physician, nurse or paramedic and ask them to serve as a trainer. First There, First Care provides the medical professional with an Instructor Preparation Package that shows them how to train motorists to give injured people basic care. It also provides free student materials to motorists who wish to take the course.  

The situations described by O'Loughlin and by NHTSA's report on rural North Carolina EMS indicate that improved recruitment and training of paramedics, including volunteer paramedics, is a key aspect in reducing EMS response times. (Understaffing is a concern shared by state EMS directors nationwide, a group who, in an opinion survey (see sidebar link), named "recruitment/retention" as the foremost rural-area challenge.) However, most regions do not have the resources to implement a program such as North Carolina's REACT and will have to rely on smaller-scale campaigns or perhaps on methods such as those suggested by O'Loughlin, where several rural counties pool their resources to provide the area with better coverage.  

In predominately rural counties, EMS providers, like the rural roads on which they travel, tend to be shortchanged when it comes to receiving adequate funding. Some counties have found unique ways to fund road improvements, such as the fast-growing Contra Costa County, which borrowed $1.5 million from one of its cities, Brentwood, to add rumble strips to the dangerous Vasco Road (Click here to read the story). Although O'Loughlin says that a few local officials have dismissed his plans of a multi-county EMS provider as "crazy," cash-strapped rural counties may find that the best methods of improving rural road safety are the unconventional ones.