Rural Emergency Response:
The Safety and Health Safety Net
Gary
Erisman Ph. D., CSP., EMT-B/D
Department
of Health Sciences
Illinois
State University
“If I cry
out, will someone come to help?”
·
Rural residents assume emergency services will be available
if needed
·
Current evidence suggests this assumption is on a shaky
foundation.
·
The 1989 edition of Agriculture at Risk: A Report to the
Nation fails to address the issue of emergency response and it’s importance
to rural residents.
·
Rural areas comprise 4/5ths of America’s land area, but only
1/5th of the population.
·
29 states have at least 1/3 of their population classified
as rural
·
18% of rural residents are over 65 yoa.
·
A greater % of rural elderly live in poverty (21%) than
urban (12%)
·
When all ages are included, agriculture has the highest
accidental work death rate of all major occupations
·
60% of all motor vehicle deaths occur in rural areas.
·
38% of all machinery related deaths ocuron farms.
·
Rural elders are more often disables and diagnosed with more
severe occupationally related illnesses than other residents.
·
Rural residents are more likely to be self employed and
without comprehensive health care coverage.
·
While 1 in 5 Americans live in rural areas, only about 1 in
10 physicians practice there.
·
243 counties in the U.S. do not have a physician.
·
Only 10% of medical specialists practice in rural areas.
Rural America is filled with people abnormally vulnerable to
emergency response needs. At the same
time it possess characteristics that make providing these services abnormally
difficult.
Some
Milestones of EMS
·
1797 -- Napoleon’s chief physician implements a pre-hospital
system of removing troops from the battlefield.
·
1920’s -- First volunteer rescue squad organize in Roanoke,
Virginia.
·
1958-60 -- CPR developed and shown to be effective.
·
1966-- Highway Safety Act establishes EMS programs in the
U.S.D.O.T.
·
1977-- Emergency Medical Services Systems (EMSS) Act
provides guidelines and funding.
·
1981 -- Omnibus Budget Reconciliation Act. consolidates EMS
funding into state block grants - eliminates funding under EMSS act.
·
1990 -- Trauma Care Systems and Development Act provides
funding to states for trauma system development.
·
1995-- Congress does not re-authorize funding under the
Trauma Care Act.
·
1996-- NHTSA releases Emergency Medical Services Agenda
for the Future document. Document
does not specifically discuss rural needs and problems.
“Because the average U.S. resident requires ambulance at
least twice in his or her lifetime, well organized medical service are
essential components of medical care.
Delays in receiving emergency care in sparsely populated areas put many
rural Americans at greater risk of permanent injury or death than those who
reside in urban areas. Therefor, the
development of effective EMS systems is crucial to the health of rural
Americans.” (U.S. Congress, OTA, 1989)
Emerging evidence indicates that rural emergency medical
services are at a crossroads. On one
hand a glowing “Vision” of the EMS future is offered by the NHTSA . On the other hand a growing crisis is being
acknowleged in the ability to provde any service at all at the rural
level. (IDPH, 2000; UND, 2000; Gibbons
and Olson, 1994)
A unique
challenge of rural EMS = logistic and time loss in response and transport.
“In Vietnam fewer men died of their battlefield wounds that
in any previous war because of Dustoff helicopters. The percentage who died of their wounds declined from 29.3% in
W.W.II, to 26.3 in the Korean War, to 19% in Vietnam.” Brower, 2000)
“The single biggest determiner of successful patient outcome
is the amount of lost time between injuryonset and delivery to the operating
room.” (Chapleau, 2000)
It
logically follows an EMS presence at the local level is essential to reduce
delay in providing medical intervention and transport services thereby
improving chances of survival for those experiencing medical emergencies.
In most rural areas, EMS has not attained the same level of
advancement as it has in urban areas.
The ORHP cites 4 reasons for this observation:
1.
Sparce populations covering large geographical areas make
the cost of providing emergency care more expensive….
2.
State and local governments in rural areas have a lower
capacity to fund programs through taxes.
3.
Failing rural economies often have difficulty maintaining
public services and responding to change….
4.
Rural communities do not have the volume and profit to
operate private sector EMS services when the public support system is absent.
(ORHP, 1990)
Emergency responders possess personality traits
significantly different from those of average people:
·
They are action oriented
·
They like to be in control
·
They are risk takers
·
They tend to enjoy public attention
·
They are dedicated and loyal
·
They are less family oriented than the norm
·
They have a strong desire to be needed and want to help
others
…” the hazards specific to rural areas, quality of life
issues, and the pain of knowing the victim are all issues with which rural
emergency workers deal. What binds them
together is community spirit and pride.
It lies deep within the hearts and minds of service providers, care
givers, and the families that support them.” (Casey and Leger, 2000)
“…Some of the main reasons why local residents agree to
participate in local EMS include the crucial medical need within the community
and the town pride in their autonomy and independence….When asked for their
main reasons why they joined local EMS…
1.
Satisfaction in helping others (86.9%)
2.
Community need (78.0%)
3.
Interest in EMS (72.6%)
4.
Interest in trauma care (59.9%)
5.
Challenges of providing EMS care (52.2%)
The review of literature shows a consistency of
findings. The “big 2” problems of rural
EMS appear to be recruitment and retention of personnel and finance.
“…Much of the nation’s EMS is provided by volunteers with
diverse occupational backgrounds. They
serve more than 25% of the population. The economic value of their contribution
is immeasurable. However, for many
possible reasons, the number of EMS volunteer organizations is decreasing. Perennial EMS issues include difficulties of
recruitment and retention and …inadequate compensation…EMS personnel experience
stressors and risks that are unique to other health care workers, and, no
doubt, to other public safety workers…” (NHTSA, 1996)
“The Illinois Rural Association has…invited conference
attendees to participate in round table discussions concerning rural health
issues. Consistently at the top of
every list had been EMS.” (IRHA, 1995)
“…The UND Center for Rural Health conducted a survey of EMS
personnel…Results indicated respondents felt the most pressing problems…were
retention of personnel (61%), recruitment of new personnel (58%), getting time
off from one’s non-EMS job (26%), lack of community acknowledgement/recognition
(24%), and inadequate medical direction (15%). (UND, 2000)
“…An opinion survey of State EMS Directors was conducted in
early 2000…Whether one looks at priority ranking or total responses, it is
clear that recruitment/retention of EMS personnel, appropriate medical
oversight, and financing are perceived as, by far, the most significant issues
facing rural EMS delivery systems.
Skill retention, continuing education and compensation are of next most
concern, and these can all be tied to the larger financing issue….(NASEMSD,
2000)
“…In response to State of Illinois Senate Resolution No. 146
a committee was formed to…review and analyze the impact of funding, training,
regulations and licensing on the access and availability of emergency medical
services in rural areas…Discussion resulting in a natural separation of issues
into six topical categories: 1) recruitment/training and etention of EMS
personnel, 2) community and provider education, 3) new service models, 4)
funding issues, 5) data needs, 6) best practices. (IDPH, 2000)
The recruitment and retention of EMS personnel is recognized
to be the #1 problem area in providing rural EMS. Obviously, without the health care provider there can be no rural
EMS.
In a North Dakota study 69.7% of rural based EMS personnel
felt this was a much bigger problem that urban areas (39.1%)
Barriers to recruitment: (UND, 2000)
1.
Time commitments (77.2%)
2.
Training requirements (71.8)
3.
Lack of interest in EMS (40.4)
4.
Stress (38.7%)
5.
Inadequate pay (38.7%)
Previous studies have indicated obtaining time off from work
is a barrier to both recruitment and retention (72.2%)
Why squad members quit: (UND, 2000)
1.
Time commitments (64.5%)
2.
Training requirements (55.4%)
3.
Personality conflicts with EMS personnel (30.5%)
4.
Loss of interest (30.2%)
5.
Shortage of backup EMS personnel (29.3%)
Recruitment and retention issues were broken down as
follows:
Time Demands:
·
Two income families working multiple jobs
·
Inability to commit to training/continuing education and
recertification demands (CEU’s)
·
Non-emergency, lengthy transport/patient contact time (i.e.
clinic visit)
·
Additional demands - administrative duties (record keeping,
scheduling)
Service Related:
·
Broader range of services (new methods and patient care
requirements- continually added responsibilities)
·
Abuse of emergency services by public (use of ambulance for
non-emergency ride to hospital)
·
Internal problems (disagreements among members)
·
Leadership problems (failure to manage change, lack of
coordination)
·
Friction/chronic problems between other health service personnel
or agencies (lack of appreciation or acknowledgement of EMS by Allied Health
Care, lack of involvement in decision making)
Social/Community Related:
·
Less emphasis on social aspects of volunteering
·
Less community pride/ loss of community feeling
·
Transience (moves, problems of reciprocity between
jurisdiction/states)
·
“Me” generation (self gratification/personal needs placed
over service requirements)
·
Aging communities (greater number of old residents, decline
in overall numbers, fewer of eligible age to step forward)
·
Poor economic growth (financially unable to continue
service)
“ A budget has only so much money…working with
administrators is complex work…often needs are misconstrued into power
struggles and everyone suffers. High
cost equipment in rural communities frequently competes with other worthy
services - streets, water, recreation, senior services - for a limited share of
the budget allocation.” (Casey and Leger, 2000)
“Tension between the fire - rescue services and the private
ambulance industry ahs escalated to a new level of anger and mistrust. It’s part of a long running, bitter battle
over who is going to be the major provider of emergency care - municipal fire
departments or private ambulance companies.
The stakes are enormous…a business worth an estimated $10 billion….”
(Bruno, 1997)
A recent NASEMSD study ranks capitol needs by category:
1.
“Communications equipment: Many of the communications
systems put in place in the mid to late 70’s with Federal grant funds are
antiquated and no longer available, and many rural systems do not have the
funds to replace their old systems and equipment…Some states estimate their
need for communications equipment to be $15 - 40 million…
2.
Medical equipment and ambulances: In the mid to late 1970’s
the Federal Government allowed the purchase of ambulances as part of the
Governor’s Highway Safety program…With matching funds no longer available, many
rural areas find it impossible to raise the capitol to buy new ambulances. Some of the rural providers are using
1970-1980 vintage ambulances, while others have replaced their ambulances with
ambulances given to them by other providers.
Many of the donated ambulances are already worn out by the time the
rural provider receives them.” (NASEMSD, 2000)
“…As a proponent of rural health issues, the Office of Rural
Health Policy should take the lead by identifying sources of funding for grants
that will address EMS issues…..Without such initiatives, the ability to provide
quality rural EMS will continue to erode to a point where public health will be
impacted.” (NASEMSD, 2000)
“…States do seek greater federal support but not at the
expense of their autonomy in decision making. …the feds can provide money,
technical assistance, and professional help, but let the states decide what
approach they will use….People in the local area know best what is needed to
address their rural EMS problems …What is needed is a balance: federal leadership and oversight, yet state
and local autonomy in specific program development and implementation…..”
(Gibbons and Olson, 1994)
·
Can the current rural systems of emergency response,
particularly EMS, being made up largely of unpaid or minimally paid volunteers,
be sustained into the future.
·
What resources and assistance will it take to make it
sustainable and who will provide them?
·
Given the close socio-cultural relationship that exists
between rural residents and their emergency service providers, how well will
they accept any other system?
·
If the current system is not sustainable, what form will
it’s replacement take?
·
If the move is away from a system of unpaid volunteers to a
fee paid system of some type, how will the already financially disenfranchised
rural residents be able to pay for it?
What costs will it add in terms of dollars? How many lives will be lost because of longer response times?
·
Who will provide leadership to an alternative system, and,
who will be willing to serve under their direction? Will they understand the uniqueness of the rural community, rural
residents, and their needs and expectations?
WE NEED TO
INSURE THAT IF A RURAL RESIDENT DOES CRY OUT, SOMEONE WILL BE GOING TO HELP
THEM QUICKLY, NOW AND INTO THE FUTURE.