by Karen McIlroy



   Rural communities are small to mid-size populations with fewer than 25,000 residents, as defined by the National Fire Protection Association (NFPA). There are approximately 19,000 of these communities nationwide in the United States being served by first responders.

   Rural Emergency Medical Systems (EMS) face substantial challenges. Few rural communities have paid EMS personnel, depending instead upon volunteers, who often work full-time in non-EMS related vocations within the community. These dedicated first responders not only donate their personal time to provide pre-hospital care, they also participate in ongoing training to ensure that they are using the most current and effective techniques for rescuing and saving lives.

   Two unique factors leading to higher costs for EMS care in sparsely populated regions include the use of more motor fuel needed to reach rural locations and the need to provide more expensive medical procedures to increasingly aging rural populations. Often there are fewer younger people living in these more remote areas due to the need to move to urban locations to attend higher education institutions and find work. Even internet access may still be an issue in some locations.

   Typically there are fewer tax dollars to fund EMS programs in rural communities, which places an increased demand on how to finance services. Additionally, poor access to training and medical supervision, higher response times, dated equipment, inadequate insurance reimbursement for services, and insufficient communications systems all combine to make rural EMS an area of critical concern. There may be fewer local philanthropic organizations and foundations in rural areas that could purchase newly developed first responder equipment needs in a timely manner, such as infra-red night goggles that are more effective than flashlights for locating someone on a hike who is lost in the dark. Opportunities for state and federal grants provide excellent funding, but there are submission and review deadlines that can take months, and there is no assurance that the dollars requested for the most current, effective equipment will be awarded.

   Finding an adequate number of professionals to employ in rural EMS jobs is also a challenge. People who have lived in or worked in a rural environment for many years have an understanding that there are non-verbalized nuances in small community dynamics. These are most often related to ethnicity-specific cultural beliefs, local community lore that only long-time residents would know about, and traditions that are followed because if they are broken they would violate the sense of generational and historical belonging.

   There may also be a mistrust of non-local first responders that would prevent the rural residents from sharing all of the information that would ensure the best outcomes for someone who needs to be transported to a hospital. Family members explaining a situation for which they called for medical help may be reluctant to reveal that use of alcohol or drugs caused the symptoms that the victim is experiencing.

   A quote by the National Academies Press, Quality Through Collaboration, provides a graphic summary about employment in the rural EMS position: “Many rural communities have difficulty attracting and retaining clinicians because of concerns about isolation, limited health facilities, or a lack of employment and education opportunities for their families. Although steps have been taken in recent years to introduce a more favorable financial climate for rural health care providers, an under-resourced health care delivery infrastructure persists.”

   The National Academies Press has published the following recommendations based on their key findings to address the challenges outlined above:

   •   Financial and policy incentives at the federal and state levels could be put in place to facilitate the gathering, analysis, and retention of health professions workforce data that are comparable across states.


   •   Fundamental change in health professions education programs and institutions will be needed to produce an adequate future supply of properly educated professionals for rural and frontier communities.


   •   A multifaceted approach to the recruitment and retention of health professionals in rural areas is needed, including interventions at every point along the rural workforce pipeline: (1) enhanced preparation of rural elementary and high school students to pursue health careers; (2) stronger commitment of health professions education programs to recruiting students from rural areas, educating and training students in those areas, and adopting rural-appropriate curricula; and (3) a variety of strong incentives for health professionals to seek and retain employment in rural communities.


   •   Enhancements to the basic curriculum, particularly the science curriculum, for middle and high school students are needed to better prepare rural students for careers in the health professions. HRSA’s Office of Rural Health Policy could work collaboratively with the various federal agencies (e.g., Bureau of Health Professions, Department of Education, Bureau of Indian Affairs, and Indian Health Service), professional associations, and rural constituencies to identify appropriate enhancements and develop an action plan.


   •   A rural health professions mentoring program might be established to expose rural students to potential careers in health care. Changes are also needed in health professions education programs.

   It is very encouraging that federal agencies are aware of, and partnering, to address the challenges faced by rural America. On June 16, 2009, the U.S. Department of Transportation (DOT), the U.S. Department of Housing and Urban Development (HUD), and the U.S. Environmental Protection Agency (EPA) formed the Partnership for Sustainable Communities. These agencies have provided tools for creating comprehensive plans to address specific issues that relate to an individual rural community’s needs, and key resources that include grant opportunity information to fund different aspects of the plans.

   The more rural community leaders have the time and opportunity to explore existing and new resources when they become available, the greater the benefit will be to meeting the needs of their populations. And the greater the impact on how EMS first responders will be able to respond when they get to an emergency first.

Research Sources

<sub>1. http://www.nfpa.org
2. Institute of Medicine Future of Emergency Care Series: Emergency Medical Services: At the Crossroads (2006); Institute of Medicine
3. Quality Through Collaboration: The Future of Rural Health. Washington, DC: The National Academies Press (2005);
4. McGinnis, L. (2004) Rural and Frontier Emergency Medical Services: Agenda for the Future Kansas City, MO: National Rural Health Association;
5. Emergency Medical Services Overview, University of North Dakota Center for Rural Health.
6. http://www.epa.gov/smartgrowth/partnership/index.html</sub>

   Karen McIlroy has 30 years experience working with rural communities and has seen the challenges faced by the first responders first-hand. Her most current projects include coordinating a Precision Agriculture Conference in Tifton, Georgia and providing grant writing services to rural first responder agencies.