LIFE OR DEATH: GETTING PATIENTS TO CARE IN RURAL AREAS

Volume 28, Issue 490 April 30, 2007

Matthew Gever and Melissa Hansen

The challenges of providing timely emergency care in rural areas are many. For example, there’s distance. “In rural Nebraska, we don’t talk about distances in terms of minutes and miles. We talk about hours to transport a patient,” said Nebraska Senator Tom Hansen at a recent NCSL meeting. The delay may cause patients to miss what physicians refer to as the “golden hour,” the window of time in which a trauma patient must receive care in order to have a chance at recovery.

Add to that the fact that the rural population is graying faster than the rest of the country; the growing shortage of both volunteer and professional emergency medical service (EMS) workers; the high costs of providing emergency care in sparsely populated regions; difficulties in maintaining private EMS due to low patient volume; and inadequate insurance reimbursement for transport services, and you’ve got a storm brewing.

Only 20 percent of the U.S. population lives in rural areas, but nearly 60 percent of all trauma deaths occur there, according to the National Safety Council. Injury-related deaths are 40 percent higher in rural communities than in urban ones, according to the Center for Rural Health at the University of North Dakota.

But states are taking steps. The Nebraska Legislature is currently considering LB 244, which was drafted after two first responders arrived to help a patient at a nursing home, and then had to wait an hour for an emergency medical technician (EMT) before they could take the patient to a hospital.

The bill would allow first responders to immediately transport patients in an ambulance. Current Nebraska law mandates that a first responder can transport a patient only if an EMT or other professional such as a nurse or doctor rides along. (First responders are firefighters, police officers and others who arrive first at the scene of an accident; they often have much less medical training than EMTs, who may perform tasks such as defibrillation and spinal injury care, and the even more highly skilled paramedics.)

In Virginia, the Office of Emergency Medical Services initiated a study to improve the retention of both volunteer and professional EMS workers. The study recommended that the state help develop flexible work environments; find ways to adapt to the lifestyles of “Generation X & Y” young professionals in order to persuade them to volunteer; and create a family-like work environment, to help make volunteers feel they are part of a team. The agency also created a motivational video using the late Christopher Reeve as a spokesperson to inspire volunteers.

North Dakota has taken a variety of approaches to improving emergency responses in rural areas. In 2007, the Legislative Assembly passed and the Governor signed SB 2016, which sets aside 20 percent of the state’s allotment of federal Department of Homeland Security funds for EMS. Those funds will be combined with general state funds to provide more than $143 million for improving the state’s EMS.

In addition, legislators passed and the Governor signed HB 1138, which exempts EMS motor vehicles and air transport from state fuel and excise taxes. “The reason for the exemption is to allow our scattered districts to continue operations,” said Representative Ralph Metcalf. “I don’t think it’s going to cure our problems, but it is a step in the right direction.”

Representative Metcalf also noted that the state will conduct a two-year study on how to improve emergency access in the most sparsely populated regions of the state. In the western part of the state, towns are anywhere from 50 miles to 100 miles apart. These areas are popular with tourists, which raises another point of concern about EMS.

Melissa Hansen is an intern with NCSL's Health Program