As difficult as it is to define rural areas, it is also difficult to make generalizations about the characteristics of rural populations in the United States. Sometimes, there is more variation between rural areas in different regions of the country than between rural and urban areas in the same region. Looking at census data from across the United States, a greater proportion of the rural population is older than 65 and white, fewer have graduated from college, and there is a lower mean household income as well as a higher poverty rate. In terms of health-related measures, there is no significant difference in health insurance coverage between rural and urban areas, although this varies by region. On a self-reported survey, more rural adults are current smokers, are obese, and more have hypertension, heart disease, cancer, or have had a stroke. Disparities exist in many areas of health care as well. There are proportionately fewer primary care physicians, with about 5 to 6 per 10,000 population in rural areas versus 9 per 10,000 in urban areas as well as far fewer specialists.7
Despite a general decline of age-adjusted mortality over the years in both rural and urban areas across the country, the rate of decline has become less in rural areas, leading to a rural “mortality penalty.” The cause of this remains unclear, but is present in cardiac disease, cancer, and stroke, the three leading causes of death in adults in the United States.8,9 Theories include difficulty initiating appropriate interventions in a timely manner for patients with time-sensitive medical conditions, such as acute myocardial infarction or stroke, and the difficulty of small hospitals in implementing advances in medical care. Although not specifically studied, it stands to reason that a lack of robust EMS systems in many rural parts of the country may contribute to this mortality penalty for rural residents. This highlights the need for improvements in all aspects of rural health care, including EMS, and the importance of active medical direction.
The challenges for rural EMS systems to help combat the mortality penalty are highlighted in some of the major medical emergencies faced by EMS on a daily basis. ST-elevation myocardial infarction (STEMI) is well established as a time-sensitive medical condition with the traditional goal of PCI being achieved within 90 minutes from arrival at the hospital (“door-to-balloon” time). However, since many patients have the diagnosis of STEMI first made on initial evaluation by EMS, emphasis is now being placed on EMS-to-balloon time, with the same goal of 90 minutes.10 However, it is estimated that 43.6 million adults in the United States live more than 60 minutes from a PCI-capable facility.11 This makes early recognition of STEMI by rural EMS providers especially important through symptom recognition and early prehospital ECG acquisition.12–14 Combined with prearrival notification of the cardiac catheterization lab team, and development of protocols to bypass closer but non-PCI capable facilities, rural EMS can help reduce delays and improve outcomes.10–15
Studies also suggest worse outcomes for stroke patients presenting to rural hospitals. Barriers to stroke care include lack of neurology specialists and designated stroke teams, lack of 24-hour CT access, and decreased comfort of providers in giving thrombolytics. Furthermore, standards of stroke care tend to be developed at large urban medical centers with extensive resources; implementation of the same standards in small rural hospitals may be impractical.16 Prehospital care of the stroke patient begins with recognition of the signs and symptoms of an acute stroke, determination of the time of onset of symptoms, and prearrival notification of the nearest appropriate facility.17 Unfortunately, it has been shown that EMS can have difficulty in stroke assessment. In response to some deficiencies in rural stroke care, the Montana Stroke Initiative sought to provide stroke education to communities, prehospital care providers, and rural hospitals.18 This and similar training programs are available to EMS providers and may help improve rural stroke care.
In addition to the challenges of rural cardiac and stroke care, multiple studies have shown a higher rate of mortality for rural versus urban trauma victims, for all causes of trauma.19–22 The cause of this disparity is still unclear, but factors specific to rural environments, such as distance from the scene to definitive medical care, higher speed limits on rural roads, decreased seat belt use, alcohol intoxication, and transport to local hospitals versus trauma centers may all play a role. Studies have reached conflicting conclusions as to the role EMS time intervals (activation, on scene, and transport times) play in mortality in trauma. 19,20,22 Intuitively, shortening the time it takes to reach a hospital would improve survival; studies show IV placement en route rather than on scene achieves a shorter time, while demonstrating a higher success rate.23,24 However, other studies have shown improved survival for patients with longer EMS contact time, possibly due, in part, to transporting directly to a trauma center and bypassing smaller, less equipped hospitals.22 Providers may be uncomfortable transporting potentially critical patients past a local hospital to a regional stroke, cardiac or trauma center; however, medical directors should work with EMS agencies and the local and regional health care systems to develop the most appropriate approach for the area.