Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android


Our colleagues in pediatrics often remind us that children “are not just little adults.” In much the same way, rural EMS is not just “little” EMS. Rural EMS departments not only face the same issues as their urban counterparts, but also must cope with challenges specific to rural areas, such as limited local resources and geographic isolation.1 Because of these differences, rural EMS requires more than just downsizing an urban system to be successful. This chapter will highlight some of the challenges unique to rural EMS systems, and allow the reader to begin to develop an approach to rural medical direction.


  • Describe the unique challenges to providing emergency response and EMS care in rural locations.

  • Describe differences in volunteer/paid status, provider certification, experience level, and burnout rates when compared to urban EMS.

  • Discuss how resource utilization may be different in rural areas.

  • Discuss unique injury types and safety concerns in rural areas.

  • Describe challenges in EMS agency finance.


The term rural brings to mind low population density, few resources spread over a large area, and perhaps a harsh or austere natural environment. The US Census defines “rural” as all areas that are not urban, with “urban” defined as areas having at least 2500 people.2 Based on this definition, about 72% of land in the United States is considered rural, and about 14s% of the US population, or around 46.2 million people, live there.3 The term frontier has also been used to classify locations of even smaller population density, and is generally defined as a population of six or fewer people per square mile, and a certain traveling distance from key services such as hospitals.4,5 According to this definition, about 56% of total land area in the United States is frontier, and about 3% of the population resides there.6 For this chapter, unless specifically stated, the term rural will serve to represent both rural and frontier areas (Figure 17-1).

FIGURE 17-1.

2010 Population distribution in the United States and Puerto Rico.


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, ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.