Rural response challenges for fire and EMS

A rural emergency incident requires the timely response of rescuers, response equipment and transport vehicles

By James Augustine

Many find the serenity and quiet beauty of a rural area to bring great peace. But for fire and EMS personnel, the challenges of managing emergencies in such areas are significant. How can leaders of rural fire and EMS agencies train and equip their providers to improve response capabilities and safety in areas with lower populations and greater distances to all emergency resources?

Challenges of rural operations and incidents
A rural emergency incident requires the timely response of rescuers, response equipment, transport vehicles and coordination that will minimize the loss of life and property.

The talents of on-scene fire and EMS providers must be allocated to deliver the best response for the victims, and a safe operation for everyone. For any unit of time, there are generally less resources then could be applied in an urban or suburban environment.

Communication systems may be less available, less durable, or even completely absent, in many rural areas.  Some counties in the United States still lack basic 911 service, and overall in rural areas there are more likely to be delays in access to emergency call centers, and subsequently a time lag between the emergency event and the activation of fire and EMS services.

There are safety challenges in all aspects of the emergency operation. In a rural area, there are lengthier response times of emergency equipment and providers to the scene of the emergency.

Many personnel have a primary occupation that is not fire or EMS related. When the primary responders request assistance, it will likely take some time before additional aid is on the scene.

Rural EMS providers have often adapted operations to work with smaller crews, and are comfortable recruiting bystanders to assist in safe parts of the operation.

But any provider in any location could be in a position to have to manage an emergency incident with fewer resources, at any time. And emergencies related to a bad weather event (ice, blizzards, windstorms, or wildland fires) may stretch rescue resources to the point where any individual incident must be managed with scarce numbers of people and rescue vehicles.

As this is not a wilderness environment, 911 callers and patients still have high expectations for emergency service. Imagine the urban resident, driving through a rural area, that finds and reports a building on fire or a serious car accident.

The activation of emergency services may or may not be available through a 911 system, and the responding rescuers may be many minutes away from the scene. That individual, who may be accustomed to 5 minute response times at his urban home, may become quite distressed when no sirens can even be heard for 20 or 30 minutes.

This can be partially addressed using a good "script" from the 911 call center operator, but usually requires an early explanation from the first responders that the closest aid is further away in the rural environment where this emergency occurred.

In major EMS emergencies in the rural environment, air ambulances may have a critical role in transporting seriously ill or injured patients. But even these resources may not be timely or available, especially in the poor weather conditions.

Positive elements of rural fire and EMS response
The communication system is an integral component of safe rural emergency operations. In a rural area, one dispatcher may be on duty and have to handle all incident communications and resource coordination for police, EMS and fire.

Rural agencies are finding solutions to the communications challenges of these smaller systems.  The emergency calltaker (through 911 or a seven digit number) is the dispatcher, and has the time and ability to directly communicate between the caller and the responding rescuers.   

Activation systems for in-station or out of station responders have been enhanced by paging, digital phone, and satellite-based communicators. Some novel systems allow a combination of devices to allow for one-step dispatching, and returns notifications about available responders that confirm an appropriate response. 

In these past few years, there are many more options for communications equipment that functions well in rural areas, and sometimes funding mechanisms to obtain those resources. This includes satellite and land-based analog and digital cellular phone and radio networks. 

In rural communities, there are opportunities for excellent mutual aid relationships, including automatic mutual aid response. These can be utilized as opportunities to place specialized and shared equipment in service that serves the needs of fire and EMS providers, and the public they serve.

This may include rural fire equipment, cooperative water tankers and brush firefighting apparatus, hazardous material control response vehicles, hose tenders, air refill apparatus, and water rescue capability.

Along with this specialized capability, there are opportunities to equip and train the emergency responders to manage incidents with fewer resources

Outside the urban areas, there are often excellent relationships with law enforcement personnel, who have critical roles in rural responses.

Vehicle traffic around the scene must be controlled by some combination of law enforcement, big vehicles, other physical barriers, and safety-oriented bystanders.

The first arriving crews of fire, EMS, and law enforcement must identify and stabilize any early hazards, keep everyone clear of down and damaged electrical lines, and spilled flammable materials.

Fire personnel must contain any fire, oversee any hot zone operations, and control other physical hazards. All personnel must identify and stabilize victims until adequate transport resources are available to move patients towards a hospital.

In a rural setting, transport times to the hospital are longer. EMS providers have much greater times to manage a patient encounter, and to provide more care to the patient. They may utilize part of that time notifying the hospital of the nature of the medical emergency, and allow the Emergency Department to prepare what is needed on patient arrival.

Strategies for success
Considering these challenges and opportunities, fire and EMS providers can be equipped and trained to manage emergency incidents in rural locations. There should be plans for "blitz attacks" in a variety of emergency situations, and for the equipment to carry such an operation out.

In a fire incident, for example, the first responding engine should be set up for rapid fire attack with hose and nozzle configurations that allow a one or two man rapid knockdown, or at least control of a fire to prevent extension, until more personnel and apparatus are on-scene.

In vehicle accidents, rural providers must be capable of handling extrication, fire control, rapid patient removal, and scene lighting with one or two vehicles.

Rural fire and EMS providers are almost certainly utilizing bystanders for manual help. The trained responders must be prepared to work with bystanders to assist in manual labor, like patient lifting.

They must be able to give bystanders a pair of gloves and rapid instruction to safely carry out an operation that will benefit the patient.

For emergency medical incidents in the rural setting, EMS providers must be well trained in providing good chest compression cardiopulmonary resuscitation (CPR), rapid placement of automated external defibrillators (AEDs), maintenance of airways in critical patients who are unable to maintain their own airway, and the use of appropriate immobilization, packaging, and positioning techniques to safely provide transport to the hospital.

With longer transport times, EMS providers must be prepared for longer patient interaction times. In appropriate medical circumstances, they should be capable of rapid extrication, to begin the transport as soon as possible.

In other circumstances, they may need to spend extra time at the incident site to provide needed care before a lengthy transport to a hospital. Rural basic-level EMS providers may be in a position to use "rendezvous" procedures with regional advanced life support services (personnel with or without a specialized ALS ground or air transport vehicle) to improve pre-hospital care

Especially in a rural environment, the operation must be carefully integrated with law enforcement, and any other needed resources like public works, environmental protection, heavy rescue, towing and salvage, and even the charitable relief organizations.

For big incidents, automatic mutual aid for major incident response is critical, and agencies that train together regularly will be better able to work productively at all emergency scenes. This is a critical element of leadership for rural fire and EMS organizations.

If these leaders work together, there are opportunities for joint purchasing; use of grants to augment funding for major acquisitions; assurance that equipment works seamlessly across the different agencies (for items as simple as hose threads, valves, RIT gear, and intravenous tubing); and development of procedures that promote safe operations, like incident rehabilitation.

Safety considerations
On an ongoing basis, emergency personnel need to recognize that all emergency scenes contain hazards, some of which cannot be avoided. Each individual should practice with his/her own safety in mind, as well as the safety of the patient, bystanders, and the emergency team.

As all emergency scenes need to be managed safely, and timely victim care provided, there are some procedures that can be adapted to allow safe operations with fewer resources.

Related to safety from traffic and violence, rural fire and EMS providers must work seamlessly with law enforcement personnel. Bystanders must be used for some operations, for the safety of all involved.

Some bystander participation in traffic control may be possible, as well as assistance in carrying equipment, moving hose, and directing other incoming emergency responders.

Rural emergency responders have to be physically fit. They may be required to work for extended periods of time without the benefit of incoming help, and in any climate conditions.

To facilitate ongoing physical work, incident rehabilitation is imperative, and must be supported with both equipment and personnel. Mutual aid support of rehabilitation operations should be available in rural areas.

Technological and communication aids to safety are being introduced at a rapid pace.  Rural fire EMS agencies need efficient activation communicators; durable communication systems that work in large, open geography; and on-site systems that make scene operations safe with smaller crews, such as PASS devices.  

Devices like thermal imaging cameras make rapid search and hazard assessment more efficient with smaller numbers of people. Again, it may require agency cooperation to purchase these more expensive, but lifesaving, devices.

In conclusion, rural incidents of all types present more challenges for fire, rescue, and EMS providers. Emergency personnel must be familiar with rural operations and scene priorities, and utilize both pre-planned operations and on-scene incident command functions that facilitate safe prehospital operations and excellent patient care.

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