Rural EMS 1

[MUSIC] >> Hello and welcome to EM Talk. As always, I'm your host, Judd Smith. And we're happy to have you with us on this episode. If this is your first time joining us, we're a podcast sponsored by an education company, Axon Education, with a goal to spread EMS knowledge and education in the world. With us today is Carapyr. She is the EMS administrator at Haskell County Ambulance Service in Haskell, Texas. And she's here to help us discuss rule EMS. Carapyr, please tell us a little bit about your history. >> I started EMS in 2010, probably. I have no idea why I get into it. I just kind of fell into it. I think I wanted to do radiology first. And somehow I ended up in the EMS building, and I was like, I'm going to do this instead. So here I am. >> And you've worked at Haskell for the entire time you've been in EMS? >> Yes. >> So you've been in the rule setting for, I guess, seven, almost eight years? >> Probably like five. >> Five. >> That was in school for- >> Right, right, okay. >> For some of that time. >> Okay, so when you go to get your EMT certification, often you get this description or vision of EMS being this crazy, high-call volume racing of the scene, body parts everywhere type of job. We're given call descriptions that often take place in the middle of a busy city. There are many different realms in which EMS exists, the city, the construction or oil field, the movie set, the air, and of course, the rule setting. This is just a short little section about rule EMS, and most texts, and a majority of the time, it doesn't really give an adequate idea of what rule EMS truly is. Today we're going to be talking about what it actually is and what it consists of. To qualify as a rule area, your town must have less than 50,000 people. There are further qualifications and subtopics that work into the definition of being rule, but it is not necessary to identify further. Many areas qualify as rule in the area in which care works, definitely falls in that definition. You might even say that it is super rule. Think of a 900 square mile county with less than 6,000 people within that area, and you'll have an idea of what setting care operates. Also in that area, you've got one ambulance service to serve over 900 square miles. So it might help for us to first understand what care works with resource-wise on a day-to-day. So how many units do you have? - We have three, but we only use one ambulance at a time. So there's two people on shift for 24 hours, each shift, if that makes any sense. - No, definitely. So you've got three units at your disposal, but generally you're going to have one crew that can function at a time, correct? - Yes. - Okay, so how often do you run into a situation where you probably could use a secondary crew? - Not too often, but we also do inter-facility transfers, so that would require another crew. - Okay, on a yearly basis, how many calls are you doing? - About 55560. - Okay, so 560 calls a year, but that's split up for one crew handling pretty much all those calls, it may be a different crew, but throughout the, through one day you have one crew to handle whatever call comes. - Yes. - Okay, so what type of calls do you see the most of? - Probably medical stuff, cardiac strokes, and then after those would probably be the traumas, falls, motor vehicle accidents, things like that. - Okay, so do you have a trauma center in your area? - No. - Do you have a stroke center in your area? - No. - Do you have a cardiac center in your area? - No. - Okay, so you have all these different types of calls, but you don't like a large area, you don't have a stroke center, you don't have a cardiac center, you don't have a trauma facility, but you do have, you have a hospital, it's a rural area hospital, and it's equipped for general emergency situations, correct? - Right, they do have a CT machine, so they can get the treatment initiated, but they can't carry it out, so we have to take them an hour down the road and get them the treatment that they need. And then does that ever cause any kind of a problem for your crew, there's what? Or the patient? - Every day. - So you have a patient that comes in as a stroke and you've evaluated the patient, and they're definitely having a stroke, and you have to make a choice, you have to decide, do I need to try to get them to a stroke facility, which generally would be the best way to do it, but you have to make that choice knowing that, if your crew takes them, there's what, there's no other crew there, right? - Right. - Okay, and so what if it's cloudy and a helicopter can't come, you have to make a decision then, too? - So you said that your hospital has a CT machine, so they can initiate the treatment, they can evaluate for brain bleed and all that kind of stuff, but they still have to get somewhere, and it's up to your crew to make that decision daily. - Okay, so you have a stroke patient, and you don't have a backup crew, and there's cloud coverage, so you can't call a helicopter. So what would Haskell EMS do in that situation? - We get on the phone and you call everybody that's surrounding you. Surrounding us would be Knox County, Jones County, Throck Morton, Stonewall, so that's like four people that you can attempt to see if they have extra crews or availability, and if those guys are out, then I mean, the patient's gonna sit there and wait until you can get a transfer service to come, and they're probably gonna be driving an hour just to get to us, and that's another hour of the patient's waiting, and then once they get to the patient, then that patient's waiting another hour just to get to a bigger hospital, so. - So you're in a unique situation where you have to cover your county no matter what, because Haskell is a 911 service, and you're covering 900 square miles, and all the counties around you are covering similar areas with very limited resources as well. So the help is limited, and in that situation, you have to think critically, because you have to figure out how do you handle this patient, and how do you take care of your area as well, because the next patient that come in could be in the exact same situation, and need just as much care as the patient before. So that's a unique thing, because in the city, I've worked both rural and city or urban EMS, and here where I'm at, I would just go and take them to wherever they need to go, because I don't have to worry about whether or not my area is gonna get covered, but in a rural setting, you still have emergencies that come up while you're dealing with this patient, and you've got you yourself and you to handle that entire situation. So that's a way that that rural EMS is completely different than the urban setting. Now, it is often that in rural EMS, you do not have the resources like we were talking about, needed to control a situation like the ones mentioned above, in the fashion that it's described by the textbooks, it varies 100% from what happens in a textbook, either they're not enough people, not enough ambulances, no close appropriate facility, weather issues, et cetera. There are so many resource issues, and most of them can occur at the same time, on the same calls. So what would you say are some of the biggest challenges of working in the rural setting? And I know we went over some of those, but specifically, what do you encounter most often? What about if you get an MCI in your area? What if you have a car wreck with seven victims, and you're in EMS service with one crew for the whole county and one ambulance to go out to that call? So what do you do? You've got seven patients, you can't put seven patients in your ambulance. What does Kara do on that day? - Triage. - Triage, okay? Triage is where I'm going to start. Maybe I can eliminate some patients with a surgery. That's not going to get them all in my truck still. I'm going to call for mutual aid. - And what is mutual aid for people that probably don't know what that is? - A mutual aid is an agreement. You have an agreement with your surrounding services that they will come and assist you. They will come into your county and assist you with transporting patients if you need them too. - Okay. So you have other areas that are near you that are willing to help, and near you is a relative term because near you might also be 30 miles away. So you still have an ambulance crew that might come help or might not be able to. But if they do, there's still some distance away. And you've got seven patients. And what if, I mean, what if you have four critical patients and you have to somehow figure out how to manage those four critical patients? What's the next step? You've triaged them. Now you have to figure out what were they going? Well, I think I can think of of a time when you and I had to do something like that in a really dangerous situation. It was icy. And for those of you that haven't figured out Karen and I have worked together for several years. But we were on a, it was an icy night. And we had, I think, what was it? It was like seven people in a, in one vehicle somehow. And they had, they had skidded off the road, flipped it. And so we had seven patients to be managed. And several of those were critical patients. And we called for mutual aid. But not only are there services that were going to help us really far away, but they're also having to travel down this icy highway to get to us. And the facility most appropriate for our critical patients was 55 miles away. And so on icy roads. So we've got to figure out what to do with these people. So the one factor is you've got environmental issues where these people are going to freeze. And so we have to figure out how to get them warm. So I remember one of the first things that we did was we ran around throwing blankets on people and triaging. You know, that was part of our triage step was to try to get people to stay warm so that they wouldn't also have hypothermia to add to their list of ailments that day. And we ended up putting several in our ambulance. Another group, another crew from another town showed up and we were able to put a few in their ambulance and we took them all to the closest places we could get them to to stabilize, get them warm and figure out a way to get them to the trauma facility. And if you compare that to what happens and when that happens in a large city, you would just call a bunch of other trucks and they'd be there in a few minutes and you take them to whatever hospital because all the hospitals are trauma facilities. And so in a rule setting, like Karen and I have worked in, you have to figure out where these people are going. You have to figure out grabbing people and get them on an icy road. And you have to figure out how to manage several people with with one truck and MCI becomes a much bigger problem and you have to think critically to manage all those patients between the two of us and some help from volunteer firefighters and things like that. And you really, you learn how to utilize everybody. Would you say that's pretty fair that you're just grabbing people and getting them to help you? Yes, I think I had bystanders that I was like, I was directing them to do things while I was running off to check on somebody else. So I was just directing whoever was standing around, just telling them to do something and then I was off to the next person. And that, I mean, that is essentially what Rulie MS becomes is you put together a puzzle and everybody and everything becomes a piece of that puzzle. And it's really unique and it's nothing like what you learn in the books. You know, the medical and in treatments and the trauma and all that, the way that you manage each individual injury is relatively the same, you know, based on whatever your local protocols are, which I will say that Haskell EMS says some of the best rule EMS protocols that out of any EMS service out there, and they utilize them 100%. But even then, they still have to figure out how to do that with very limited resource. So we've heard the difficulties surrounding the rule setting and it's staggering to understand the differences in urban and rural EMS. And Cara gave us an idea of how her and I have managed that together before and and hopefully it's helped everyone to understand the big differences that exist there. So what would you say are like four things you could do to be better in the rule setting? What are some things you could do to prepare yourself for being in the rule setting? Like for new people. For new people. For someone who's never been in EMS before at all. I mean, you better just know everything about everything, but don't come in like you know everything. Know everything, but understand that that's going to mean nothing. Definitely. What's another thing? I don't know. I feel like new students, I don't know, they make me a little crazy because they do act like they know everything and we're fired apartments there first and you're going to get there and fired apartments going to tell you what's going on with the patient. So you already have your rundown like when you show up at Haskell after you've been called to somebody's house, you have to figure out that story. You have to find the patient because sometimes you don't even know where they are. Sometimes you're knocking on a door and nobody's answering and you don't know what you're going to find around the corner, but it's you. It's you doing it, you and your partner and you've got to figure out how to get them out of tiny little houses and you know hoarder's houses and things like that. So every every little situation is a little more difficult in the rule setting. So that's what I was trying to say is you're not going to run into a fireman that's given you the whole medical history and everything. You've got to get it out of your patient and your patient doesn't want to talk to you because they just want to go to the hospital. They called you there to take you and they are agitated and they don't want to tell you anything. They don't want any treatment. They just want to go and the family is upset and mad at you because you're not going fast enough and everybody's yelling at you and everybody hates you and it's really unappreciated and that's kind of what it is. I 100% agree. It is one of the EMS settings where you know the whole thing is up to you. From scene size up to the very end, it's unique because a lot of times there's nobody else but you and your partner and you've got to do all of it. You've got to gain entrance. You've got to make sure you're safe. You may not even have a police officer that can respond to your scene. Yeah, this is Texas. Everybody's got to go in. They sleep with the guns by the bed and we've gone into houses before where the guy was still asleep and I mean he could wake up and just shoot us because we're standing in his house. After he's pressed his life alert button in his sleep and didn't even know it and then we're breaking in. I mean it's interesting. Interesting is probably a great word to sum up what rule EMS is. You know it takes your critical thinking. You have to know your limitations. You have to think before you respond because there's nobody else there to do it for you and I think what we've done that's really helped in the rule setting is we've got we go over our calls. We figure out what do we do good, what do we do bad and how do we do it better next time and that's something that can help you anytime in EMS but in the rule setting you know all you have there to help you figure out what to do next or what you did wrong or what you did right is your partner and you really learn to rely on these people that you work with. You know you can't take that for granted. You can't take what you learn for granted and you can't take what you have to learn for granted. EMS is such a challenging field. It would seem that we don't need anything to add to that. Urban EMS has its own unique challenges and you can expect discussion on this at some point but rule EMS is it is and can be so different from every other type of EMS. It is often called a thinking man's game or thinking woman's game simply because the usual responses often don't work or can't work due to whatever issues can arise. We've discussed what rule EMS is, how it's challenging and how to meet those challenges. It takes a special kind of EMS provider to choose to work in the rule setting. It takes art, intelligence and patience. If you find yourself in the rule setting try to remember this illuminating discussion with Kara and try to remember the challenges she and her cruise base every day. If you choose to work rule EMS, know your resources, know your partner and think critically. Thanks to Kara for being willing to talk with us today and join us. We're glad that you all chose to join us. If you ever have any questions about EMS or EMS education including gaining your EMT certification, paramedic certification or just working to increase your knowledge, please feel free to contact us at [email protected] and life you're never done learning. Knowledge is vital, an EMS it's life or death. I'm your host Judd Smith and we will see you next time on EMTALK. (upbeat music)