On June 26, 2005, my father-in-law suffered a cardiac arrest from which he could not be resuscitated. His sudden death clearly demonstrates the difficulties and realities of rural EMS.
He was stricken while at a family campground. The campground is located several miles from the nearest volunteer BLS ambulance service. The closest ALS is approximately 15 miles away, with the nearest hospital about 20 miles away.
My father-in-law had no history of cardiac problems, and was generally healthy. He was enjoying an afternoon at the campground, a day before his 68th birthday. According to family members that were with him, he was feeling well and had attended church services and a birthday lunch at a restaurant operated by his nephew.
While tossing horseshoes, he turned to his son, stated “I think I’m having a heart attack” and collapsed in cardiac arrest. CPR was started immediately by family members. Other people at the campground were told to call an ambulance. The campground had no telephone service. The area in which it is located has no cellular service. The closest telephone was at the nearest house, approximately a mile down the road. Luckily the resident (who is also the son of a paramedic) was home, called 911 and came to the scene to assist with CPR.
The local volunteer ambulance responded, with ALS support dispatched from the closest ALS service. The BLS service arrived at the scene in 10-12 minutes, continued CPR and applied their AED. No shock was advised. They loaded him into the ambulance and initiated transport to the closest facility. ALS was met enroute and appropriate treatment administered. After arrival at the hospital, it was clear that he would not be resuscitated and resuscitation efforts were stopped.
Research has shown that early CPR and defibrillation make all the difference in cardiac arrest resuscitation. Recent news articles have compared various cities in terms of their cardiac arrest survival rates. Those cities where there is a quick response by the public or first responders and the rapid delivery of defibrillation the survival rates were significantly higher. Unfortunately, the nature of rural areas across the country make it difficult to improve rural survival rates.
Cardiac arrests in rural areas may occur in areas where activation of the EMS system is difficult due to the lack of notification systems for 911. People who are stricken while away from a landline telephone or in an area where cell phone service is not available will experience a delay in notification. For incidents that occur far from a phone, it may be several minutes before 911 can be notified to initiate an EMS response. It may take time for someone to drive to the nearest telephone or to an area with cell phone service to be able to dial 911. These delays eat away at the short period of time available to deliver CPR or defibrillation with a successful outcome.
Additionally, ambulances and first responder units may have to travel significant distances to get to the patient. Rural residents realize that when the nearest grocery store may be a half-hour drive, that it will take time for an ambulance or other EMS unit to reach the scene. Driving times of 15-20 minutes or longer are not unexpected or unusual. Primary coverage areas may be several hundred square miles. Services may also be volunteer and require additional time for the crew to respond to the station to get the vehicle before responding on the call. Frequently when an AED is delivered to the scene it is outside the window of effectiveness.
ALS support, where available, often comes from a significant distance. Medications and advanced airway control probably play less of a role in successful resuscitation than early CPR and defibrillation, but may be of assistance in longer resuscitations. The longer that these advanced procedures are delayed, the less effective they will be. Long response times due to travel times further impact the possibility of a successful resuscitation.
As news articles discuss potential solutions to improve cardiac arrest survival rates in urban areas, the issues in rural areas are far more complex and difficult to solve. Long times, long distances and sparse populations make it difficult to develop and maintain EMS systems that can quickly respond to life-threatening events. The cost of such a system would also be prohibitive.
Living in a rural area is a trade off. When the nearest McDonalds is more than 10 miles away, you accept that it will take longer for an ambulance to reach you in an emergency situation.
Impact can be made against cardiac arrest in rural areas, but it may be in different areas and mechanisms than urban areas. AED’s must be distributed to higher traffic sites such as churches, schools and major stores so that they are pre-positioned should a cardiac arrest occur. People must be educated to identify precursors to cardiac arrest such as chest pain and to call quickly and early to start EMS resources towards the scene before the patient collapses. Efforts must also be dedicated to preventing cardiac arrests from occurring through education and screening for cardiac disease. We will never be able to prevent all arrests, but we may be able to improve the odds.
The EMS system and the EMS crews that responded to treat my father-in-law did all that they could. His family could not have asked for more. They have our thanks and appreciation.
My father-in-law did not like hospitals and did not want to end his life in a hospital bed attached to machines. He frequently stated that when he went, he wanted to go quickly. He got his wish. He died surrounded by those that he loved, doing what he enjoyed.
It’s not a bad way to go…but it would have been nice to have him a little longer…
