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Rural Health Information Hub
Rural Health Information Hub

Rural Emergency Medical Services (EMS) and Trauma

Emergency medical services (EMS) provide emergency medical care to people who have had a sudden or serious injury or illness, or who have suffered major trauma. Access to EMS is critical for rural residents but providing pre-hospital services in rural areas can be challenging. Responding to a mass casualty incident, such as a crash involving a bus, can deplete EMS resources from several jurisdictions.

Rural EMS typically serve a geographically large and sparsely populated area. Due to the nature of rural areas, EMS providers may need to travel farther or navigate difficult terrain when responding to a call or transporting a patient to the hospital. Adverse weather conditions, when combined with longer distances and geographical obstacles, can significantly affect response or transport times. Also, additional transport time is necessary for patients whose illnesses and injuries are so severe that their needs cannot be met in the nearest rural hospital.

Trauma care is treatment of serious and life-threatening physical injury. Disparities in Access to Trauma Care in the United States: A Population-Based Analysis, published in 2017 in Injury, found significant disparities in trauma care access for vulnerable populations and identified disparities directly affecting rural residents. The article states that “As of 2010, 29.7 million Americans lacked access to a Level I or II trauma center within 60 minutes.”

Frequently Asked Questions:

How can a rural EMS agency find funding to purchase major equipment, such as an ambulance?

Multiple programs can assist rural EMS agencies with purchasing or obtaining major equipment:

  • The Federal Emergency Management Agency (FEMA) Assistance to Firefighters Grants (AFG) program offers funding to promote the safety of the public, firefighters, and first responders by providing for the needs of fire departments and EMS agencies. These grants have been used to buy equipment, protective gear, emergency vehicles, training, and other resources necessary to assist and protect emergency personnel.
  • EMS agencies may be eligible to obtain surplus government property through the Federal Surplus Personal Property Donation Program. Applications are accepted on an ongoing basis. To inquire about this program, contact your State Agency for Surplus Property (SASP) representative.
  • U.S. Department of Agriculture (USDA) Rural Development's Community Facilities Direct Loan and Grant Program offers direct loans and/or grants for essential community facilities in rural areas, which can include equipment for EMS. Applications are accepted on an ongoing basis. To begin the application process, contact your USDA Rural Development State Office.
  • Savvik Buying Group is a cooperative purchasing group that serves EMS and other public safety organizations. Membership is required.

Other funding programs and grants can be found on our list of funding opportunities related to EMS, which includes federal, state, and private foundation funding opportunities.

How are rural EMS agencies funded?

Rural EMS providers often travel longer distances per run due to the larger service areas and lower population density in rural areas. This results in higher average costs per trip for agencies as compared with their urban counterparts. According to the 2015 WWAMI Rural Health Research Center report, Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States, public/government funding was most common for both urban and rural agencies, but urban agencies were funded this way more often. Large rural, small rural, and isolated small rural EMS agencies reported a higher percent of funding from private nonprofits and public/private partnerships compared with urban EMS agencies.

According to the 2021 report Characteristics and Challenges of Rural Ambulance Agencies – A Brief Review and Policy Considerations, ambulance services are usually supported by payments from public and private insurance sources, as well as tax revenue, grants, and charitable contributions. However, the rate of unbilled care and unpaid debt is higher for EMS than other types of healthcare providers, resulting in additional financial burden.

Making Informed Decisions about Rural EMS, a 2019 Rural Monitor article, profiles a community in rural Maine that went through the process of Informed Self-Determination to determine the level of EMS response wanted by the community and how those services would be financially supported by the community.

Are there continuing education programs for EMS personnel?

There are many continuing education programs available for EMS personnel. Many rural EMS agencies have internal training officers who coordinate local trainings and use resources from area hospitals, larger ambulance agencies, air ambulance agencies, or area colleges. Online continuing education is available from a variety of sources. Some state EMS associations conduct conferences with continuing education content. For local or state opportunities near you, contact your state EMS agency for information about continuing education. Other opportunities for continuing education programs include:

Where can I find a list of state EMS contacts?

NASEMSO maintains a list of EMS state agency contacts.

Why should a rural hospital be part of a regional and statewide trauma system?

The American Trauma Society defines a trauma system as:

“an organized, coordinated effort in a defined geographical area that delivers the full range of care to all injured patients and is integrated with the local public health system.”

Rural hospitals should be part of regional and statewide trauma systems to provide appropriate, collaborative care for their patients.

A 2016 Surgery article, Rural Risk: Geographic Disparities in Trauma Mortality, found that rural residents are more likely to die from a trauma-related injury than non-rural residents. This is not a new finding; Safety in Numbers: Are Major Cities the Safest Places in the United States?, in the Annals of Emergency Medicine, states that the risk for injury death increases as rurality increases.

Being part of a trauma system allows rural facilities to respond and treat patients at the local level. It also ensures that patients receiving a higher level of care can be quickly identified and transferred to an appropriate facility.

Many states have a trauma program manager who may be employed by the state EMS office, state office of rural health, or at a freestanding program. For more information on your state or regional trauma systems, contact your state EMS agency.

How can local EMS agencies be integrated into the local and regional trauma system?

Hospitals play a role in engaging the EMS agencies that transport patients to their hospital in discussion, education, and training on trauma care. The medical director for an EMS agency can be affiliated with the local hospital. This provides a natural bridge between the hospital and EMS agency to coordinate, identify, and implement policies and procedures, including triage protocols, trauma team activation, or quality improvement and quality assurance reviews. It can be beneficial for communities to engage in a specific community planning process that sets out to use existing EMS resources at the community level. A planning guide and associated materials are found in Community-Based Needs Assessment: Assisting Communities in Building a Stronger EMS System.

Are there training programs to help rural hospitals' medical and support staff become better organized and prepared to receive injured patients?

These rural-specific programs provide this type of training:

  • Comprehensive Advanced Life Support (CALS)
    CALS offers a training curriculum focused on emergency medical training for physicians, nurses, physician assistants, nurse practitioners, and paramedics in rural areas. CALS allows providers to learn and practice infrequently used skills to save lives.
  • Rural Trauma Team Development Course (RTTDC)
    RTTDC is a one-day course focusing on rural medical personnel response to an incoming trauma patient. The course emphasizes a team approach when performing initial evaluations and resuscitations on trauma patients at rural facilities and is intended to assist hospital personnel who may provide support or care for injured patients. RTTDC is sponsored by the American College of Surgeons (ACS).

What are the levels of trauma care? Are these levels mandated by the federal or state government?

Trauma center designations are defined at the state or local level and are usually outlined through a legislative or regulatory authority. There are no federal standards or designations for trauma centers or levels of trauma care. The American Trauma Society (ATS) provides a list of common criteria for each level of trauma care. ATS derived the trauma center level criteria from trauma centers verified by the American College of Surgeons and state trauma designations.

The American College of Surgeons (ACS) states:

“The designation of trauma facilities is a geopolitical process by which empowered entities, government or otherwise, are authorized to designate. The ACS does not designate trauma centers; instead, it verifies the presence of the resources listed in Resources for Optimal Care of the Injured Patient.”

The process of becoming a verified ACS trauma center is voluntary, unless otherwise required by state law. Trauma centers can be designated or verified as an adult and/or pediatric trauma center(s). ACS provides a list of verified trauma centers that you can search by institution name, city, state, and country, or by ZIP code and distance.

Where can I find statistics and data on trauma-related deaths and nonfatal injuries treated in emergency departments?

A 2017 statistical brief, Trends in Emergency Department Visits, 2006-2014, from the Agency for Healthcare Research and Quality (AHRQ) describes 2006 and 2014 emergency department (ED) visit rates as “the highest among patients living in micropolitan and noncore areas, 472.7 and 512.5 visits per 1,000 population, respectively.”

According to an August 2023 NHTSA report, Traffic Safety Facts, 2021 Data: Rural/Urban Comparison of Traffic Fatalities, an estimated 20% of the U.S. population live in rural areas but rural deaths accounted for 40% of all traffic fatalities in 2021. Rural Unintentional Injuries: They're Not Accidents – They're Preventable discusses the leading causes of rural unintentional injuries, including rural motor vehicle fatalities, and prevention strategies. An article from the September 2017 Morbidity and Mortality Weekly Report, Rural and Urban Differences in Passenger-Vehicle-Occupant Deaths and Seat Belt Use Among Adults – United States, 2014, found that rurality was associated with:

  • Decreased seat belt use among adults
  • An increase in the proportion of unrestrained passenger-vehicle-occupant deaths
  • An increased age-adjusted passenger-vehicle-occupant death rate

According to National Characteristics of Emergency Medical Services in Frontier and Remote Areas, in Prehospital Emergency Care, approximately 1 in 15 EMS responses in the continental U.S. occur in frontier and remote (FAR) areas and on-scene deaths were more commonly reported in FAR areas than non-FAR areas. The 2022 Journal of Rural Health article The Association of Crash Response Times and Deaths at the Crash Scene notes that although approximately 0.3% of people involved in crashes in urban areas were classified as having died at the scene (DAS) within one minute of the crash, in rural areas the proportion of DAS is 0.6%. In addition, the article notes that whereas only 2.7% of people involved in crashes in urban areas experienced an EMS response delay of over 5 minutes, in suburban and rural areas the percentages rose to 8.2% and 13.4%, respectively.

CDC's Web-based Injury Statistics Query and Reporting System (WISQARS) is an interactive, online database that provides statistics on fatal and nonfatal injuries, violent death, and cost of injuries. WISQARS also provides data in the form of Fatal Injury Reports, that can be stratified by urbanization classification, and Fatal Injury Mapping at the state and county level.

The Healthcare Cost and Utilization Project (HCUPnet) provides data on rural ED visits. A tutorial is available online.

How do hospital closures in rural areas affect EMS?

The Rural & Underserved Health Research Center's policy brief Do Hospital Closures Affect Patient Time in an Ambulance? notes that although hospital closures in urban and suburban areas do not result in longer transport times for patients needing emergency care, rural patients experience longer waits for hospital emergency department treatment if a hospital in their ZIP code stopped providing general in-patient care during the previous year. According to this report, rural patients over 64 years of age are likely to experience the greatest increase in time spent in an ambulance following a 9-1-1 call.

Who makes up the rural EMS workforce?

A 2015 WWAMI Rural Health Research Center report, Prehospital Emergency Medical Services Personnel in Rural Areas: Results from a Survey in Nine States, notes that rural EMS agencies often rely on volunteers to staff their operations and that their staff members often have lower skill levels and higher vacancy ratios compared with their urban counterparts. These rural EMS services may also have fewer opportunities for skills training and review through regular interactions with a medical director and less access to online medical consultation during emergency calls. The 2022 University of Washington Center for Health Workforce Studies document How Actual Practice of Emergency Medical Services Personnel Aligns with the Recommended National Scope of Practice in Rural Versus Urban Areas of the U.S. notes that EMS professionals in agencies that served small rural areas and had unpaid or mixed paid/unpaid staffs were less likely to perform skills that correspond to their credential levels as outlined in the National EMS Scope of Practice Model.

According to the 2021 report Characteristics and Challenges of Rural Ambulance Agencies – A Brief Review and Policy Considerations, the pool of potential rural EMS workers is shrinking, due to demographic factors such as declining rural population, higher average age residents, and the challenging nature of EMS work.

While the frequency of EMS runs can be lower in rural areas, EMS personnel are frequently on call, participate in interfacility and nonemergency transfers, and attend training to validate their skills and meet the continuing education requirements to maintain their license or certification. This places a substantial burden on volunteers with full-time jobs and family responsibilities. The National Association of State EMS Officials (NASEMSO) in 2020 released Fatigue in EMS Risk Management Guidelines, a framework and evidence-based guidelines to mitigate fatigue-related accidents and safety concerns in the EMS workforce.

Difficulties in recruiting volunteers have led some rural EMS systems to offer paid employment to meet some of their staffing needs. Community paramedicine programs are growing in popularity as a way to provide reimbursable community-based healthcare services. For information on starting community paramedicine programs and the benefits they can provide to rural communities, see the Community Paramedicine topic guide.

The 2008 findings brief, Challenges for Rural Emergency Medical Services: Medical Oversight, from the North Carolina Rural Health Research Program, shows that maintaining adequate medical direction can be difficult for rural EMS agencies, with 19% of rural survey respondents reporting difficulties recruiting a medical director. Rural EMS agencies report obstacles that include:

  • Local providers unwilling to perform the duties of a medical director
  • Inability to pay a medical director
  • No physician, nurse practitioner, or physician assistant in the area
  • Local providers not qualified to perform the duties

What can rural EMS agencies do to recruit volunteers?

Recruiting volunteers to maintain and supplement the existing rural EMS workforce is vital to the provision of EMS in rural communities. NAEMT offers many suggestions to increase public awareness and recruit volunteers:

  • Host an open house
  • Host a public safety or injury prevention event or make it part of a recurring community event
  • Teach CPR
  • Offer ride-along opportunities
  • Use your local media
  • Host a survivor summit
  • Use social media to promote your EMS organization and interact with your community members

Recruitment and Retention: Overcoming the Rural EMS Dilemma describes the challenges in rural EMS recruitment and proposes tactics to help organizations and communities in rural areas, including moving to a mixed workforce structure, in which hourly or per-call stipends may be offered as incentives. The article includes a list of additional recruitment and retention resources.

The National Rural Health Resource Center publication Sustainable Rural EMS: Navigating Change notes that as volunteerism has declined, it might be necessary for community leaders to change the structure of their EMS agencies to promote a sustainable model. The guide describes a multi-step process including conducting a formal assessment of the current service, exploring alternative models, and implementing the change.

Is there training available to teach and train community members or laypersons to assist in a medical emergency?

Yes, there are a few trainings widely available that allow community members, families, businesses, and other laypersons to become better prepared for the unexpected.

Stop the Bleed is a joint initiative between the American College of Surgeons and the Hartford Consensus that provides information, resources, and training on bleeding control for the layperson. You can search for a Bleeding Control Basics class by city, state, or ZIP code. Trauma Training Initiative Teaches Rural Laypeople how to “Stop the Bleed” is a Rural Monitor article highlighting Stop the Bleed training initiatives in rural communities.

First aid, CPR, and automated external defibrillator (AED) trainings are often offered together. The American Red Cross and the American Heart Association maintain a comprehensive list of available courses you can search by training, date, or location. For information on hosting an on-site group training session, see the Red Cross Training Services' Get Started page or the American Heart Association's CPR & First Aid Training Programs page.

Last Updated: 8/4/2023
Last Reviewed: 8/11/2022