Rural EMS Under Pressure: Longer Calls, Higher Acuity

Challenges abound in rural emergency medicine, from patients seeking treatment to the emergency medicine responders rendering that aid.

Case in point: A national study noted EMS call times in rural areas take at least 20 minutes longer than the national average and rural patients are more likely to have severe injuries requiring more specialized trauma care.

The study “Disparities in Timely Access to Prehospital Care in Rural America” presented at the American College of Surgeons Clinical Congress 2025 found nearly 40% of EMS calls in rural areas were for patients facing medically complex injuries, compared with 26.4% nationally. 

Lead study author Isabella Turcinovic, a third-year medical student at Baylor College of Medicine in Houston, Texas, noted rural patients were four times more likely to end up at trauma centers designated for less severe injuries and five times more likely to go to critical access hospitals—small, rural hospitals that provide essential care.

Call times for rural patients transported to specialty centers were more than 40 minutes longer compared with the national average. 

The study’s authors analyzed data from the National Emergency Medical Services Information System, comparing outcomes between rural (more than 4.8 million) and national EMS (64.6 million) calls from January 2023 to January 2025.

Among the key findings:

• EMS call times across all acuity levels were 92.8 minutes in rural communities compared with 74.1 minutes nationally.
• High-acuity activations were far more common in rural settings: 39.3% versus 26.4% nationally.
• Among patients with more high acuity injuries, total call times were 97.1 minutes compared with 69 minutes nationally. For patients transported to specialty centers, call times were even longer: 155 minutes compared with 114 minutes. 
• Rural patients were four times more likely to be transported to a trauma center designated for less severe injuries and five times more likely to go to a critical access hospital.  

Turcinovic noted policymakers and planners may use this information to further justify the need for rural hospitals and to better deploy EMS resources in rural areas.

Pediatric Care in Rural Regions

Pediatric care in rural areas is of particular concern and an area that doesn’t get nearly enough attention, said Peter Antevy, MD, Handtevy founder and chief medical officer. He noted rural EMS providers often manage longer scenes and transports, effectively delivering ICU-level care in the field. Communication gaps, weather, terrain, and staffing shortages amplify the cognitive and emotional load, particularly when caring for children or people they personally know.

“They maintain a broader skill set, including pediatrics, obstetrics, trauma, and critical care, often with fewer personnel,” he said. “Expanded scope of practice, strong medical direction, and reliable decision-support tools are not optional in rural EMS—they’re essential.”

Recently, the Florida Department of Health partnered with Handtevy to equip rural EMS agencies and hospitals with its mobile application, training, and support to participating clinicians at no cost.

“The driving factor behind Florida’s investment in pediatric resuscitative care for rural hospitals and EMS systems was a recognition that children in rural settings face a fundamentally different risk profile,” Antevy said. “Transport times are longer, specialty resources are farther away, and providers may only encounter critically ill or injured children a few times a year. That combination creates real risk for delayed care and medication errors, even among highly skilled clinicians.”

This wasn’t happening in a vacuum, he pointed out.

“National reporting over the past few years—including major New York Times, Wall Street Journal, and Axios articles—has clearly exposed how unprepared many hospitals and EMS systems across the country are to care for children, particularly outside large urban centers,” Antevy said. “Those stories validated what many of us in pediatric emergency medicine and EMS have been seeing on the ground for years and helped create urgency at the policy level.”

He said the initiative funding directly addresses gaps that are especially pronounced in rural systems:

• Limited access to pediatric-specific training and refreshers
• High-stress, low-frequency pediatric events where clinicians must rely on memory alone
• Long scene times and transports requiring EMS to deliver extended critical care
• Wide variability in pediatric readiness between rural EMS agencies and emergency departments

“The goal was to reduce variability and cognitive load by supporting standardized pediatric workflows and education statewide,” Antevy noted.

As part of this effort, Florida is working with clinical partners—including Handtevy—to deliver pediatric readiness training for both rural EMS agencies and rural hospitals.

“The focus is intentionally practical: scenario-based education, medication safety, and standardized resuscitation processes that work whether care is being delivered in a small critical access ED or in the back of an ambulance 45 minutes from the nearest pediatric center,” said Antevy, adding the program has already been implemented at several Florida rural designated facilities.

Antevy noted that in the long term, “this shifts pediatric emergency care from being experience-dependent to system-dependent. It supports rural clinicians during rare, high-stakes events, improves coordination between EMS and hospitals, and helps ensure that a child’s outcome is not determined by geography.”

Narrowing the Healthcare Gap

“By deploying Handtevy’s evidence-based platform to frontline clinicians in rural Florida, we’re narrowing the healthcare gap and ensuring that every resident, regardless of geography, has access to high-quality emergency care,” said Steve McCoy, Florida Department of Health director of the division of emergency preparedness and community support.  

Through the “Resuscitation Systems for Rural EMS and Hospitals” project, eligible agencies and hospitals in designated rural regions will receive comprehensive support, including:

• Handtevy’s point-of-care technology
• Customized pharmacology integration
• Durable medical equipment
• Comprehensive education programs designed to improve clinical outcomes and operational readiness

Handtevy Mobile allows EMS professionals and hospital clinicians to deliver real-time, age-specific medication dosing, equipment sizing, and resuscitation protocols for pediatric and adult patients. In time-critical emergencies, Handtevy’s technology and training have been shown to significantly reduce medication errors and improve survival rates, particularly in resource-limited rural environments.

Rural EMS agencies and hospitals in Florida that qualify for this initiative can submit their information to begin the enrollment process and access details on program eligibility, benefits, and support.

Mental Health Challenges in Rural EMS Providers

While patients in rural areas face more challenges than those in suburban and urban areas, so do emergency medicine providers.

The UCF RESTORES 2nd Alarm Project conducted the Rural Counties Pilot Project (RCPP) from February through June 2025 across six rural Florida fire rescue agencies, representing a range of sizes, organizational structures (career and volunteer), and geographic contexts. Participants included agency leadership, line personnel, and peer support representatives.

The pilot engaged agencies in a structured, facilitated process to examine existing mental wellness practices, identify gaps, and develop realistic, scalable strategies.

“The intent of the pilot is not only to support the participating agencies, but also to identify best practices that can be replicated by other rural fire and EMS departments,” said Kellie O’Dare Wilson, PhD, 2nd Alarm Project founder and executive director. “The results are being used to inform future program development, technical assistance, and broader rural mental wellness efforts.”

The RCPP was guided by eight best-practice domains critical to strengthening mental health systems in rural fire and EMS agencies: culture, mental health benefits, mental health resources, workplace policies and practices, healthy work environment, leadership support, outcomes measurement, and innovation.

Key outcomes included stronger leadership engagement, increased regional collaboration, and more sustainable peer support models. Agencies emphasized the importance of proactive stigma reduction, clear confidentiality safeguards, and practical tools for measuring impact.

A pilot analysis, “Building Resilience in Rural Fire and EMS: Best Practices for First Responder Mental Wellness,” highlights the distinct mental health challenges faced by rural first responders. These include limited access to behavioral health providers, heightened stigma, emotional proximity to traumatic incidents, staffing shortages, and resource constraints—factors that collectively create barriers to sustainable mental wellness.

Research over the past decade has documented elevated rates of anxiety, depression, post traumatic stress disorder, sleep disturbances, substance misuse, and suicide risk among first responders. Some 30% will develop behavioral health conditions, compared to about 20% in the general population. Firefighters and EMS personnel report higher rates of suicidal ideation and attempts than the public at large. Recent stressors, including the opioid overdose epidemic and the COVID-19 pandemic, have further intensified workloads.

Rural responders often work in close-knit communities, responding to emergencies involving neighbors, friends, or family members—experiences that can intensify trauma and grief.

Many departments are volunteer-based or minimally staffed, leading to high workloads, fatigue, excessive overtime, and burnout. Limited resources can require crews to manage crises without backup, advanced care access, or specialized support, often during long transport times.

Stigma remains a significant barrier. Rural first responders may feel pressure to "tough it out” and avoid admitting struggles. Lack of anonymity in small communities can discourage seeking help, particularly when accessing therapy is highly visible. Shortages of occupationally competent mental health providers further limits care.

O’Dare Wilson noted that from a mental wellness standpoint, the time and distance challenges of rural EMS, “increases stress, decision fatigue, and moral distress, as crews may manage complex patients for extended periods without immediate backup.”

The pilot project focused on helping agencies build sustainable, occupationally competent mental health systems over time. This is done by normalizing help-seeking, strengthening peer support, improving access to occupationally competent mental health care, protecting confidentiality in small communities, and supporting leadership in creating psychologically safe workplaces.

“A strong emphasis is placed on regional collaboration so rural agencies can share resources, training, and peer support rather than operating in isolation,” O’Dare Wilson said. “When providers feel prepared and supported, rather than constrained without backup, it can have positive mental health implications.”

Policymakers often underestimate how isolation, lack of anonymity, and limited access to care affect rural EMS mental health, O’Dare Wilson noted.

“Rural systems cannot simply rely on generic employee assistance programs,” she said. “They require tailored, community-aware, and occupationally competent approaches. At the same time, policy discussions too often frame rural EMS only in terms of deficits rather than strengths. Rural EMS providers are highly adaptable, resourceful, and deeply embedded in their communities, with strong informal peer networks and a high level of local knowledge.”

The Strengths of Rural Departments

Despite the challenges, rural departments also possess distinct strengths. Many operate like families, with strong interpersonal trust, mission-driven personnel, and deep community support. Rural agencies have a long history of mutual aid and collaboration, a mindset that can be applied to mental wellness through shared training, pooled resources, and regional peer support teams.

This study contributes to growing evidence that tailored, context-sensitive approaches are essential for first responder mental health. The pilot demonstrates that with collaboration, innovation, and strong cultural foundations, rural fire and EMS agencies can lead the way in building sustainable, effective mental wellness programs.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) recently announced in late December all 50 states will receive awards under the Rural Health Transformation Program, a $50 billion initiative established under President Trump’s Working Families Tax Cuts legislation to strengthen and modernize health care for more than 60 million Americans in rural communities across the country.

States this year will receive first-year awards from CMS averaging $200 million within a range of $147 million to $281 million to help states expand access to care in rural communities, strengthen the rural health workforce, modernize rural facilities and technology, and support innovative models bringing high-quality, dependable care closer to home.