By Stephanie Nixon, QAS Advanced Care Paramedic II

Charleville, Bidjara Country

The rural environment has a range of challenges, benefits and differences from the metropolitan environment

“It’s different in the country” and “You should do a stint out rural” are often phrases heard by student paramedics and those working in the metropolitan areas. To go along with these, we sometimes hear snippets of their jobs that are not usually things uttered outside of a major hospital, things such as “We were lucky the hospital had a doctor that day”, “Yeah they have their own airstrip so RFDS could land out there” and “Thankfully he only had the two broken femurs and no airway compromise because it was a bit of a drive to the hospital and we only had morphine”.

The rural environment has a range of challenges, benefits and differences from the metropolitan environment. While some seem obvious, like having fewer staff available for job responses, different response models (on-call verse shifts) and having more time to study on shift in rural locations, there are many more differences that make the rural environment a unique experience.

I have spent the past decade in rural and remote locations and wanted to take this opportunity to talk about some of my experiences working there as a paramedic. As above, some differences are obvious; however, others might not be things you had considered before.

My time in rural has been an incredible experience. I have been able to work within multiple communities, with each one different to the next. Rural communities are a network of connection; there are hundreds of stories and links that you begin to understand as you meet more people and become embedded in the community.

In rural understanding, the person and their connections within the community are vital for ensuring they are getting the help needed when calling the ambulance. Working within the same communities over a long period of time really helped cement for me disease progression, the impact that changes to lifestyle/circumstances can make, and the importance of finding medications/regimes that give back quality of life.

While university taught me what disease progression “looked” like, I never really “saw” it until my patients progressed in their disease. I can recall a patient we attended multiple times for diabetic-related issues; the diabetes remained uncontrolled leading to peripheral neuropathy in the right foot resulting in the loss of that foot, and then later the loss of the right leg to the knee.

Another patient who was living independently on a property had years of slow decline resulting in a nursing home admission and a later fall which ultimately led to a broken hip and death. There was a patient who had heart disease progress to heart failure and began to slow down in their abilities use mobility devices that six months prior were not even a consideration.

Further to this, I recall a patient diagnosed with cancer progress to being bedbound with catheters and a feeding tube. While it was awful to see the slow transformation of these patients, it was an honour to be able to help them in their times of need and allow them a familiar face within the chaos.

This identification always helped me to understand the importance of truly getting these patients the help they need and helped me push harder for their ongoing care. While this is possible to see within the metropolitan context, it isn’t as usual. It also isn’t usual to then see the patient or their family out within the community during days off and be able to have an informal hello.

The impact that changes of lifestyle and circumstances can make was highlighted during my time rural. Patients who were able to get NDIS funding were then calling the ambulance less as their needs were able to be met at home. Patients who had been long-term mental health-related callers suddenly found a support system that worked, at-risk children intersected and measures were put in place to ensure their ongoing health and wellbeing, and lonely older patients were being supported to attend local groups to foster connections.

It was incredible to watch the various services within the community highlight patients in need and work together to find solutions or options to ensure their ongoing health.

I also saw the impact of the right treatment. There was a patient who had uncontrolled blood pressure who we regularly attended until they were able to find a medication that worked to lower their blood pressure; we rarely saw them after that (except in the community where you could always say hello). There was a patient having multiple seizures requiring an ambulance until they were able to find the right combination of medications to reduce the number of seizures, or the patient who was able to access medical marijuana and giving them more movement than they had had in years. While again these may be things seen within the metropolitan context, it isn’t then someone you continue to see for years afterwards or then attend their kids or family.

Another different part of rural was when there was a death within the community. Connection is what makes a community, and when there was a death it affected everyone to some extent, even if they didn’t know them personally. They might have friends that knew them or kids that went to the school or heard stories about them around town. The local community would build each other up and support them during these times. And again, while this happens to an extent in metropolitan areas, there is no comparison to a town of less than 4000 losing someone everyone knows.

Another aspect to rural life was the connection between the ambulance and the community. The community needs to trust the ambulance and use them when needed. To achieve this, many small towns heavily invest in community engagement activities. These include things like first aid programs, CPR training, visits to the kindies, under-8s days, visiting nursing homes and participating in local activities. These connections make it easier when an ambulance must attend. For example, I attended a child with croup who I had seen at the daycare visits, and they were much more relaxed than a child I hadn’t previously met.

There are many challenging aspects to working rural. Housing options are often limited, expensive, or difficult to acquire. Some services have houses in rural areas or offer subsidies when renting. There is often limited incentive to buy in the local area, making it more likely to have paramedics who travel away on days off or who only stay for shorter periods. This is true of other medical staff and it often can be challenging to keep nurses, doctors and allied health professionals rurally. Doctor shortages are a real issue, with the use of telehealth helping to mitigate this in some instances.

Services are lacking in rural/regional areas, meaning that sometimes chronic illnesses, cancer and other conditions will have late diagnosis, resulting in poorer outcomes. Tests such as X-rays, CT, MRI and PET scans are often kilometres upon kilometres away and not always available for paramedics to transport to in the first instance. This can be disheartening when you know the signs indicate a stroke, potential head trauma or complex fracture. However, it provides an opportunity for paramedics to make a real difference with early recognition and getting the patient to definitive care early. Paramedics have a critical role in early recognition - without this, patients will have a longer wait before they can access definitive care.

While rural does not always offer the career progression as readily as metropolitan areas (think secondary triage, managerial roles, policy/research involvement, communication centres) what it offers in job satisfaction does not compare. Being there for someone in there moment of need is important, but being there to support someone ongoing throughout their and their families lives (as well as in their moment of need) is a feeling that’s hard to describe. But what I can say is, “It’s different in the county, you should go and do a stint out rural”.