Rural EMS and the Low-Volume Competency Challenge
Does it really matter who's in the ambulance?
There are clinicians who talk about emergency medicine. And then there are those who have lived it across three time zones, at altitudes above 4,000 meters, in blizzards and on mountain slopes, in tactical operations and at the finish lines of hundred-mile races through the Rockies.
Nick Nudell is the second kind.
For over 25 years, he has worked as a paramedic in some of the most geographically unforgiving corners of the American West — Montana, Wyoming, Colorado. He has directed medical operations for more than 50 ultra-endurance events. He leads regional trauma planning for a territory larger than Switzerland. And in parallel, he researches the governance structures that determine whether patients in remote areas live or die.
We asked him about one of the most uncomfortable truths in emergency medicine: what happens to clinical competency when critical patients are rare. His answer applies whether you work in rural Colorado or the Italian Alps.
You've spent over two decades working in rural EMS across Montana, Wyoming, and Colorado. What does "rural emergency medicine" actually mean in the American West — and how does it differ from what most people imagine?
"Dr. Presciani, thank you for the invitation. It is an honor to participate in this dialogue through EMSy. My education and practice have developed within the Anglo-American EMS model used in the United States and other Commonwealth nations, and I approach this exchange with humility and curiosity about your system as well.
In the American West, "rural" is often defined administratively, usually in relation to funding programs or population thresholds. Operationally, however, that definition is incomplete. — says Nudell — I increasingly use the term geographically constrained contexts because it better reflects what clinicians experience on the ground.
Rural is not simply about distance or low population density. It often represents environments characterized by structural inequities in access to healthcare, specialty services, infrastructure, and workforce. Distance matters, but so does system capacity and redundancy.
In the Colorado region where I live and work, the service area spans more than 45,000 square kilometers and serves just over 800,000 residents. Elevation ranges from approximately 1,000 meters to 4,350 meters. One-third of the region is mountainous terrain that includes Rocky Mountain National Park; the remaining two-thirds consists of prairie, agricultural communities, dairy operations, beef processing, and a growing energy industry. Population density varies dramatically — from fewer than one person per square kilometer in some counties to more than 140 in others.
From a paramedic perspective, this variability defines practice. — he continues — I have responded to emergencies separated by three hours of driving in a single 12-hour shift. I may begin the day managing intoxication or violence in a city center and later drive more than an hour to a remote roadway crash, an elderly patient with chest pain, or a cardiac arrest on a snow-covered mountain slope.
Some communities are served by small hospitals staffed by two or three nurses and a general practitioner. Others are 30 to 60 kilometers from the nearest hospital. Helicopter transport is available but limited by terrain and weather.
Quality can be high even when capability is constrained. — according to Nudell — Rural clinicians are often exceptionally resourceful and deeply committed. The limitation is not professional dedication — it is system capacity. Staff mix, available equipment, specialty access, and transport timelines are shaped by geography and infrastructure. That distinction is essential."
In Italy, prehospital emergency care is physician-led: doctors respond on scene, make clinical decisions, and perform advanced procedures in the field. In Colorado, the system is built around paramedics operating under medical direction. What are the real clinical consequences of this structural difference?
"This is a thoughtful question, and I approach it with respect for both traditions.
I work closely with highly skilled emergency physicians, and I do not suggest that paramedics possess equivalent breadth of training. Physicians bring extensive diagnostic reasoning and clinical depth developed over many years.
At the same time — says Nudell — in the North American context, available evidence has not consistently demonstrated improved outcomes from routine on-scene physician presence for the majority of common emergency presentations. This may reflect differences in geography, system design, and case mix rather than clinical capability.
Properly educated paramedics operating within a structured clinical governance framework — including guideline development, quality assurance, audit, and interdisciplinary accountability — are capable of delivering the time-sensitive interventions that matter most before hospital arrival.
An important nuance lies in environmental preparation. — he adds — In the United States, physicians are primarily trained within hospital settings. Out-of-hospital medicine requires working in uncontrolled environments with limited personnel, weather exposure, and prolonged timelines. Some urban systems now deploy EMS board-certified physicians in rapid response vehicles to support paramedics in complex cases, rather than replace them, although that remains rare.
Different systems evolved to solve different geographic and demographic challenges. Comparing them is less about determining superiority and more about understanding design tradeoffs.
There is also an economic dimension. — according to Nudell — Training a physician requires a substantial investment of time and public resources. In geographically large, low-density regions, deploying physicians to every out-of-hospital response may not be economically scalable. This reality influenced the historical development of paramedic-led systems in North America. The differences between models largely reflect structure, history, and resource allocation rather than differences in professional commitment to patients."
Your research at WWAMI showed that rural EMS agencies provide less evidence-based care than urban ones, and that the gap widens with remoteness. Is this primarily a training problem, a volume problem, or a governance problem?
"The most accurate answer is governance. — says Nudell — The issue is not a lack of concern or professionalism. In many rural American communities, volunteer EMTs form the backbone of emergency response. These individuals balance full-time employment and family responsibilities while serving their communities without compensation.
They provide high-quality stabilization and transport within their licensure level. The challenge arises at the intersection of workforce composition and scope-of-practice regulation. In some rural areas, physicians do not respond to scenes. In others, paramedics are not available. EMTs may wish to perform certain advanced procedures, but are restricted by regulatory frameworks that standardize scope across the state.
When regulatory structures are not aligned with local workforce realities — he continues — access to certain interventions may be limited. Over time, this can contribute to inequities in service delivery. The issue is not knowledge or willingness — it is how governance structures align with geography and workforce distribution."
One challenge we share across both systems is maintaining clinical competency with low call volumes. A rural paramedic in Colorado and a mountain rescue physician in Valle d'Aosta face the same problem: not enough critical patients to stay sharp. What solutions actually work?
"This is one of the most honest and uncomfortable realities of rural emergency care. — says Nudell — High-acuity, low-occurrence events are, by definition, rare. Yet when they occur, performance must be immediate, precise, and confident.
In rural Colorado, a paramedic may go months without performing a surgical airway, managing a complex airway under extreme environmental stress, or caring for a critically injured polytrauma patient with prolonged transport time. Similarly, a mountain rescue physician may not frequently encounter major hemorrhage or cardiac arrest in the field. The paradox is that rarity does not reduce consequence. When these cases occur, there is no margin for hesitation."
Volume alone cannot be manufactured in sparsely populated areas, so competency must be constructed intentionally.
Immersive simulation is foundational. — according to Nudell — Not classroom rehearsal, but scenario design that incorporates environmental realism: cold temperatures, low lighting, communication barriers, time pressure, and incomplete information. The brain encodes stress differently than it encodes technical repetition. Training must simulate the physiological and cognitive load of real events. In austere medicine curricula — particularly those adapted from prolonged field care concepts — there is increasing recognition that resilience under uncertainty is as important as procedural memory.
The second solution is a structured exchange between high-volume and low-volume environments. — he continues — Rural clinicians benefit from temporary placements in urban systems where procedural frequency is higher. Urban clinicians, in turn, benefit from rural rotations where transport times are extended, and decision-making must account for delayed resources. These exchanges are not simply about skill repetition; they broaden cognitive frameworks. Urban clinicians may refine technical speed, while rural clinicians refine anticipatory planning and prolonged care strategy. Both skill sets are valuable.
Third, deliberate case review matters. — says Nudell — Rural systems sometimes lack the data infrastructure of larger urban agencies, but honest audit and reflective practice are possible at any scale. Reviewing near-misses, analyzing decision points, and reconstructing cases through high-fidelity mannequins builds pattern recognition. Competency is not only procedural; it is diagnostic and anticipatory.
There is also an individual responsibility component. Rural clinicians often must seek continuing education beyond minimum requirements. That may mean traveling long distances for advanced courses or participating in virtual case conferences to remain engaged with evolving best practices.
Ultimately, competency in low-volume environments depends on humility. — according to Nudell — The clinician must acknowledge that infrequent exposure requires proactive preparation. Confidence in rural settings should come not from repetition alone, but from disciplined training, reflective practice, and collaborative networks.
In both Colorado and Valle d'Aosta, the terrain may differ, but the cognitive challenge is the same: how to be ready for the rare event that will define your performance."
You work at the intersection of clinical practice, governance research, and AI applications in EMS. If we look five years ahead, what's the single biggest change that could improve survival in rural and remote settings — regardless of whether the system is physician-led or paramedic-led?
"When I reflect on this question, I return repeatedly to the concept of access. — says Nudell —
Access is often interpreted narrowly as ambulance response time, but in rural environments, it is broader than that. It includes access to primary care, preventive services, medications, mental health support, and specialty consultation. Emergency calls frequently represent downstream manifestations of upstream inequities. A patient in cardiac arrest may have lived years with limited access to hypertension management. A traumatic injury may occur in a region without rapid surgical capability.
If I narrow the lens to acute survival, time remains physiologically decisive. — he continues — Reducing the interval between recognition and intervention saves lives. Technologies such as drone-enabled delivery of defibrillators, hemorrhage control supplies, or blood products could shorten that interval in ways previously impossible in remote terrain. These innovations are not theoretical; pilot programs are emerging.
Telehealth integration may be equally transformative. Real-time specialty consultation during prolonged field care reduces cognitive isolation for rural clinicians. It allows decision-making support, refines triage, and may prevent unnecessary transfers while ensuring appropriate ones.
Yet if I am fully candid — according to Nudell — technology alone will not solve rural survival disparities. Governance alignment and equitable infrastructure investment may ultimately have a greater impact. A system that prioritizes data transparency, equitable funding distribution, and integration across public health, emergency services, and hospital networks will outperform one that relies solely on technological augmentation.
Whether physician-led or paramedic-led, survival in rural settings improves when delay is minimized, expertise is extended across distance, and governance structures treat geographic isolation as a solvable systems problem rather than an inevitable limitation.
In five years, the most meaningful improvement may not be a device or a credential. — he concludes — It may be a system that is better aligned with the realities of the people it serves."
In the next article, Nick Nudell takes us inside the medical operations of a 100-mile race through the Rocky Mountains — and explains what prehospital clinicians everywhere can learn from managing emergencies at the edge of human endurance.
