Frontier areas are the most sparsely populated areas of the United States. According to the 2000 U.S. Census, this area covers about 56% of the land and 3% of the U.S. population, and includes rural farm land, natural resources, national parks, and military installations (2000 Update, 2002). There are more miles of rural roads than any other type of roadway in the United States, and it is on these roads that around 60% of fatal accidents occur. In keeping with the 60% fatality figure, "rural" is defined as anything bordering population centers of 5,000 or less (Complexity, 2004).
The challenge for EMS in responding to a crash scene becomes greater in rural areas because of geography, distances, and budget constraints. The Traffic Safety Center reports that, "on average, the rural area EMS response times come dangerously close to exceeding that critical window of opportunity beyond which mortality rates rise drastically" (Complexity, 2004, par. 19). This period of time is known as the "Golden Hour," and the ability of EMS to arrive at the scene in time becomes a factor in whether a fatality occurs.
Comparing urban and rural EMS is difficult because of differing urban-rural population characteristics and roles for rural ambulance teams. A comparison of services in Nebraska, for instance (Stripe & Susman, 1991) showed a higher percentage of elderly in the rural county, almost twice that of the urban area. Similar advanced life support measures were applied in both rural and urban areas. In North Dakota, an assessment made between 1999-2001 (Rural Emergency, 2002) showed that EMS in rural areas were experiencing significant problems due to:
1. Sparse populations over large geographic areas.
2. State and local governments in rural areas with lower capacity for funding through taxes.
3. Rural economies having difficulty maintaining and upgrading services.
4. Dependency of rural EMS on volunteer personnel, not always fully trained or sufficiently available.
Third party payers such as Medicare tend to view EMS as a transportation service, not a medical care service. Although the public has been aware of EMS's medical capabilities since the early 1970s, many third party payers continue to be oblivious of them after 30 years of EMS successes (Emergency: Future Challenges, 2006).
Accelerating Factors Affecting EMS
The safety net of the EMS is further affected by an "aging population, increased number of automobile injuries and an explosion of crime-related injuries in metropolitan areas. . . . [and] injuries from farm, industrial and outdoor sport accidents have overburdened EMS systems" [in rural areas] (Chang et al, 2001, par. 1). Reliance on volunteers in rural areas is far greater than in urban areas and the volunteer pool is becoming depleted.
Primary revenue streams for EMS are fees for service (Medicare, Medicaid, private insurance, private pay, and special services contracts. EMS is largely a locally financed enterprise, and financing of rural and frontier EMS is a particular problem because of low volume of calls in relationship to overhead costs of full-time preparedness (Center for Health, 2001). Federal and state level education resources