Charles F. Rinker II and Nels D. Sanddal
THE RURAL ENVIRONMENT
While the majority of the population of the United States lives in an urban environment, 70% of the trauma deaths occur in a rural locale. “It is surprising that a disease that kills rural citizens at nearly twice the rate of urban citizens has not received more attention.”1,2 The chance of dying in a rural area from a severe injury sustained in a motor vehicle–pedestrian collision is three to four times greater than in urban areas.3 The relative risk of a rural victim dying in a motor vehicle crash is 15:1 compared with a victim of an urban crash,4 and death from motor vehicle crashes is inversely related to population density.5 In fact, death rates from all unintentional injuries combined are generally 50% greater in rural, sparsely populated counties of the western United States than they are in the densely populated northeastern counties.6,7 And pediatric deaths from injury in a rural setting are more frequent than they are in an urban setting, despite the recent increase in gunshot wounds in the urban population.8,9 Finally, autopsy studies have suggested preventable trauma death rates of 20–30% in rural populations.10–13
Not only are mortality rates higher, but outcomes in survivors based on Functional Independence Measure (FIM) scores are also worse. When fatalities are excluded, the rural to urban odds ratio of poor outcome is 1.52.14 Poor functional outcomes have also been documented in patients with traumatic brain injury sustained in rural versus urban locales. What are the reasons for these differences?15
In this chapter we will attempt to identify circumstances that make rural trauma care difficult and consider some solutions. An illustrative case will help to explain some of the unique features of trauma care outside an urban setting. A 48-year-old real estate developer was mountain biking with friends in a national forest in the Rocky Mountains. While unhelmeted, he rode ahead of the group and down a steep slope. Several minutes later his companions found him unconscious at the bottom of a ravine after he had apparently lost control of his mountain bike. One of the friends rode out for help, which arrived 45 minutes following the crash in the form of a basic life support (BLS) ambulance unit from the local ski area. The patient had to be extricated from a ravine and carried several hundred yards to the ambulance, which then had a 1-hour trip to the nearest hospital, a Level III trauma center. Communication (handheld radio) with the hospital was not possible until the ambulance exited a narrow mountain canyon about 15 minutes before arrival. His Glasgow Coma Scale (GCS) score on the scene and in the emergency department was 8. He was hemodynamically normal, but a computed tomography (CT) scan of the head showed a large epidural hematoma with >5-mm shift. No other injuries were identified. Following consultation with a neurosurgeon at the nearest Level II center (150 air miles away), a general surgeon trained in emergency limited craniotomy (and following established local protocols) drilled a burr hole and enlarged it sufficiently to permit evacuation of the clot and to control the hemorrhage. The patient was transferred directly from the operating room to a helicopter, which flew him to the neurosurgeon for a formal craniotomy. He survived with a Glasgow Outcome Score of 4 and is now independent, although no longer able to function in his former capacity.
This true scenario could have any of the following plausible variables: unaccompanied victim hours or days to discovery, less accessible to rescuers, greater distance to hospital, lack of trauma team and trained surgeon, or adverse weather preventing air transport to Level II trauma center. He might have been a hunter injured by firearm or animal, a backcountry skier caught in an avalanche, a rancher thrown from a horse, or the driver of a car on a remote rural road.
Remoteness, rugged beauty, and “nature” are powerful magnets for tourists, recreationists, and those seeking a quieter, less stressful lifestyle. Such visitors are often shocked to discover that medical services they take for granted at home are simply unavailable in a rural setting. In contrast, local residents tend to be independent, fatalistic and accepting of limitations, suspicious of outsiders, resistant to both change and regulations (helmet and seatbelt laws; gun control), and unaware of trauma as a public health problem because, in their limited experience, it is a rare event.1,16
Rural spaces are sparsely populated and support only one third as many physicians as do urban areas.1 Specialists and, sometimes, even primary care physicians cannot make a living in communities under a certain population threshold. Lack of physicians skilled in rapid assessment and treatment of the critically injured has a significant effect on outcomes. Conversely, the number of physicians in a given county, and particularly emergency physicians who have taken the Advanced Trauma Life Support (ATLS) course, is associated with lower death rates from trauma.17
An urban area consists of a central city and its environs with a combined population of greater than 50,000 and a population density of 1,000 or more per square mile. As far as the US Bureau of the Census is concerned, everything else is rural. Not all rural environments, however, support farming, and many are surprisingly close to cities, but separated by geographic barriers such as mountains or large bodies of water. Residents of coastal Marin County, only a few miles north of San Francisco, may have difficulty accessing a trauma center because of intervening steep mountains, narrow roads, and local regulations prohibiting noisy and disruptive helicopters. San Diego County, home of a model trauma system, reports morbidity and mortality from delayed discovery of victims of motor vehicle crashes on remote county roads.18 North Carolina is the 10th most populous state, but 29 counties in the eastern part of the state are served by a single trauma center, 12 counties have no general surgeon, 17 no orthopedic surgeon, and 23 no neurosurgeon. In only 14 of these counties can a victim of trauma reach an emergency department staffed with emergency physicians in less than 30 minutes.17
Hypothermia is an independent predictor of mortality in injured patients, with mortality rising as core temperature falls. Urban trauma centers, with more rapid discovery and transport times than rural prehospital systems, have reported a 5% incidence of trauma patients with low core temperatures.19 A Level I trauma center in North Carolina serving 29 mostly rural counties and a combined population of 1.4 million reported transport times averaging 1 hour and time from injury to definitive care of 4 hours. Their trauma registry identified 1,490 of 9,482 (16%) patients suffering from hypothermia (<36°C) on arrival. These hypothermic patients had a 14.6% mortality rate, compared with 4.5% among normothermic patients.20 Virtually all regions of our country have many areas that are sparsely populated and relatively poor in resources. In the central and northern plains, one sees the combination of few people and great distances from urban centers as nowhere else in the lower 48 states. Alaska, of course, along with some portions of the northern Rocky Mountains, is more accurately described as a frontier area (six or fewer people per square mile).
The state of Western Australia forms the western third of the country, with an area of 2.5 million km2, and a population density of 0.8 people/km2. Because of a lack of doctors and hospitals, some trauma patients may be transported in excess of 2,000 km over more than 24 hours to receive initial care. Investigators there developed an Accessibility/Remoteness Index of Australia (ARIA+) to reflect the ease or difficulty people face accessing services in nonmetropolitan areas of the country. The index is a continuous variable with values ranging from 0 (high accessibility) to 15 (high remoteness). Employing ARIA+, with Perth (the most isolated capital city in the world) as the reference point, they demonstrated that the remote rural trauma death rate is over four times the rate in major cities.21
Rural, then, may be defined in accordance with census data based on metropolitan statistical areas, in terms of geography and distance, or by virtue of limited resources. In a recent analysis of the general surgery workforce, Thompson et al.22 identified significant differences between communities with a population between 10,000 and 50,000 (large rural) and those with 2,500–10,000 residents (small, or isolated rural). Large rural towns are far more likely to have the necessary resources such as general surgery, medical and surgical subspecialties, advanced life support (ALS) ambulance services, and essential equipment to provide prompt and sophisticated trauma care.
Environmental factors are also important as “rural trauma occurs in areas where geography, population density, weather, distance, or availability of professional and institutional resources combine to isolate the patient in an environment where access to definitive care is limited.”23 An alternate, somewhat more precise definition has been proposed as follows: “… A rural trauma region would be an area in which the population served is fewer than 2500, has a population density of fewer than 50 persons per square mile, has only basic life support prehospital care, has prehospital transport times that exceed 30 minutes on average, and is lacking in subspecialty coverage for specific injuries (such as a neurosurgeon to manage the patient with head injuries).”1 In any event, though we may think we know it when we see it, it is apparent that “rural” is difficult to define.
There are reasons why few people live in rural locations. The climate may be harsh, the terrain rugged and remote from services, the roads badly engineered and maintained, communications rudimentary, and the economy marginal. Career opportunities for the young are limited, so the young leave. As a result, significant segments of the population are elderly, poor, poorly educated, and in ill health. Population density (low) and personal income (also low) are the strongest predictors of per capita trauma death rates.17 Nearly one fourth of adults in this environment sustain some form of unintentional injury per year. The injuries are usually relatively minor, but they can be major and/or fatal. Binge drinking and depression are strongly associated comorbid factors, and suicide accounts for 10% of all rural trauma deaths.1,24Elderly rural patients tend to start out with a lower Injury Severity Score (ISS) and are less likely to die at the scene, but have a higher complication rate and worse overall survival for comparable severity of injury. Based on data from the Major Trauma Outcome Study (MTOS), rural geriatric trauma patients fare less well than do those in an urban cohort.25 In addition, older age and lower population density independently increase vehicle-related mortality.26 A study by Wigglesworth27 compared two groups of five states each with the highest (Group 1) and lowest (Group 2) traffic death rates, respectively. Epidemiologic data from the Centers for Disease Control and Prevention (CDC) indicated that the fatality rates for falls, poisoning, drowning, fire, suffocation, homicide, and suicide conformed closely to the traffic death rates in the two groups of states. Group 1 states were rural, western, and below national averages for per capita income; Group 2 states were urban, eastern, and financially well-off.27Overall, 60–70% of all trauma deaths occur in rural areas despite the fact that only 20–30% of the nation’s population lives in these areas.28
Unintentional blunt injury comprises about 90% of cases, largely because of the prevalence of motor vehicle crashes and the paucity of injuries from firearms. The most common causes of fatal injury are motor vehicle crashes, suicide, homicide, and falls. For these and the next 10 most frequent causes, rural death rates exceed urban rates for all but poisonings. Some of the most hazardous occupations such as mining, logging, and farming are almost exclusively rural by their very nature.29 Large animal injuries may occur on a farm or ranch in the course of daily work or in conjunction with such recreational pursuits as hunting, pleasure riding, or rodeo. Typical injuries are falls (horses), tramplings and gorings (bulls, wild game), and kicks (cows).30 Travel on rural highways entails the additional hazard of motor vehicle crashes with wild animals (elk, deer, bear, or moose). As a mature moose weighs half a tonne or more, a driver unfortunate enough to strike one risks significant injury to the brain or death.31 Fatal accidents are significantly higher for loggers (140/100,000) than they are for workers in other industries (94/100,000), and are typically the result of being struck by falling trees, limbs, or snags. Crush injury between moving logs and encounters with heavy equipment are other common mechanisms, and access to care is often a problem.32 Recreation also provides endless opportunities for serious injury and death. Particularly dangerous are four-wheeled all-terrain vehicles (ATVs). In 2004, ATV crashes were shown to result in more than 136,000 injuries and 500 deaths and one third of the deaths were in children. In Oregon, the rate of such injuries and deaths doubled between 2002 and 2005.33 Small community hospitals bear the brunt of these misadventures, particularly when situated in proximity to ski hills, wilderness areas, national parks, and seashores or lakefronts.
Most people feel safe in rural setting as the risk of violent assault and penetrating trauma is very low as noted above. The low homicide rates, however, are negated by high suicide rates, particularly among adolescents and young adults.34–36 Blunt trauma comprises 95% or more of the trauma case load at most rural community hospitals, 85% of which is minor or moderate (ISS < 10) and can be treated without the need for transfer to a trauma center. Blunt trauma is less time dependent, which is fortunate since it is far more difficult to mount a rapid response in a small community hospital. It can be subtle, however, requiring experience and a high index of suspicion to avoid missed injuries.37 Although motor vehicle crashes cause the greatest number of trauma deaths in this country and in the rest of the world, they are sporadic events in small towns and the countryside.
In essence, the greatest problems confronting rural trauma care are access to the system and lack of resources. The challenge is to devise a system, ensure access, and make the most of limited resources.
RURAL RESOURCES AND LIMITATIONS
Discovery and Access to the System
Discovery of the victim and access to appropriate care are the most important explanations for the high mortality rates of trauma victims in rural areas. When people are scarce and distances between population centers are great, the injured may be lost or misplaced, whether in the backcountry or on a remote highway.1,16,38–40 Delays of hours are common, and, occasionally, days may pass before a victim can be found. In rural systems of care, time of crash until time of arrival at the hospital is more than an hour in 30% of cases, as opposed to 7% in urban systems.41 Prolonged mean prehospital times have been reported in rural Vermont (105 minutes), upstate New York (96 minutes), northern California (55 minutes), rural Washington (48 minutes), and Georgia (40 minutes). Thus, the “golden hour” is often spent on the road and not in the hospital.1 In extreme cases, crash victims in a snow-filled roadside ditch or ravine, a hunter, or a backcountry Nordic skier may not be found until spring breakup. Retrieval is equally challenging and often relies on the special skills of search-and-rescue volunteers equipped to go into swamps and tidal flats, high mountains, or dense forests and other wilderness areas. Even when a helicopter is at hand, victims must often be moved over rough terrain by litter, watercraft, snowmobile, ATV, horse, or other conveyance to a suitable and safe landing area. Fortunately, most guides and outfitters now carry global positioning satellite (GPS) units, cellular phones, and/or handheld radios to facilitate rescues in emergency situations.
If a hospital lacks a trauma program and leader, the response to a major trauma event tends to be disorganized as the patient will often arrive unannounced. Obvious extremity injuries may overshadow more critical internal injuries and prompt a call for an orthopedic surgeon when a trauma team led by a general surgeon is more appropriate. Even when notification occurs, the physician in the emergency department may wait to see just how badly a patient is injured, instead of mobilizing the trauma team and alerting the helicopter for interhospital transfer. The opportunity to eliminate a critical rate-limiting step is then lost. The patient proceeds from scene to litter to ambulance to local hospital and then, perhaps, on to the next higher level of care sequentially, and precious time is wasted (see Fig. 9-1).
FIGURE 9-1 Roadside crosses on rural Montana highways mark fatal crash sites. (Reproduced with permission of the Critical Illness and Trauma Foundation, Bozeman, MT.)
One of the most important steps a small hospital can take toward improving trauma care is the establishment of a trauma team. When possible, the team should be led by a general surgeon.42–44 Criteria for team activation should be established, and team members should commit to come to the patient’s bedside immediately when called. In very small hospitals lacking general surgery support, it is still possible to provide appropriate emergency care.45 The Rural Trauma Subcommittee of the American College of Surgeons Committee on Trauma conducted an informal survey of small rural hospitals and found that most could mobilize three health care providers most of the time including physician extenders, nurses, and technicians (lab, x-ray, respiratory therapy). Drawing on these resources (as well as primary care physicians, or surgeons, in slightly larger facilities) the committee’s Rural Trauma Team Development Course trains these individuals in the team approach to the initial assessment, resuscitation, and transfer to definitive care for the injured patient. This 1-day interactive course is patterned on ATLS, but is inexpensive to present and may be given in modular form. The program is coordinated through the state chair of the Committee on Trauma.46 Obstacles to this logical solution include the following: (1) medical staff reluctance to participate in trauma care; (2) fears that overtriage will place greater demands on surgeons; (3) turf wars between ambulance services, hospitals, and communities; and (4) financial incentives to treat patients locally rather than transport them. In addition, the Emergency Medical Treatment and Active Labor Act (EMTALA) may have the unintended consequence of discouraging efficient transfers within a trauma system.
Physicians who practice in rural areas likely grew up in a small town, were influenced by a mentor, or have an independent streak.47 They usually have no fears of being overworked, underpaid, and unable to obtain backup or guidance. If the social and cultural deprivations bear heavily on a spouse, the sojourn will be brief. Patient volumes are insufficient to support specialty services, and generalists with little or no formal trauma training predominate. Such individuals are expected to treat a significant number of minor trauma cases as well as the occasional complex major trauma case for which they have not been trained. A study of five small hospitals in rural Washington and Idaho revealed that they averaged three patients per year with an ISS greater than 19, and each physician saw, on average, 0.6% of these patients.48 Because trauma events are sporadic and infrequent, rural physicians may develop a fear of or aversion to care of the injured. Furthermore, despite evidence to the contrary, general surgeons believe they are more likely to be sued by trauma patients.49
Rural surgeons, more so than their urban counterparts, have traditionally viewed trauma care as an integral part of their service to their communities.50 Perhaps the greatest threat to our future ability to treat the injured in rural America is the unwelcome fact that this sense of commitment is changing. Rural surgeons are, for the most part, general surgeons. And this specialty has lost its appeal among young trainees who increasingly (70–80%) choose a subspecialty and avoid embarking on rural practice. Currently, the vast majority of rural surgeons are men, while more than half of medical school graduates are women. Women now account for 25% of surgical residents, and surveys confirm that they are much more inclined to practice in an urban or suburban setting.51,52 Furthermore, declining reimbursements compounded by a heavy burden of debt accrued during medical school have led many general surgeons to insist on compensation for call. Small rural hospitals may not be able to afford underwriting emergency call. Finally, the current cadre of rural general surgeons is retiring because of advancing age or because of burnout. As they are not being replaced, the net effect is that access to definitive trauma care at the local level is rapidly disappearing. This places a greater burden on regional Level I and II trauma centers, while at the same time denying essential revenue to the small community hospital. Perhaps most distressing, loss of surgical services may lead to the closing of the only hospital in a large geographic area.53
In many communities, a nurse practitioner or autonomous physician’s assistant is the town “doctor.” Their educational background and experience, as well as that of their supervising physician, rarely includes exposure to sufficient cases of major injury. Ambulance workers are predominantly volunteers trained in advanced first aid, emergency medical technician (EMT)-Basic, or, at most, EMT-I level, usually at their own expense. Their experience with trauma is also very limited, though trauma may be one third to one half of the case load in some rural ambulance services.54
Outside the academic medical center it is uncommon for resident staff or independent practitioners to stay in-house after hours. In hospitals with less than 30 inpatient beds it is unusual to have emergency physicians. In many small communities, a nurse or physician’s assistant is the only professional at the hospital on nights and weekends. The doctor may be at home or out of town and may or may not be willing to come in if called for a trauma emergency. If the doctor does come in, he or she will conduct the resuscitation with minimal assistance and limited equipment. Despite these shortcomings, there usually is no other choice since the next hospital may be many miles distant and may be no better equipped. It is for reasons such as these that it is so important for rural physicians, physician assistants, and nurses to take or audit the ATLS course and to become involved in the regional trauma system.
An effective emergency medical service (EMS) program is vital for proper trauma care. In rural areas, the configuration of such systems varies and may include fire department–based, hospital-based, or freestanding entities. Personnel may be volunteers, salaried, or partially subsidized. Most are trained to the EMT-Basic level, which permits noninvasive interventions to reduce the morbidity and mortality associated with acute, out-of-hospital medical and trauma emergencies.55 Skills and capabilities may be enhanced with the addition of certain modules, under the guidance of their medical director. Some rural communities have personnel trained at higher levels of care.56Specific trauma training (i.e., Prehospital Trauma Life Support [PHTLS]) may be challenging to conduct in rural areas for lack of instructors, but should be supported and encouraged. The nomenclature for the various levels of training is in transition, which may be clarified by the publication of a new scope of practice document in 2007.57 Currently, the primary challenges to rural EMS are maintenance of skills in a low-volume environment and dealing with collapse of infrastructure as a result of an aging volunteer workforce that is not being replaced. One proposed solution is to upgrade volunteer EMT-Bs to paramedics, employ their new skills as an adjunct to a broader community health program, and pay them.58,59
Aeromedical and ground transport systems that furnish critical care are becoming more common; however, their availability lags behind in many rural areas. In some locations direct scene responses may be available while in others rendezvous with such units is more practical. Thoughtful incorporation of all resources into a regionalized response system for time-sensitive, life-threatening conditions (high-risk obstetrics, stroke, and STEMI as well as trauma) is beginning to evolve. Surgical leadership into the evolution of such systems is essential to ensuring the needs of the injured patient are not overshadowed by other acute conditions.
The original EMS legislation and subsequent funding bills recognized the need for effective and reliable communication between field and hospital. Availability of funds to improve communications infrastructure following the 9/11 bombings has improved radio coverage in many metropolitan areas. Paradoxically, those same systems have in some instances resulted in poorer rather than better coverage in rural areas due to terrain and distance issues. Skilled dispatchers are hard to find in small towns. Physicians and nurses at the hospital may be unfamiliar with and wary of communications equipment, and, accordingly, reluctant to talk with field personnel to provide medical guidance. Cellular telephones have improved prehospital provider-to-physician dialogue in many areas. In some areas with appropriate infrastructure and networks, telemedicine technology permits audio, video, and data transmission from field to hospital. Many 9-1-1 systems have upgraded to E9-1-1 (associates caller’s telephone number with a physical address). Even as rural areas are beginning to catch up in E9-1-1 availability, next generation NG9-1-1 is beginning to be deployed. NG9-1-1 is a network of systems that enables the transmission of voice, data, video, and text from various types of communication devices to a public service answering point. It makes that information actionable so that it can be moved into interconnected emergency responder networks. With the explosion of cell phone use that is not attached to a specific address, the FCC is mandating that cell phone services develop the ability to provide the latitude and longitude coordinates of the calling handset, accurate to within 50–300 m, to any Public Safety Answering Point (PSAP). Ultimately, cell phones will be able to transmit images and data.
Communication between the local hospital and regional trauma center may also be difficult and unrewarding. Local practitioners often complain of unpleasant encounters with flight crews, emergency room personnel at the receiving hospital, and surgical staff on the trauma service. Attending surgeons are infrequently available for telephone consultation, despite the fact that they are, in essence, being referred a patient by a colleague. Feedback and constructive criticism regarding transferred patients are frequently sought by referring physicians, but not often attainable. In addition, they may receive mixed messages including criticism for overtriage on the one hand to holding onto a patient too long on the other.
The net effect of problems in communication is that the rural practitioner ends up functioning in a relative vacuum, receiving little advance warning from the field, limited help at the hospital, and negative or no feedback from the regional center.
Evacuation of rural trauma victims is generally accomplished by surface conveyances. If the victim is inaccessible to an ambulance, various methods, all of them slow, may be employed to convey the patient to a road. The ambulance may then need to negotiate a sequence of roads from unsurfaced or gravel to county or state highway. Even the latter may be narrow, winding, and poorly maintained. Most often the destination is the nearest hospital, which will vary in its capabilities, and may be many miles distant. Response times, which include travel from the dispatch site to scene, extrication or retrieval, packaging, and travel to the hospital, are sometimes measured in hours, not minutes, as previously noted.
Ambulance services may be freestanding or, in some instances, an integral part of the local fire department. Funding may be through a special ambulance district or as part of the county budget, jealously guarded by county commissioners.37 Frequently, because of limited funding, the ambulance service may employ aging although lovingly maintained vehicles, which are limited in number. In Vermont, it is estimated that the average local ambulance is unavailable 15% of the time.1 Surveys of state EMS directors in 2000 and 2004 indicated that the greatest need for rural services is the adequate recruitment and retention of staff. In the same surveys, 24/7 coverage rose from the 22nd to the 2nd most important rural EMS issue. Response time rose from 20th to 5th. If an ambulance is in service on a call or out of service for maintenance, the next call might have to be answered by a crew in a neighboring district through a mutual aid agreement.60 Multiple incidents or victims can easily overwhelm the transport system.
Helicopters can be used both for scene rescue and for interhospital transport. Ideally, evacuation from the scene of injury directly to the trauma center should afford the patient the best opportunity for recovery. Due to reimbursement changes, there has been a proliferation and associated overutilization of helicopter services in some areas. In the urban environment, ground ALS has actually been shown to be preferable for relatively short distances, since it takes time to prepare the aircraft for flight. With flight times above 15 minutes, helicopters gain the advantage.61 In Fresno County, California, a study of ground versus helicopter transport in a relatively flat, nonmountainous area served by one Level I trauma center concluded that, within 10 miles of the hospital, ground transport yielded the shortest 9-1-1–hospital interval. Beyond that distance, the simultaneous dispatch of ground and air transport was the most efficient as ground personnel could extricate and resuscitate in advance of the arrival of the helicopter. For surface transports of more than 45 miles, helicopter was faster even if dispatched after the ground unit.62
In the rural environment, provided the scene is within the range of aircraft without the need to refuel, direct transport may be worthwhile if the time to the local hospital by ground ambulance is greater than that of the helicopter flight.63 If not, surface transport is preferable.64 A helicopter may also be invaluable in wilderness rescue if a suitable landing site can be assured. The downside is that such aircraft are expensive ($900,000–2,200,000 start-up; $500,000–2,000,000 annual maintenance), hazardous (fatal accident rate 4.7/100,000 hours),65 and have a limited range. They are also sensitive to weather and altitude and are not always available. Although newer models are roomier, it is still difficult to examine, monitor, and resuscitate unstable patients while airborne. Finally, their effectiveness is open to question. In one study of scene (18.8%) and interhospital (79.5%) transports, the most severely injured patients (17%) died en route or shortly after arrival at the medical center, while 55% had relatively trivial injuries that did not require the use of the rotorcraft.66 The group with intermediate severity of injury (27%) benefited from use of the helicopter, but was difficult to identify in advance. ISS was not used in this study, but, in another study of scene transports alone, the group that benefited appeared to be those with an ISS of 22–30.65
In the remote rural setting, helicopters are used primarily for interhospital transfers, following stabilization at the local facility. Even in this circumstance, the solution is not ideal. Once the initial outlay for equipment and personnel has been made, an incentive exists to use it, even when surface conveyance may be an acceptable alternative. Helicopters become an important part of the sponsoring hospital’s marketing program. Overtriage reflected in an average ISS of 19 is a major problem that remains to be solved.61,65 In some mature programs, as many as 55% of patients transported were determined retrospectively to have minor trauma. It would appear that continued refinement of triage criteria is necessary to ensure that helicopters are used judiciously and effectively.
Fixed-wing transfers are another option, but are restricted to interhospital transfer. These aircraft are fast and, when properly equipped, can function as an airborne intensive care unit.67 Their use is common in the noncoastal western states in helping to bridge vast distances. Drawbacks include the 30 minutes or more needed to get the plane airborne and the need to transport the victim by ground ambulance between airport and hospital on both ends of the transfer.
Urban trauma systems attempt to identify those hospitals with the resources and staff commitment to care for the critically injured patient and direct patients to those facilities. The system bypasses hospitals unable or unwilling to provide appropriate response and treatment. In less populated areas, where resources are not so abundant, bypass may not be an option. In the two decades following introduction of state EMS programs, most authors have asserted that rural community hospitals are the logical destination for critically injured patients.10,13,25,44,64,68–71 Following stabilization, they can then be transferred to the nearest trauma center. While this time-honored principle still applies in remote areas, studies indicate that bypass may be possible in some rural areas. With improved triage criteria, astute prehospital personnel, and good communications, a system can allow for transport of some stable rural patients with severe injuries directly to the trauma center without stopping at the local hospital.72–76 In rural Georgia, where one third of all ambulance trips were trauma related, 50% of patients were taken to the local hospital, but the remainder could be taken directly to a regional trauma center or urban hospital. The more remote the county, the more likely the patient was taken first to the local hospital.54 It is still true that in many rural systems, it is simply not feasible to transfer unstable patients, whether by ground or helicopter, directly and over long distance to a trauma center. Bypass of the local hospital is, most often, not appropriate in these circumstances. A corollary of this observation is that rural health care facilities should be prepared, within their capabilities, to treat the sporadic seriously injured patient. Unfortunately, as a result of trauma legislation, malpractice concerns, uncertainty regarding the appropriate role of the local hospital, and lack of surgeon commitment, many patients are now transferred to trauma centers when they could have been treated locally.72
In a few select locations, a Level I academic trauma center may be strategically situated close to a large rural referral base. (For purposes of this discussion, Levels I–IV are those defined by the American College of Surgeons Committee on Trauma.23) More commonly, particularly in the plains and mountainous western states, huge distances intervene between regional trauma centers. Also, there may be no Level I, or, in some cases, even a Level II center. These trauma centers serve the population with equipment and technical expertise unavailable in smaller hospitals and furnish system development, performance improvement, professional and lay education, prevention programs, and rehabilitation services.
Some rural Level II centers are located close enough to a Level I that their job is primarily to share some of the burden of the trauma case load as well as responsibility for education and outreach.42 Many serve a vast geographic area, however, and must assume a larger role. They will differ from a Level I center in terms of lower volumes, mostly blunt trauma, surgeons who take calls from home, and lack of certain sophisticated services such as limb replantation or management of complex pelvic and acetabular fractures.71 Most will provide helicopter and/or fixed-wing transport to their region. They may have resident house staff and medical students, but most do not. Leadership in education, outreach, performance improvement, and system development, normally the purview of Level I academic centers, becomes their mission.
A rural Level III trauma center, even though it may lack many of the capabilities of the regional Level II, is a critical resource that will receive patients from many smaller hospitals in its region.2,44,77 It is expected to provide full-time emergency medicine, general surgeons, orthopedic surgeons, and operating room availability. Size will vary from about 40 to 150 beds. Case volumes are low with approximately 50–125 trauma registry patients per annum, and most have an ISS less than 15. In addition, the medical staff will usually have specialists in internal medicine, a variety of medical subspecialists, and family practitioners. Anesthesia is provided by anesthesiologists or nurse anesthetists. Services that are important to the care of trauma patients, but are usually unavailable, include neurosurgery, cardiovascular surgery, plastic and reconstructive surgery, interventional radiology, dialysis, comprehensive blood banking, in-house operating room team, and backup. Imaging services will include ultrasound and a CT scanner, while angiography, nuclear medicine, and magnetic resonance imaging may be available. The trauma team takes call from home and is committed to early evaluation and treatment of critically injured individuals. This is based on prehospital triage and timely notification from the field so that the team may be present when the patient arrives. Physicians in the emergency department and, sometimes, surgeons should provide both online and off-line medical direction for local ambulance services. The hospital has sufficient equipment and personnel to provide definitive care for the majority of patients, but must recognize those patients who exceed local capabilities and need rapid, efficient stabilization followed by transport to the next appropriate level of care.78 The trauma program, aided by a trauma registry, is expected to conduct ongoing performance improvement for itself and prehospital personnel and to provide outreach services to smaller hospitals within its catchment area. The rural Level III is more likely to encounter and provide definitive care for moderately injured patients (ISS 9–25) and to serve as a regional resource than its urban or suburban conterpart.73,74
Level IV hospitals may or may not have surgical capability. If they do, there is often only one surgeon, who accordingly will not be available at all times.40,42,44 With the aid of improved triage criteria and prompt assembly of the trauma team, a group of nondesignated, isolated rural hospitals (size 18–77 beds) in northern California demonstrated the ability to provide care to 266 patients (mean ISS 26) that exceeded MTOS norms. They lacked the financial resources to be designated by the state as Level III, but were able to provide operative and inpatient care under the proper circumstances. Above all, they demonstrated commitment to care of the injured, without which no hospital, regardless of other resources, will succeed as a trauma center.79 In many small hospitals, however, those requiring surgical or inpatient care will usually need to be transferred early. Observation of patients with blunt injury to a solid organ is not advisable in this setting unless the surgeon and operating room staff commit to being available at a moment’s notice if nonoperative management fails. The trauma team and trauma program will be led by a surgeon when possible, but will include family physicians, physician assistants, and nurse practitioners. Damage control surgery or operative stabilization before transport should be undertaken when indicated, provided the surgeon and operating room staff are available.
Several trauma systems (WA, CO, MT, UT, and WY, among others) include Level V trauma centers in their designation process. These are health care facilities lacking inpatient capability, but which commit to early availability for resuscitation, stabilization, and transport within the system. Some regions of California have developed Emergency Department Approved for Trauma (EDAT) in rural areas of the state to serve the same stabilization and transport function. Most hospitals in most states are undesignated, but also have an important role to play in an inclusive system.
EDUCATION AND MAINTENANCE OF SKILLS
Severe trauma represents 5% or less of the workload of most rural general surgeons.2,44,48 Rural health care workers at all levels have difficulty maintaining their skills because they will have few opportunities to exercise them. ATLS was designed specifically to teach physicians how to manage patients in the early minutes and hours after a critical injury. The target audience was the rural physician or surgeon who sees such patients infrequently and must cope with very limited resources to resuscitate and transfer such patients. It has now become the international standard for early care of the injured and has had a positive impact on rural trauma care. PHTLS has been developed in conjunction with ATLS to educate EMTs about trauma.
In the early 1980s and early 1990s, before the general dissemination of ATLS, most articles on rural trauma care were in agreement that a significant proportion of preventable trauma morbidity and mortality resulted from inappropriate care at the local hospital.10,13,16,18,40 More recent studies indicate that, at least in some areas, patients are now being stabilized much more effectively before transport to the regional Level I or II trauma center, and delays in discovery, retrieval, and transport are the principal causes of death.1,17,38,39,76,80–82 On the other hand, a recent report from Rhode Island where ATLS is not mandated for emergency room staff demonstrated frequent departures from ATLS guidelines, with resultant delays in transport to the centrally located Level I trauma center.78,83
New technology and techniques take time to arrive in rural areas. Expense and lack of need contribute to the delay. For instance, most rural surgeons and physicians in the emergency department will not encounter enough patients with serious abdominal injuries to become adept in the use of ultrasound to identify intra-abdominal hemorrhage. For them, time and expenditures for capital equipment may be better directed at more basic and utilitarian items. Ignorance of new methods, however, is not acceptable. Members of the trauma team should assume responsibility for remaining sufficiently current in the trauma literature and in ATLS. They should know how to evaluate and resuscitate severely injured patients, recognize the need for operative intervention before transfer, know when nonoperative management is appropriate and safe, and realize when a patient’s needs exceed local resources.
Feedback on specific cases and trauma educational outreach programs are primary responsibilities of the leading trauma center in the area. Intramural offerings, particularly if based on local registry information, will help all members of the team to remain up to date. Prevention programs will help raise public awareness of the impact trauma has on individual lives and may assist in increasing support for the purchase of equipment and development of a regional trauma system.
Stabilization and Transfer to Definitive Care
When a trauma patient is en route or has already arrived at a small hospital with limited resources, one of the most critical decisions to be made is whether the patient can be treated locally or whether transfer is necessary. Trauma outcome is directly related to time to definitive care. If it is clear from the field report that the victim’s injuries will exceed local resources, that is the time to begin making transfer arrangements in order to eliminate the principal rate-limiting step (i.e., dispatch and arrival of the transport team and conveyance).84 Hospitals that need to transfer patients frequently know in advance which trauma centers will receive them and should have transfer agreements in effect.
Once the patient is in the emergency department, it is the responsibility of the surgeon or physician leading the team to recognize the need for transfer and initiate arrangements as soon as possible. From that point onward, all efforts should be directed at optimizing the patient’s physiology. ATLS should be the guide to the resuscitation, and testing and interventions should be limited to essentials and should not delay the departure.85 Unfortunately, inappropriate imaging particularly with CT has been shown to delay some transfers. Compounding the problem is the fact that, because of unavailability of images or reports from the referring hospital, many of these studies are repeated at the receiving Level I or II center, creating further delay, expense, and risk to the patient. One institution reported that 53% of 410 patients required repeat imaging at an average cost of $2,985 per patient.86 Referring physicians appear to obtain such studies out of liability concerns or because the trauma center may not accept the patient without confirmation of the severity of injury. A potential solution, beyond education and outreach, could be the establishment of regional Picture Achieving and Communication System (PACS) networks that are connected by broadband technology between referring and receiving hospitals.
The team leader should speak directly with the receiving trauma surgeon and should avoid transferring care directly to a subspecialist (orthopedic surgeon, neurosurgeon, plastic surgeon). If the receiving hospital is on diversion, its representatives should help the referring hospital find an alternate destination.
Federal law now governs transfer of patients from an emergency department to another hospital, to another area within the same hospital, or to home. Violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations can lead to draconian penalties for hospitals and individuals. Punishments include denial of the ability to care for Medicare and Medicaid patients, as well as civil liability. This set of rules, originally enacted in 1985 to prevent patient “dumping” (inappropriate transfer of unstable indigent patients from private to public emergency rooms), has been expanded to what is essentially a federal right to emergency care and a federal malpractice act. The receiving hospital is obligated to report whenever a patient was “unstable” or inappropriately transferred. A complaint by any concerned party must be investigated by the Office of the Inspector General (OIG).87
Most traumatic events will be viewed by the patient, although not necessarily by health care workers, as an emergency. Any patient has a right to request a medical screening exam (MSE) for a perceived emergency medical condition (EMC). The hospital or clinic is required to determine by this exam whether or not an EMC in fact exists. If the patient has an EMC, “the hospital must stabilize the emergency condition, or, if it is unable to stabilize the patient, the hospital must transfer the patient to a hospital that is capable of stabilizing the emergency condition. Hospitals with specialized capabilities or facilities are required to accept transfers of patients who require such specialized services ….”87 What constitutes an EMC, and the details of the MSE, is open to interpretation.
How are hospitals and physicians to respond (Table 8-2)? One strategy already being employed is for surgeons to refuse to take trauma calls and for hospitals to close their doors to injured patients. The ethical and legal ramifications of this approach are debatable and will undoubtedly be subjected to close scrutiny. The proactive response is for health care workers and facilities to familiarize themselves with the provisions of the law and to establish, in cooperation with each other, a trauma program that will be in compliance. Properly executed transfer agreements should, in most cases, streamline the process. It is likely that the strongest defense in any given instance will be the ability to demonstrate that actions were directed toward the patient’s best interest. For the trauma patient, the following would be appropriate:
1. Prehospital triage protocols for identification of critically injured patients
2. A mechanism for ensuring early evaluation at the bedside by the appropriate surgeon or emergency medicine physician
3. Prompt initiation of resuscitation and stabilization measures
4. Early decision regarding the medical need for transfer
5. Consultation with the receiving hospital (ideally with the trauma surgeon)
6. Documentation of indications for, and acceptance of, transfer
7. Arrangement of the appropriate transfer team, conveyance, and equipment
8. Before transfer, stabilization of the patient’s condition to the degree possible given the resource imitations of the transferring hospital
Managed care may also interfere with the orderly transfer of patients as established by a regional trauma system. Several types of problems have arisen. Payments for emergency and after-hours transfers have been denied for lack of prior authorization, even though such authorization was impossible to obtain at the time. Triage to a hospital within the managed care system may be mandated, even though that facility may not be an authorized trauma center. The American College of Surgeons has issued a statement condemning such practices and encouraging cooperation of managed care and trauma systems.88
Operative Stabilization and Transfer
Most patients respond to standard resuscitative measures and, once stabilized, can be admitted locally, discharged home, or transferred to a higher level of care. A small proportion, probably less than 10%, will be either transient or nonresponders and will remain hemodynamically abnormal despite continued skilled resuscitation. If the patient has multiple injuries, suffers from significant medical comorbidity, is at the extremes of age, or has injuries requiring subspecialty (i.e., neurosurgical) or complex intensive care, transfer will likely be necessary. The more remote the primary facility is, the greater the risk that the patient will deteriorate during transfer unless something is done to address the underlying problem, generally hemorrhage. In this circumstance, the local general or subspecialty surgeon should be prepared to operate and stabilize the patient before transfer.89 With a properly equipped transport vehicle, usually a fixed-wing aircraft or helicopter, the patient may often be transferred immediately thereafter into the hands of the flight team without any compromise of care.67,90 Operative stabilization of this sort falls into the following two categories: definitive surgery and damage control surgery.
Under most circumstances a stabilizing procedure can be conducted and completed in conventional fashion, such that no further treatment will be required for that particular problem. Examples would include, but are not limited to, the following:
1. Establishment of a surgical airway
2. Splenorrhaphy or splenectomy, hepatorrhaphy, resection and debridement, or insertion of perihepatic packs
3. Closure of evisceration
4. Closure of injuries to the gastrointestinal tract
5. Repair or shunting of truncal and extremity vascular injuries
6. Reduction of dislocations
7. Debridement and control of hemorrhage from open fractures in an extremity or mangled extremities
Damage Control Surgery
Damage control operations followed by temporary closure of the abdomen have been described for a variety of truncal injuries with an emphasis on limiting time in the operating room and avoiding the triad of acidosis, hypothermia, and coagulopathy.91–93 Candidates for these desperate measures typically have an overwhelming constellation of injuries. Most reports on damage control surgery and temporary closure techniques have come from urban trauma centers. Following a period of rewarming and correction of hypothermia, acidosis, and a coagulopathy in the intensive care unit, the patient is then returned to surgery for definitive repair of the remaining injuries. Rural surgeons can apply the same principles. Occasional patients will have such complex injuries that definitive management exceeds the technical abilities or resources of the local surgeon and hospital, but may be amenable to temporizing maneuvers, followed by rapid transfer in an aircraft equipped as an airborne intensive care unit.94 Examples include packing of the liver for complex hepatic injuries; peritoneal cleansing, hemorrhage control, and stapling or rapid suture of multiple bowel perforations; temporary abdominal closure; and abbreviated thoracotomy, hemorrhage control, and temporary chest closure for patients with extensive pulmonary and thoracic vascular injuries.95 If interventional radiology is not available locally, patients with unstable pelvic fractures may benefit from application of external fixators prior to transfer.
Surgeons in Alberta compared outcomes in patients referred to a Level I center from Level III and IV hospitals in the region, focusing on those patients arriving in unstable condition and requiring emergency laparotomy. Most had multisystem injuries and required operations by surgical subspecialists, as well. Despite the presence of serious concurrent injuries, however, they concluded that while the community surgeons in the Level III hospitals were triaging patients appropriately, some patients might have benefited from a damage control operation prior to transfer.96
Injury to the brain remains the single greatest source of morbidity and mortality for trauma victims.18 Many patients sustain their closed head injuries far from the nearest neurosurgeon, and time becomes the enemy. Under most circumstances, the only option is to minimize secondary brain injury with appropriate ventilatory and pharmacologic maneuvers and expedite transfer.97,98 A small proportion of these patients, however, will have lesions amenable to surgical drainage. While rural hospitals generally lack neurosurgical services, most hospitals in the United States now have CT scanners. General surgeons can be trained to perform burr holes and/or limited craniotomy for decompression and hemorrhage control in patients with epidural or subdural hematomas noted on a CT scan.99,100 When a patient with an injury to the brain shows signs of rapid deterioration and a delay of more than 90 minutes to definitive neurosurgical care is anticipated, consideration should be given to emergency decompression of the hematoma.98,101 The necessary components are as follows:
1. A general surgeon trained in indications for and technique of burr holes with limited craniotomy
2. Traumatic brain injury with lateralizing signs and threatened herniation
3. Surgical lesion present on CT scan
4. Consultation with, and approval of, neurosurgeon at receiving trauma center
5. Limited craniotomy for decompression and hemorrhage control
6. Immediate transfer to definitive care97
Local Definitive Care
Most trauma patients can be cared for at a local community hospital capable of offering continuous surgical care. “The mindset that a well-trained general surgeon is not able to care for many trauma patients must be corrected.”72Although triage and transfer guidelines address anatomic, physiologic, and mechanism of injury parameters, there are few publications that describe specifically which patients might reasonably be cared for in small hospitals. Currently accepted examples are patients with isolated extremity fractures, minor burns, lacerations, a hemothorax and/or pneumothorax, multiple rib fractures, traumatic brain injury with GCS of 14–15, and a variety of organ and vessel injuries within the ability and comfort range of the attending surgeon. It is important for surgeons to remember that colleagues, nursing staff, and ancillary services must also be able to provide the necessary adjunctive care. Patients at the extremes of age, with multiple organ system involvement, the need for prolonged ventilator support and/or intensive care, and serious underlying illnesses, will probably benefit from care in a trauma center under most circumstances. Patients should always be advised of the option to be transferred. It is important to be aware of pertinent state statutes or transfer guidelines used by the regional trauma system and to realize that in the event of misadventures, the burden of proof will rest with the doctor who chooses not to transfer a patient.
The management of patients with blunt injury to solid abdominal viscera (particularly spleen and liver) presents some difficult logistical problems for the rural surgeon. Most patients with injuries to the spleen or liver and normal hemodynamics can be managed without an operation. When an operation is necessary, the well-trained general surgeon is certainly fully capable of performing a splenectomy or splenorrhaphy. Major hepatic injuries have the potential for overwhelming the technical ability of the surgeon or the resources of a small blood bank, but may be amenable to simple suture repair, resectional debridement, or packing and immediate transfer. It is to the patient’s advantage to be managed in the local hospital rather than be transferred to a distant Level I or II center, if it can be done safely. The problem lies with the patient who deteriorates unexpectedly, becomes hypotensive, and requires urgent surgery. In a hospital lacking house staff, immediate availability of the surgeon, and a plan for rapid preparation of the operating room, there is a small but real potential for death from exsanguinating hemorrhage. In these circumstances, a lower threshold for early operation or transfer is appropriate.102
When patients are selected properly for local treatment, a number of advantages accrue. It is generally more convenient for patient and family as friends, clergy, and support groups in the area provide moral support and can hasten recovery and reintegration into the community. Risks inherent in emergency transfers are eliminated. Use of local services keeps money in the community. Because most rural trauma is motor vehicle related, insurance coverage is better than average and supports the financial stability of the hospital. Finally, appropriate local care reduces the burden on busy regional trauma centers.72,103
A downside for many surgeons is that trauma of this sort, particularly in the era of observation of injuries to solid organs, is not very exciting and produces relatively few operations. Overseeing care for patients while subspecialists perform a variety of operative procedures does not appeal to many general surgeons. Hours are inconvenient, and trauma emergencies can wreak havoc with elective schedules. The high incidence of substance abuse in association with traumatic events is well documented and may make evaluation and management of injured patients difficult or unpleasant. Surveys of surgeons’ attitudes toward trauma reflect many of these concerns and yet, interestingly, demonstrate that rural surgeons are significantly more willing to accept these burdens than are their urban colleagues.50,104 In fact, the opportunity to provide potentially lifesaving treatment to friends, neighbors, or acquaintances and to see its long-term effects is one of the benefits of a general surgery practice in a small town.72
Population shifts in the coming years will have an impact on the problems of rural trauma. Although many parts of the Great Plains are becoming progressively depopulated, rural areas of the coastal regions, Rocky Mountains, Southwest, and Sunbelt states are experiencing an influx of young, active people who are tired of city life and eager for what small town America has to offer. Equipped with cell phones, modems, GPS-based equipment, and sport utility vehicles, these members of generations X and Y (and their baby boom parents) are very much into hiking, camping, climbing, skiing, and other activities that are best pursued in rural and frontier settings. They are affluent and well educated and accustomed to getting what they want. It is likely that, in order to support their desired lifestyles, they will expect or demand a trauma infrastructure that is sophisticated, efficient, effective, and comparable to what is available in a resource-rich environment. Whether they will be willing to pay for it through taxes or user fees is another matter. An important mission for rural systems will be convincing constituents of the importance of financial support for trauma activities.
Many of the problems of rural communities could be mitigated with the use of technology for prevention and for discovery. In the 1990s, rural EMS notification times (from time of motor vehicle crash) dropped significantly with the advent of wireless phones. In mountainous terrain, wireless communication is hampered by line of sight, but this problem is already being addressed through the installation of low-power, short-distance relay boxes. Vehicles produced by the leading automobile manufacturers can now include advanced automatic crash notification (AACN) equipment. For those vehicles lacking such systems, however, all is not lost. Provided ambulances are equipped with GPS units, law enforcement at a crash scene can radio either an actual address or latitude/longitude coordinates to EMS personnel to guide them. Using such a system, mean rural response times have been reduced from 13.7 to 9.9 minutes, a differential which can prove lifesaving in some circumstances.105 A combination of crash sensors, GPS devices, and a wireless phone allows for automatic phone activation on impact to notify EMS of the location and severity of a crash.41
Crash avoidance is possible with sensors installed in the roadway to measure road edge, lane tracking, intersections, and merging traffic. Vehicle sensors can assist with avoidance of rear-end crashes, vision enhancement, navigation and routing information, and driver condition. The development of smart highways will be expensive, however, and, predictably, rural areas will be the last to benefit. Improvements in crash protection will result from refinements of existing passive restraints (seatbelts, airbags) and structural characteristics of vehicles.
While the advances just described are specific for automobile occupants, wireless communication and location systems will also benefit hikers, hunters, workers, and others in the backcountry, provided they equip themselves with cell phones and GPS monitors. Another device under investigation is the personal status monitor (PSM), which is worn like a wristwatch and combines pulse, blood pressure, and arterial hemoglobin saturation with GPS.106 The resulting improvement in notification and location will guide rescuers to victims more efficiently and eliminate much of the delay to definitive care that currently plagues rural EMS.
Transport systems are another area where technology combined with a secure funding source could improve outcomes for trauma victims. Helicopters are very expensive, but may have the greatest potential for eliminating delay and downtime in the process of getting the right patient to the right hospital at the right time. Extended range, expanded capacity for onboard equipment and access to the patient, safer landing areas, and creative methods of funding are all possible areas for investigation. If national health policy moves toward regionalization of medical and surgical care, improved transport from scene or local hospital will be essential.
If we are unable to improve on methods of transporting the patient to the trauma center, investigators are now actively studying strategies for bringing the trauma center to the patient. Telemedicine, particularly digital radiology, is already in use in many parts of the country. Outpatient follow-up of patients discharged from a trauma center to a remote rural area has been successfully accomplished using videoconferencing over T1 lines at 768 kbps. Internet broadband technology is increasingly available in rural areas and is also being successfully used for video and data transmission. Cable-based broadband technology is increasingly available in rural areas and is an even faster mode of data transmission. Adjuncts include an analog electronic stethoscope, document cameras and close-up cameras with macro lenses, and a fax line, scanner, or document camera for document transmission.107 Satellite uplinks on emergency vehicles and appropriate audiovisual equipment can allow trauma experts at the medical center to observe a rescue in real time and offer suggestions regarding appropriate evaluations, interventions, and disposition at a distance.108,109 Laptops and landlines have been used to transmit real-time images of trauma resuscitations at remote rural hospitals. In one case the trauma surgeon talked a local doctor through a lifesaving cricothyroidotomy in a patient with an injury to the brain, and, in another, recommended a diagnostic peritoneal lavage that was positive and led to local laparotomy for control of abdominal hemorrhage prior to transfer.110 The Internet has been used to transfer images to aid in assessing candidates for replantation of an extremity.111 Improvements in compression/decompression software have overcome some of the previous bandwidth limitations in rural areas. Limiting factors include money and infrastructure including T1 lines at 2 Mbps, broadband fiber-optic lines at 155 Mbps, and advanced communication satellite access at 622 Mbps. Surgeons in Taiwan have reported on 35 patients with a total of 60 traumatic digital amputations who were evaluated at a distance with the aid of a camera phone to determine whether transfer for replantation was appropriate.112
The trauma service at the University of Vermont has developed a remote teleconsultation service to provide immediate access to the trauma surgeon for physicians and physician extenders in rural northern New York. Each of the on-call surgeons has a telemedicine workstation at home that can communicate by interactive video with a similar workstation at one of the nine participating community hospitals using three ISDN lines. (ISDN is a digital network capable of transmitting voice, video, and data over telephone lines at speeds up to 1.4 Mbps.) The surgeon can observe the physical exam, monitor vital signs, and view x-rays. In one case, the surgeon walked a physician’s assistant through reduction of an elbow dislocation prior to transfer (3.5 hours by ground) to definitive care at the Level I trauma center. Telemedicine has also been used to evaluate burns, enhancing early management, while in some cases avoiding the need to transfer to a burn center.113 Adaptation of similar technology to moving ambulances is under development by the same group.114 Medicolegal considerations, including licensure if the supervising doctor is in another state, and the essence of the doctor–patient relationship if he or she never physically encounters the patient, have yet to be resolved.
The Arizona Telemedicine Program, based at the University of Arizona in Tucson, was developed in the mid-1990s and funded by the state legislature. It is now a well-established service providing real-time consultations to hospitals around the state over a broad range of specialties. Trauma surgeons participating in the program have obtained credentials at the referring hospitals, dictate their consultations, and charge a nominal fee. They report experience with 35 trauma patients evaluated by telemedicine (audio, video via single camera with 12x zoom capability in the ED, data transfer by T1 line at 1.0 Mbps) at six separate rural hospitals since 2004. As a result of the consultation process, 27 patients were transferred to Tucson, 9 of whom underwent surgical intervention. Four of those transferred were felt to have life-threatening conditions that were significantly impacted by the consultation process. Equally important is the finding that 17 patients who might otherwise have been transferred were treated locally, saving an estimated $105,000 in transfer costs alone. Furthermore, physicians at the local sites appear to appreciate the backup provided by this service.115
These strictures will also apply in another area under investigation, telepresence surgery, in which a surgeon uses a robotic system designed to make him or her feel as if he or she is actually at the remote site with the patient. Much of the research in this area has been sponsored by the Defense Advanced Research Projects Agency (DARPA) for the US military to develop methods for safely operating on troops at or near a battlefield. If it can be done under those circumstances, it surely can be applied to less hostile rural environments. One limitation is the latent period required to transmit signals (currently 200–300 km by terrestrial cable, and 35–50 km by wireless transmission) at an acceptable delay of 200 minutes. Communications satellites, by comparison, have a latent period of 1.5 seconds.116 Laparoscopic surgery lends itself ideally to this technology and has, in fact, been accomplished by specially trained surgeons performing cholecystectomies from a “remote” console within the same operating suite.117,118 Efforts are underway to accomplish similar surgery at a much greater distance. The equipment utilized was originally designed for endoscopic coronary bypass surgery and has been used with success for that purpose, as well.119 At the moment, the acquisition cost of one of these robotic systems is approximately $1 million.
Trauma systems are covered in depth elsewhere in this book. Most trauma experts are convinced that an inclusive and integrated approach to trauma will be necessary in the future. Computer models are now available that can help policymakers decide where to place trauma hospitals and helicopters in order to best meet the trauma needs of a given region and population.120 It is important to emphasize that a system will offer rural hospitals and health care workers the best opportunity to expand their limited resources. By pooling efforts with others in the region in common purpose, small hospitals benefit from educational and prevention services, improved patient transport, increased political influence, better financial support, and access to new technology. Failure to take advantage of these opportunities may consign a rural hospital and its patients to isolation and inadequate trauma care. “One of the most important functions of a trauma system is to ensure that patients do not die of simple injuries. Death caused by easily correctable and relatively minor injuries still occurs with an alarming frequency in the rural setting.”121
1. Rogers F, Shackford S, Osler T, Vane D, Davis J. Rural trauma: the challenge for the next decade. J Trauma. 1999;47:802–821.
2. Wayne R. Rural trauma management. Am J Surg. 1989;157:463–466.
3. Muelleman R, Walker R, Edney J. Motor vehicle deaths: a rural epidemic. J Trauma. 1993;35:717–719.
4. Maio R, Green P, Becker M, Burney R, Compton C. Rural motor vehicle crash mortality: the role of crash severity and medical resources. Accid Anal Prev. 1992;24:631–642.
5. Baker S, Whitfield R, O’Neill B. Geographic variations in mortality from motor vehicle crashes. N Engl J Med. 1987;316:1384–1387.
6. Baker S, Whitfield R, O’Neill B. County mapping of injury mortality. J Trauma. 1988;28:741–745.
7. Kearney P, Stallones L, Swartz C, Barker D, Johnson S. Unintentional injury death rates in rural Appalachia. J Trauma. 1990;30:1524–1532.
8. Vane D, Shackford S. Epidemiology or rural traumatic death in children: a population-based study. J Trauma. 1995;38:867–870.
9. Rausch TK, Sanddal ND, Sanddal TL, Esposito TJ. Changing epidemiology of injury-related pediatric mortality in a rural state: implications for injury control. Pediatr Emerg Care. 1998;14(6): 388–392.
10. Certo T, Rogers F, Pilcher D. Review of care of fatally injured patients in a rural state: 5-year follow up. J Trauma. 1983;23:559–565.
11. Esposito T, Sanddal N, Hansen J, Reynolds S. Analysis of preventable trauma deaths and inappropriate care in a rural state. J Trauma. 1995;39:955–962.
12. West J, Trunkey D, Lim R. Systems of trauma care: study of two counties. Arch Surg. 1979;114:455–460.
13. Houtchens B. Major trauma in the rural mountain West. J Am Coll Emerg Phys. 1977;6:343–350.
14. Sihler KC, Hemmila MR. Injuries in nonurban areas are associated with increased disability at hospital discharge. J Trauma. 2009;67: 903–909.
15. Schootman M, Fuortes L. Functional status following traumatic brain injuries: population-based rural–urban differences. Brain Inj. 1993;13:995–1004.
16. Waller J. Urban-oriented methods: failure to solve rural emergency care problems. JAMA. 1973;226:1441–1446.
17. Rutledge R, Fakhry S, Baker C, et al. A population-based study of the association of medical manpower with country trauma death rates in the United States. Ann Surg. 1994;219(5):547–563.
18. Shackford S, Mackersie R, Holbrook T, et al. The epidemiology of traumatic death: a population-based analysis. Arch Surg. 1993;128: 571–575.
19. Wang HE, Callaway CW, Peitzman AB, Tisherman S. Admission hypothermia and outcome after major trauma. Crit Care Med. 2005;33:1296–1301.
20. Waibel BH, Schlitzkus LL, Newell MA, Durham C, Sagraves S, Rotondo M. Impact of hypothermia (below 36°) in the rural trauma patient. J Am Coll Surg. 2009;209:580–588.
21. Fatovich DM, Jacobs IG. The relationship between remoteness and trauma deaths in Western Australia. J Trauma. 2009;67:910–914.
22. Thompson M, Lynge D, Larson E, Tachawachira P, Hart L. Characterizing the general surgery workforce in rural America. Arch Surg. 2005;140:74–79.
23. Anderson JA. Rural Trauma Care: Resources for Optimal Care of the Injured Patient. Chicago: American College of Surgeons; 2006.
24. Nordstrom D, Zwerling C, Stromquist A, Burmeister L, Merchant J. Epidemiology of unintentional adult injury in a rural population. J Trauma. 2001;51:758–766.
25. Rogers F, Osler T, Shackford S, et al. A population-based study of geriatric trauma in a rural state. J Trauma. 2001;50(4):604–609.
26. Clark D. Motor vehicle crash fatalities in the elderly: rural versus urban. J Trauma. 2001;51:896–900.
27. Wigglesworth E. Do some US states have higher/lower injury mortality rates than others? J Trauma. 2005;58:1144–1149.
28. Deaths and Injuries in the Workplace, Home and Community, and on Roads and Highways. Available at: http://www.nsc.org/library/report_injury_usa.htm.
29. Pratt D. Occupational health and the rural worker: agriculture, mining and logging. J Rural Health. 1990;6:399–417.
30. Norwood S, Myers M. Outcomes following injury in a predominantly rural-population-based trauma center. Arch Surg. 1994;129:800–805.
31. Farrell T, Sutton JJ, Clark D, et al. Moose-motor vehicle collisions: an increasing hazard in northern New England. Arch Surg. 1996;131: 377–381.
32. Helmkamp J, Derk S. Nonfatal logging-related injuries in West Virginia. J Occup Environ Med. 1999;41:967–972.
33. Mullins R, Brand D, Lenfesty B, Newgard C, Hedges J, Ham B. Statewide assessment of injury and death rates among riders of off-road vehicles treated at trauma centers. J Am Coll Surg. 2007;204: 216–224.
34. Coben JH, Tiesman HM, Bossarte RM, Furbee PM. Rural–urban differences in injury hospitalizations in the U.S., 2004. Am J Prev Med. 2009;36(1):49–55.
35. Perkins R, Sanddal TL, Howell M, Sanddal ND, Berman A. Epidemiological and follow-back study of suicides in Alaska. Int J Circumpolar Health. 2009;68(3):212–223.
36. Centers for Disease Control and Prevention. Web-Based Injury Statistics Query and Reporting System. Atlanta, GA: Centers for Disease Control and Prevention; 2010.
37. Robertson R, Mattox R, Collins T, Parks-Miller C, Eidt J, Cone J. Missed injuries in a rural area trauma center. Am J Surg. 1996;172: 564–567.
38. Rogers F, Osler T, Shackford S, Martin F, Healey M, Pilcher D. Population-based study of hospital trauma care in a rural state without a formal trauma system. J Trauma. 2001;50(3):409–414.
39. Rogers F, Osler T, Shackford S, Cohen M, Camp L, Lesage M. Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting. J Trauma. 1999;46:328–333.
40. Martin G, Cogbill T, Landercasper J, Strutt P. Prospective analysis of rural interhospital transfer of injured patients to a referral trauma center. J Trauma. 1990;30:1014–1019.
41. Champion H, Cushing B. Emerging technology for vehicular safety and emergency response to roadway crashes. Surg Clin North Am. 1999;79:1229–1240.
42. Zulick L, Dietz P, Brooks K. Trauma experience of a rural hospital. Arch Surg. 1991;126:1427–1430.
43. Bintz M, Cogbill T, Bacon J. Rural trauma care: role of the general surgeon. J Trauma. 1996;41:462–464.
44. Rinker C, Sabo R. Operative management of rural trauma over a 10-year period. Am J Surg. 1989;158:548–551.
45. Sariego J. Impact of a formal trauma program on a small rural hospital in Mississippi. South Med J. 2000;93:182–185.
46. Foley T, Kessel J, Schmitz G, RTTDC©. New course to improve rural trauma care. Bull Am Coll Surg. 2005;90.
47. Rabinowitz H, Diamond J, Markham F, Paynter N. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286:1041–1048.
48. Smith N. The incidence of severe trauma in small rural hospitals. J Fam Pract. 1987;25:595–600.
49. Stewart R, Johnson J, Geoghegan K, et al. Trauma surgery malpractice risk: perception versus reality. Ann Surg. 2005;241:969–975.
50. Esposito T, Maier R, Rivara F, Carrico C. Why surgeons prefer not to care for trauma patients. Arch Surg. 1991;126:129–133.
51. Doty B, Zuckerman R. Rural surgery: framing the issues in surgical practice in rural areas. Surg Clin North Am. 2009;89:1279–1284.
52. Lynge D, Larson E. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285–1291.
53. Doty B, Zuckerman R, Gold M, et al. General Surgery in Small Rural New York Hospitals. A Pilot Survey of Hospital Administrators; 2009. Available at: http://www.aamc.org/workforce/pwrc06/doty.pdf.
54. Morrisey M, Ohsfeldt R, Johnson V, Treat R. Trauma patients: an analysis of rural ambulance trip reports. J Trauma. 1996;41: 741–746.
55. Institute of Medicine. Emergency Medical Services: At the Crossroads. Washington, DC: Institute of Medicine; 2008.
56. Messick W, Rutledge R, Meyer A. The association of advanced life support training and decreased per capita trauma death rates: an analysis of 12,417 trauma deaths. J Trauma. 1992;33:850–855.
57. National Highway Traffic Safety Administration. National EMS Scope of Practice Model. Washington, DC: National Highway Traffic Safety Administration; 2007.
58. McGinnis K. Rural and Frontier EMS Agenda for the Future. Kansas City, MO: National Rural Health Association; 2003.
59. Mason S, Wardrope J, Perrin J. Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emerg Med J. 2006;23:479–481.
60. McGinnis K. State EMS Rural Needs Survey 2004. Falls Church, VA: National Association of State EMS Directors; 2004.
61. Brathwaite C, Rosko M, McDowell R, Gallagher J, Proenca J, Spott M. A critical analysis of on-scene helicopter transport on survival in a statewide trauma system. J Trauma. 1998;45140–144.
62. Diaz M, Hendey G, Bivins H. When is helicopter faster? A comparison of helicopter and ground ambulance transport times. J Trauma. 2005;58:148–153.
63. Gabram S, Jacobs L. The impact of flight systems on access to and quality of care. Probl Gen Surg. 1990;7:203–222.
64. Grossman D, Hart L, Rivara F, Maier RV, Rosenblatt R. From roadside to bedside: the regionalization of trauma care in a remote rural county. J Trauma. 1995;38:14–21.
65. Cunningham P, Rutledge R, Baker C, Clancy TV. A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene. J Trauma. 1997;43:940–946.
66. Urdaneta L, Miller B, Ringenberg B, Cram A, Scott D. Role of an emergency helicopter transport service in rural trauma. Arch Surg. 1987;122:992–996.
67. Sharar S, Luna G, Rice C, Valenzuela T, Copass M. Air transport following surgical stabilization: an extension of regionalized trauma care. J Trauma. 1988;28:794–798.
68. Wald S, Shackford S, Fenwick J. The effect of secondary insults on mortality and long-term disability in a rural region without a trauma system. J Trauma. 1993;34:377–381.
69. Veenema K, Rodewald L. Stabilization of rural multiple trauma patients at Level III emergency departments before transfer to a Level I regional trauma center. Ann Emerg Med. 1995;25:175–181.
70. Rutledge R, Shaffer V, Ridky J. Trauma care reimbursement in rural hospitals: implications for triage and trauma system design. J Trauma. 1996;40:1002–1008.
71. Wenneker W, Murray D, Ledwich T. Improved trauma care in a rural hospital after establishing a Level II trauma center. Am J Surg. 1990;160: 655–657.
72. Richardson J. Trauma centers and trauma surgeons: have we become too specialized? J Trauma. 2000;48:1–7.
73. Richardson J, Cross T, Lee D, et al. Impact of Level III verification on trauma admissions and transfer: comparisons of two rural hospitals. J Trauma. 1997;42:498–502.
74. Sampalis J, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. J Trauma. 1997;43:288–295.
75. Barquist E, Pizzutiello M, Tian L, Cox C, Bessey P. Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes region of New York State. J Trauma. 2000;49: 63–69.
76. Esposito TJ, Sanddal TL, Reynolds SA, Sanddal ND. Effect of a voluntary trauma system on preventable death and inappropriate care in a rural state. J Trauma. 2003;54(4):663–670.
77. Tinkoff GH, O’Connor RE, Alexander EL, Jones MS. The Delaware trauma system: impact of Level III trauma centers. J Trauma. 2007;63(1):121–127.
78. Svenson J. Trauma systems and timing of patient transfer: are we improving? Am J Emerg Med. 2008;26:465–468.
79. Karsteadt L, Larsen C, Farmer P. Analysis of a rural trauma program using the TRISS methodology: a three-year retrospective study. J Trauma. 1994;36:395–400.
80. Ali J, Adam R, Butler A, et al. Trauma outcome improves following the Advanced Trauma Life Support program in an developing country. J Trauma. 1993;34:890–889.
81. Ali J, Adam R, Stedman M, Howard M, Williams J. Advanced Trauma Life Support program increases emergency application of trauma resuscitative procedures in a developing country. J Trauma. 1994;36: 391–394.
82. Rogers F, Shackford S, Hoyt D, et al. Trauma deaths in a mature urban vs. rural trauma system. A comparison. Arch Surg. 1997;132: 376–381.
83. Harrington D, Connolly M, Biffl W, Majercik SD, Cioffi WG. Transfer times to definitive care facilities are too long. A consequence of an immature trauma system. Ann Surg. 2005;241:961–966.
84. Cone J. Tertiary trauma care in a rural state. Am J Surg. 1990;160: 652–654.
85. Committee on Trauma, American College of Surgeons. Stabilization and Transport. In: Advanced Trauma Life Support Program for Physicians. 8th ed. Chicago: American College of Surgeons; 2002.
86. Haley T, Ghaemmaghami V, Loftus T, Gerkin RD, Sterrett R, Ferrara JJ. Trauma: the impact of repeat imaging. Am J Surg. 2009;198: 858–862.
87. Bitterman R. Overview of hospital and physician responsibilities mandated by EMTALA. In: Providing Emergency Care under Federal Law EMTALA. Dallas: American College of Emergency Physicians; 2000.
88. ACS statement on managed care and the trauma system. Bull Am Coll Surg. 1995;80:86–87.
89. Wemyss-Holden S, Bruening M, Launois B, Maddern G. Management of liver trauma with implications for the rural surgeon. ANZ J Surg. 2002;72:400–404.
90. Gilligan J, Griggs W, Jelly M, et al. Mobile intensive care services in rural South Australia. Med J Aust. 1999;171:617–620.
91. Hirshberg A, Walden R. Damage control for abdominal trauma. Surg Clin North Am. 1997;77:813–820.
92. Granchi T, Liscum K. The logistics of damage control. Surg Clin North Am. 1997;77:909–920.
93. Mattox K. Introduction, background, and future projections of damage control surgery. Surg Clin North Am. 1997;77:753–759.
94. Kudsk K, Ivatury R, Morris J, Rotondo M. Symposium: damage control in the trauma patient. Contemp Surg. 2001;57:325–343.
95. Vargo D, Battistella F. Abbreviated thoracotomy and temporary chest closure: an application of damage control after thoracic trauma. Arch Surg. 2001;136:21–24.
96. Ball C, Sutherland F, Dixon E, et al. Surgical trauma referrals from rural level III hospitals: should our community colleagues be doing more, or less? J Trauma. 2009;67:180–184.
97. Mann N, Mullins R, Hedges J, Rowland D, Arthur M, Zechnich A. Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system. Med Care. 2001;39:643–653.
98. Committee on Trauma, American College of Surgeons. Head injury. In: Advanced Trauma Life Support Program for Physicians. 8th ed. Chicago: American College of Surgeons; 2002.
99. Rinker CF, McMurry FG, Groeneweg VR, Bahnson FF, Banks KL, Gannon DM. Emergency craniotomy in a rural Level III trauma center. J Trauma. 1998;44:984–989.
100. Schecter W, Peper E, Tuatoo V. Can general surgery improve the outcome of the head-injury victim in rural America? A review of the experience in American Samoa. Arch Surg. 1985;120:1163–1166.
101. Cohen J, Montero A, Israel Z. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma. 1996;41:120–122.
102. Mangus R, Mann N, Worrall W, Mullins R. Statewide variation in the treatment of patients hospitalized with spleen injury. Arch Surg. 1999;134:1378–1384.
103. Engelhardt S, Hoyt D, Coimbra R, Fortlage D, Holbrook T. The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon? J Trauma. 2001;51:633–637.
104. Richardson J, Miller F. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma. 1992;32:229–233.
105. Gonzalez RP, Cummings GR, Mulekar MS, Harlan SM, Rodning CB. Improving rural emergency medical service response time with global positioning system navigation. J Trauma. 2009;67:899–902.
106. Maniscalco-Theberge M, Elliott D. Virtual reality, robotics, and other wizardry in 21st century trauma care. Surg Clin North Am. 1999;79: 1241–1248.
107. Boulanger B, Kearney P, Ochoa J, Tsuei B, Sands F. Telemedicine: a solution to the follow up of rural trauma patients? J Am Coll Surg. 2001;192:447–452.
108. Kirkpatrick A, Brenneman F, McCallum A, Breeck K, Boulanger B. Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals. J Trauma. 1999;46:1017–1023.
109. Aucar J, Granchi T, Liscum K, Wall M, Mattox K. Is regionalization of trauma care using telemedicine feasible and desirable? Am J Surg. 2000;180:535–539.
110. Rogers F, Ricci M, Shackford S, et al. The use of telemedicine for real time video consultation between trauma center and community hospital in a rural setting improves early trauma care. J Trauma. 2001;51: 1037–1041.
111. Buntic R, Siko P, Buncke G, Ruebeck D, Kind G, Buncke H. Using the internet for rapid exchange of photographs and x-ray images to evaluate potential extremity replantation candidates. J Trauma. 1997;43: 342–344.
112. Hsieh C, Jeng S, Chen C, et al. Teleconsultation with the mobile camera-phone in remote evaluation of replantation potential. J Trauma. 2005;58:1208–1212.
113. Saffle J. Telemedicine for acute burn treatment: the time has come. J Telemed Telecare. 2006;12:1–3.
114. Mahoney D. Telemedicine program serves rural Vermont. Surg News. 2005;1(10):1, 20–21.
115. Latifi R, Hadeed G, Rhee P, et al. Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients. Am J Surg. 2009;198:905–910.
116. Satava R, Bowersox J, Mack M, Krummel T. Robotic surgery. State of the art and future trends. Contemp Surg. 2001;57.
117. Satava R. Emerging technologies for surgery in the 21st century. Arch Surg. 1999;134:1197–1202.
118. Marescaux J, Smith M, Folscher D, Jamali F, Malassagne B, Leroy J. Telerobotic laparoscopic cholecystectomy: initial clinical experience with 25 patients. Ann Surg. 2001;234:1–7.
119. Reichenspurner H, Damiano R, Mack M, et al. Use of the voice-controlled and computer-assisted system ZEUS for endoscopic coronary artery bypass graft. J Thorac Cardiovasc Surg. 1999;118:11–16.
120. Branas C, ReVelle C, MacKenzie E. To the rescue: optimally locating trauma hospitals and helicopters. LDI Issue Brief. 2000;6:1–4.
121. Norwood S, McAuley C, Vallma V, Fernandez L, McLarty J, Goodfried G. Mechanisms and patterns of injuries related to large animals. J Trauma. 2000;48:740–744.