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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.1013

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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

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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 ...

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