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.1,47,62,63,64 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.65 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.24 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.
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.66 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.67 Specific trauma training (ie, 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 has been clarified by the publication of a scope of practice document.68 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.69,70
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 often measured in hours, not minutes.
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.61 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.24 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.71 Multiple incidents or victims can easily overwhelm the rural transport system.
Aeromedical and ground transport systems that furnish critical care are becoming more common; however, their availability lags behind in many rural areas.72 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.
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.73 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.74 Interestingly, one large study identified that helicopter transports trauma patients in rural environments were associated with higher mortality and shorter distances than ground transports when stratified by ISS.75 Such results suggest, however, that patients transported by helicopter were more physiologically unstable. A similar study with patients stratified by Revised Trauma Scores or the Trauma Score—Injury Severity Score (TRISS), which incorporate physiologic assessments, would be enlightening.
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. If not, surface transport is preferable.76 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),77 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.78 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 22–30.77
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.73,77 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.79 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.
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.
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 9-1-1 (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. Cell phones and several easily accessible websites now have the ability to identify their longitude and latitude, and GPS capabilities are available globally through the use of satellite technology.
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.80 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.65
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.81 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.
Rural Health Care Facilities
Physicians who practice in rural areas likely grew up in a small town, were influenced by a mentor, or have an independent streak.82 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.83 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.84
Rural surgeons, more so than their urban counterparts, have traditionally viewed trauma care as an integral part of their service to their communities.85 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.86,87 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.88
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.89
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.
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.
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.90,91,92 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.93 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 (RTTDC) 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.94 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. Nevertheless, data has now been published indicating that use of the RTTDC significantly improves the efficiency of trauma care in small rural facilities.95,96 In addition, due to concerns over potential penalties for “dumping” trauma uninsured trauma patients to trauma centers, the Emergency Medical Treatment and Active Labor Act (EMTALA) may have the unintended consequence of discouraging efficient transfers within a trauma system.
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.
Education and Maintenance of Skills
Severe trauma represents 5% or less of the workload of most rural general surgeons.33,83,92 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.26,41,44,47,64 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.24,25,62,96,97,98,99,100 On the other hand, there are reports of frequent departures from ATLS guidelines, with resultant delays in transport to the centrally located level I trauma center, often because ATLS is not mandated for emergency room staff.101,102,103
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.
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.104 Satellite uplinks on emergency vehicles and appropriate audiovisual equipment (including video captured on cell phones) 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.105,106 Laptops and landlines have been used to transmit real-time images of trauma resuscitations at remote rural hospitals. Cases have been described in which the trauma surgeon talked a local doctor through a lifesaving cricothyroidotomy in a patient with an injury to the brain, or, in another, recommended a diagnostic peritoneal lavage that was positive and led to local laparotomy for control of abdominal hemorrhage prior to transfer.107 The Internet and cell phones have been used to transfer images to aid in assessing candidates for replantation of an extremity.108 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 1.544 (original T1) to 400.352 Mbps (at fifth level) to broadband fiber-optic lines at 1000 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.109
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 examination, 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.110 Adaptation of similar technology to prehospital care is also growing in use.111 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.112
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 milliseconds. Communications satellites, by comparison, have a latent period of 1.5 seconds.113 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.114,115 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.116 At the moment, the acquisition cost of one of these robotic systems is approximately $1 million.
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.41,44,49,71,92,117,118,119,120 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.97,121,122,123,124 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.89 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.121,125
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.32) 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.90 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.120 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.33,92,126 It is expected to provide full-time emergency medicine, general surgeons, orthopedic surgeons, and operating room availability. Size will vary from about 40–150 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.101 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 counterpart.122,123
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.64,90,92 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.127 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.