Chapter 9: Rural Trauma

HISTORICAL PERSPECTIVE

Trauma care in rural America and public awareness of it has improved remarkably over the past 50 years. This is a tribute to those farsighted surgeons who coauthored the landmark publication “Accidental death and disability: the neglected disease of modern society” (National Academy of Sciences/National Research Council or NAS/NRC) in 1966.¹ This pamphlet detailed the nation’s many deficiencies in trauma care, especially those in rural communities. In addition, recommendations were made that stimulated interest within the public, professional, and governmental sectors to develop essential building blocks (eg, trauma units, surgical training, improved prehospital equipment, trained personnel, and trauma registries). During that same “watershed” year, two Chicago orthopedic surgeons, Deke Farrington and Sam Banks, developed the curriculum for the Emergency Medical Technician-Ambulance (EMT-A).² The Department of Transportation subsequently established the National Highway Traffic Safety Administration that set many of the early standards and provided funding for EMT-A’s, ambulances and communications.³ Two other Chicago general surgeons, Robert J. Baker and Robert J. Freeark, established the first civilian trauma unit at the Cook County Hospital.⁴ As a resident surgeon at Cook County Hospital, the senior author developed the first trauma registry under a NIH grant.⁵

At Illinois Governor Richard B. Ogilvie’s request, the senior author wrote a plan for a statewide system of selectively designated trauma centers and a supporting Emergency Medical Services System (Trauma/EMSS).^6,7,8 This Trauma/EMSS program would demonstrate the organizational principles of involving local surgeons to improve trauma care for their respective rural areas. The Illinois Trauma/EMSS program became the model for Congressional action and passage of Emergency Medicine Service Systems (EMSS) legislation in 1973 (amended in 1976 and 1979).⁹ This legislation provided the following: grant funds for Regional Trauma/EMSS; a lead agency in each state health authority; technical assistance (TA); special training and research; the organization of specific clinical systems and operating components for a Trauma/EMSS system.^10,11 Organization of trauma centers would become the primary task followed by developing the essential prehospital services. The success and acceptance of the Illinois “downstate” trauma regionalization program would lead to the federal emphasis on Rural Trauma/EMSS development.^{12,13,14,15,16,17,18,19,20}

The Illinois Trauma/EMSS program was designed to incorporate the “accidental death” recommendations into on unified “system” and to deploy these on a “regional” basis covering every part of the state. The regional differences within the state initiated a mental framework around the concept of flexible “technology transfer” of systems concepts, plans and operations and would become the test of future “innovations” in Rural Trauma/EMSS.

There are obvious differences between urban and suburban areas when compared to rural and, especially, extremely remote rural communities. The goal of this chapter is to describe some of the relevant differences and the intelligent “systems” adaptations that many rural communities, even ...