Definitive Trauma Care in Rural Hospitals

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Definitive Trauma Care in Rural Hospitals

• Charles F. Rinker II, MD, FACS
• Bozeman Deaconess Hospital
• Bozeman, Montana

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WHAT IS RURAL?

• Geographic isolation
• Basic medical resources
• Population
• gt50,000 Urban
• 10,00050,000 Large rural
• lt10,000 Small rural
• Thompson MJ, Lynge DC et al. Characterizing the
  general surgery workforce in rural America. Arch
  Surg. 2005 140 74-79

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Small Rural

• Torrington and Wheatland, WY
• 19 bed hospital (critical access) each
• 1 general surgeon/ 1 OR
• Part-time OB
• CRNA
• Family practitioners (do C-sections)
• Denver 200 mi

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Looks rural to me
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Large Rural

• 50K population
• Transition from 1º care to referral center
• Tourism, recreation, farming and ranching
• College town
• Billings150 mi
• Seattle,Denver500m

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Bozeman Deaconess Hospital

• 87 bed hospital
• 4 GS, 8 ORS, 2 ENT, GU, no NS or Cardiac
• 3 GI endoscopy
• 8 bed ICU Cath lab
• Excellent imaging
• Level III Trauma Ctr
• 1st yr med students
• Nursing students

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Options in Trauma Patient Management

• Stabilization and transfer
• Operative stabilization and transfer
• Local definitive care

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Local Definitive Care

• Most trauma can be treated locally (85)
• Local care offers distinct advantages
• Less expensive (usually)
• Convenience for patient/family
• Availability of local support groups, service
  clubs, clergy
• Relieves regional trauma centers of some burden
• Supports local institution(s)

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Downside

• Inexperienced caregivers (low volume issues)
• ? Increased risk of missed injuries
• Limited resources
• Personnel
• Equipment
• ? Delayed response to sudden deterioration
• Bad outcome ? must justify failure to transfer

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Basic Principles

• When in doubttransfer
• Do what is best for the patient
• Be realistic about your ability to treat
• Personal capabilities
• Institutional capabilities
• Understand EMTALA
• Know state statutes/trauma system regulations
• Transfers go upstream, not down

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Case 1

• EMS reports they are transporting an elderly
  patient who hit her head in a fall at church. She
  is unconscious and has a dilated pupil. ETA is 20
  minutes. The nearest neurosurgeon is at the
  regional level II trauma center 120 miles away.

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Case 2

• You are called to the ED to see an elderly
  patient who hit her head in a fall at church. She
  is awake but slightly confused there are no
  other CNS abnormalities. She has a forehead
  laceration and an irregularly irregular pulse.

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Case 3

• A 14 year old boy presents to the ED with LUQ and
  L shoulder pain following a fall from his
  bicycle. CT scan shows a Grade III splenic
  laceration. After 1500 cc LR
• Scenario 1 P 130, BP 80/60, Hct 38, pain
  refractory to morphine
• Scenario 2 P 70, BP 110/70, Hct 44, resting
  comfortably.

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Case 4

• A 27 year old climber fell 75 feet from a rock
  face, landing on his feet two hours before
  arriving in your ED. VS on arrival R 26, P 120,
  BP 90/60. He initially responded to 2L
  crystalloid, but now has a P 115 and BP 80/P.
  Imaging studies demonstrate bilateral calcaneal
  fractures, lumbar compression fractures, a
  ruptured diaphragm, and a grade IV liver
  laceration. A helicopter was dispatched 20
  minutes ago from the Level II trauma center, 175
  miles away.

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Case 5

• A 68 year old was the restrained driver in a
  one-vehicle rollover. He is found to have sternal
  and bilateral rib fractures, a pulmonary
  contusion, and a broken femur. He is
  hypertensive, obese, and a type II diabetic.
  Medications Atenolol, Lisinopril, Metformin.
  Following initial fluids and analgesics, he has
  normal vital signs and GCS.

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