Back to Table of Contents | January 2005

Perspective

Rural Minnesota Needs a Trauma System

The proposed trauma system is a better, and doable, way of caring for injured patients.

By James L. Harris, M.D.

It’s 9 p.m. when a member of an ambulance team calls to inform the ER staff at Riverwood Health Care Center in Aitkin, Minnesota, that they are going out to a car that has been hit by a semi. The Riverwood staff begin to assemble the phone numbers of co-workers who are taking call that evening. Five minutes later, first responders call in: There is one victim, and they’re calling a trauma alert.

Hospital staff are notified. As the ambulance arrives at the scene of the accident, the staff in the ER prepare the trauma bay. Trauma blocks are placed on the cart, and X-ray cassettes and the portable X-ray machine are put into position. Nurses prime the fluid warmer, get IV equipment ready, and make sure rapid sequence intubation (RSI) drugs are readily available. The ER physician checks airway equipment and confirms the ultrasound is functioning. Carts with trauma equipment are wheeled into the trauma bay, and staff review and assign duties.

The EMS team calls to report that they have a 58-year-old female who was unrestrained and rear-ended by a semi traveling at highway speeds. She is alert but complaining of chest and pelvic pain. She is boarded, and her c-spine is immobilized. Her BP is 102/62, pulse is 96, RR-24, and O2 sat 91% on four liters nasal cannula.

Estimated time of arrival: five minutes.

By the time the patient is wheeled into the trauma bay, all staff are present and begin working on the patient. During the first five minutes, IVs are started and blood is drawn off the IV starts and sent to the lab; X-rays of the chest, pelvis, and lateral c-spine are obtained; the patient’s clothing is cut away so the physician can survey the injuries. The patient is alert but perseverating. She has an abrasion on her forehead and a bruise on her chest from where she hit the steering wheel. She complains of pain in her pelvis. Warmed IV fluids are started, and a Foley is put in place while the physician performs a FAST (focused assessment with sonography for trauma) exam of the abdomen, which turns out to be negative. The patient has been in the ER about 20 minutes, and the X-rays and labs have come back. They show a right pneumothorax with a widened mediastinum and a complex pelvic fracture that is unstable. The finding of a widened mediastinum is suggestive of an aortic arch injury. Staff recognize this is an injury that they are not capable of treating at their facility and begin making transfer arrangements.

The helicopter will be at the hospital within 15 minutes.

Meanwhile, the patient’s pelvic fracture is stabilized using a sheet technique. A chest tube is placed and connected to a drainage system with auto-transfusion capabilities. The patient’s respiratory status declines, and RSI is performed. Despite the IV fluids, her hypotension worsens and transfusion with PRBCs is initiated. An oral gastric tube is placed by nursing. Ongoing sedation, pain control, and paralysis are also addressed. It has been 45 minutes since the patient’s arrival, and her respiratory status and blood pressure have improved. Her other vital signs are holding steady.

The helicopter is at the hospital, and the physician has talked with the receiving physician at the Level I trauma center where the patient will be transported. Copies of labs and X-rays are sent with the patient.

Although the patient in the above case is fictional, the care that she would have received at Riverwood is not. In fact, the patient’s care is much like that which she would have received in the first hour at a large metro trauma center.

Emergency rooms in rural Minnesota see many of the same types of trauma cases that Level I or II trauma centers in large cities see. Patients presenting in rural emergency rooms are no less ill and require the same type of initial interventions and resuscitation as patients in their metro counterparts—they just arrive less frequently.

But colleagues have told me that people living or traveling in rural Minnesota should not expect to receive state-of-the-art trauma care. They point out that you can’t expect to see a Broadway production of Cats, eat at Ruth’s Chris Steakhouse, or shop at Neiman Marcus in a town of 2,000 people in the middle of nowhere. And they ask, So why would you expect the quality of trauma care to be on par with that offered in the city?

I answer, Why not? I’ve seen it done at several rural hospitals around the state. But having the capability to provide this kind of care requires making trauma a priority.

And ensuring that this kind of care is available around the state will require upgrading the standard equipment and training of staff at small rural hospitals, defining patient transfer pathways, including backups, and establishing a process of ongoing feedback for performance improvement. It requires a well-planned statewide trauma system.

We know from experience what is possible when systems are streamlined. Only three years ago, it was commonly believed that primary angioplasty for STEMI in hospitals without cath labs was impossible. Today in greater Minnesota these patients regularly receive rapid evaluation, initial resuscitation, and preliminary treatment before they are transferred to larger hospitals. What made this possible? A well-organized, efficient system that links sending and receiving hospitals with transfer organizations. There is similar potential for trauma.

So when the staff at Riverwood learned that a plan for a statewide trauma system was in the works, we were excited to participate in the pilot program. We implemented the trauma center criteria as outlined in the proposed statewide trauma plan. (To learn more about the plan, see “Raising the Bar for Trauma Care in Minnesota,” p. 36.) This entailed creating a trauma program with a medical director and a program manager, reviewing and revising policies, reviewing capabilities throughout the hospital, developing transfer agreements with other hospitals, enhancing our trauma performance improvement program, and getting the state trauma registry up and running at our facility. We also tracked the expenses associated with these activities to help the Minnesota Department of Health estimate the cost of implementing the system statewide.

The Unique Needs of Rural Hospitals

The state’s small rural hospitals would play an important role in a statewide trauma system. In the first place, not all trauma patients require Level I or Level II care. Some need only initial evaluation and resuscitation. However, determining when a patient needs to be treated at a Level I or Level II facility is an essential first step in the process. Sometimes the decision to transport a patient to a trauma center that provides higher levels of care can be made at the scene of an accident or injury. But often it requires rapid assessment by ER personnel. Emergency staff at rural hospitals need to be trained to make these initial decisions and take these first life-saving measures.

Early activation of the system, which involves notification of hospital staff that an injury has occurred, is critical in rural settings. Many rural ERs are staffed with a single R.N. (there may be only two or three nurses in an entire hospital), and X-ray, respiratory therapy, and lab staff may take call from home in the evenings. Early notification would give staff time to arrive at the hospital if they are not already there, prepare equipment, anticipate procedures, review or assign roles for team members, and even anticipate the need for transport. Early notification can make the difference between having a well-organized team of four or five people who understand their roles and have organized the equipment versus having a single nurse and a single physician with no equipment ready. Implementing this portion of the trauma system only requires providing clear guidelines and empowering the right people to make these calls.

Requiring rural hospitals to meet basic training and equipment standards will remove the temptation to cut corners in these critical areas. It will provide a common language so that ER staff can more easily communicate with staff at metro trauma centers about transfers. And it will enable the state’s small rural hospitals to serve as a safety net for urban trauma centers overwhelmed by a mass casualty incident or as the site of care for patients who cannot be immediately transferred to a trauma center.

In traveling the northern half of the state as a Comprehensive Advanced Life Support instructor, I have found that the majority of hospitals already have most of the equipment required for Level IV certification as it is outlined in the proposed state trauma plan. I’ve been impressed by the creativity that has allowed these hospitals to obtain this type of equipment. For example, I’ve seen the cost of a fluid warmer shared by departments throughout a hospital. A fluid warmer can be used intraoperatively for surgical patients, on the nursing floor or in the outpatient area for patients receiving blood transfusions, and in the ER for trauma and hypothermia patients. In a smaller hospital, none of these uses alone would justify the expense.

A Sensible Investment

Until we participated in the pilot for the statewide trauma system, we had not formally defined what kind of injuries were beyond the scope of Riverwood Health Care Center. We found it very helpful to identify the kind of injuries our hospital could handle and the ones that exceeded our capabilities. For example, we realized that certain injuries could be handled in the ER and were within the capabilities of our surgeons, but limited availability of blood products made it unwise for us to keep patients with these injuries. Until we participated in the pilot program, we were making decisions about which injuries required transfer on the fly—while the patient was in the ER. Now support staff can start working on a transfer as soon as the injury is diagnosed without having to be specifically told to do so. This saves critical time.

Implementation of a statewide trauma system will allow hospitals such as ours to learn from each other, as good trauma care requires cooperation, not competition. As outlined in the state’s proposal, hospitals will submit trauma registry data to the Minnesota Department of Health. Hospitals will be able to use the aggregate data to compare how their procedures, staffing, and outcomes stack up against those of similar-sized facilities. Feedback on trauma patients will be especially valuable for rural hospitals, which at present, have no way of knowing how they compare with hospitals elsewhere in greater Minnesota.

Trauma is predictable. It happens daily in both urban and rural areas. What is needed is a predictable, systematic approach to managing these patients. A statewide trauma system—much like the ones that are in place in 41 other states—would provide the framework needed to achieve this goal. We found implementing the requirements of the proposed system to be very achievable at our small facility. We know others can do the same and experience the same kind of benefits in terms of coordination and care that we have experienced. A statewide trauma system would improve the quality of care trauma patients receive, regardless of where they live. It is time for Minnesota, a leader in so many other health measures, to catch up with the rest of the nation in terms of trauma care. MM

James Harris is the emergency room medical director at Riverwood Health Care Center in Aitkin, Minnesota.