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 the most remote, have utilized to provide optimal trauma care and effective EMS within their environmental constraints. Trauma care is a time-dependent disease. The key and immediate determinant in trauma care is place of injury, where the risk survival clock starts (Fig. 9-1). Our ability to mitigate the risk of death (and many disabilities) depends on the Trauma/EMS System in place the day before that injury. R. Adams Cowley remarked, “It matters more where you are injured in Maryland than how you were injured.”²¹ Improving trauma care is a function of diminishing time utilization over irreducible distance (T/D) factors (Fig. 9-2). These post-injury risk factors are universal but progressively detrimental in rural areas with greater T/D constraints to definitive advanced care in a designated trauma center (TC).

The Federal Trauma/EMSS program utilized “rural” as a descriptor of a regional trauma care capacity. In short, each Rural Trauma/EMSS region represented a marketing area for advanced clinical care. These Trauma/EMSS regions are complementary with other economic and medical distribution patterns. In these rural regions there are gradations in social, economic, and medical care capacity diminishing with distance from population centers. Rural populations concentrate near economic potential and where advanced medical care capacity exists. Rural cities, towns, and hamlets are not randomly distributed, but have arranged themselves differently in two recognizable patterns of populations and social and economic conditions. For rural trauma it is useful to consider two distinct regional subsets of a moderate and ultrarural Trauma/EMSS. These are described by recognizable socio-geographic conditions and are classified as distinct regional groupings; that is, rural-metropolitan and rural-wilderness (with wilderness described as an area with one or less human inhabitants per square mile).^{22, 23}

Understanding the inherent dissimilarity in the capacities and time/distance (T/D) factors of these two rural categories is basic to developing effective Trauma/EMSS programs. These include patient access, prehospital response, emergency medical care services, education and training, trauma center networks, systems evaluation and research. Many of the published reports on rural trauma do not describe nor account for these differences.

The vast underpopulated rural areas contribute enormously to the well-being of the national community. These areas support agriculture, basic extractive industries, recreation and maintain the major conduits of commerce on roads, highways, and railroads. These activities produce injuries, many times beyond the capacity of local resources. Over the past 50 years significant improvements have been made in rural trauma care by developing effective large area Regional Trauma/EMSS systems.^22,23 These systems organize essential resources, upgrade operative components and devise new technologies compatible with rural capacities. The process is called, “A systems approach to the care of the trauma patient.”²³ The first step in this process is to understand and overcome the geographic constraints in each rural area.

Rural trauma is best understood by a wide-angle approach. The integration of resources, motivation of participants and practical solutions are obtainable in rural communities. Decision makers can evaluate and accept a sound proposal to change and improve their “system” more readily than urbanites. Three features important to understanding Rural Trauma/EMSS development are the following: (1) the power of a respected general surgeon leader, (2) the community wisdom and acceptance of practical and sustainable initiatives, and (3) the willingness of communities to work with government agencies at all levels. These rural regions provide real-time laboratories where medical-surgical technologies proven in high resource centers, specialty care trauma units and the battlefield might be transferred to outlying rural trauma centers, etc. Similar rural socio-geographic regions can be quantitatively analyzed and qualitatively compared and should inspire a new field of trauma research.

Rural spaces are sparsely populated and support only one-third as many physicians as do urban areas.²⁴ Specialists and, sometimes, even primary care physicians cannot make a living in communities under a certain population threshold. Lack of physicians skilled in rapid assessment and treatment of the critically injured has a significant effect on outcomes. Conversely, the number of physicians in a given county, and particularly emergency physicians who have taken the Advanced Trauma Life Support (ATLS) course, is associated with lower death rates from trauma.²⁵

An urban area consists of a central city and its environs with a combined population of greater than 50,000 and a population density of 1000 or more per square mile. As far as the US Bureau of the Census is concerned, everything else is rural. Not all rural environments, however, support farming, and many are surprisingly close to cities, but separated by geographic barriers such as mountains or large bodies of water. Residents of coastal Marin County, only a few miles north of San Francisco, may have difficulty accessing a trauma center because of intervening steep mountains, narrow roads, and local regulations prohibiting noisy and disruptive helicopters. San Diego County, home of a model trauma system, has reported morbidity and mortality from delayed discovery of victims of motor vehicle crashes on remote county roads.²⁶ North Carolina is the 10th most populous state, but 29 counties in the eastern part of the state are served by a single trauma center, 12 counties have no general surgeon, 17 no orthopedic surgeon, and 23 no neurosurgeon. In only 14 of these counties can a victim of trauma reach an emergency department staffed with emergency physicians in less than 30 minutes.²⁵

Hypothermia is an independent predictor of mortality in injured patients, with mortality rising as core temperature falls. Urban trauma centers, with more rapid discovery and transport times than rural prehospital systems, have reported a 5% incidence of trauma patients with low core temperatures.²⁷ A level I trauma center in North Carolina serving 29 mostly rural counties and a combined population of 1.4 million reported transport times averaging 1 hour and time from injury to definitive care of 4 hours. Their trauma registry identified 1490 of 9482 (16%) patients suffering from hypothermia (<36°C) on arrival. These hypothermic patients had a 14.6% mortality rate, compared with 4.5% among normothermic patients.²⁸ Virtually all regions of our country have many areas that are sparsely populated and relatively poor in resources. In the central and northern plains, one sees the combination of few people and great distances from urban centers as nowhere else in the lower 48 states. Alaska, of course, along with some portions of the northern Rocky Mountains, is more accurately described as a frontier area (six or fewer people per square mile).

The state of Western Australia forms the western third of that country, with an area of 2.5 million km², and a population density of 0.8 people/km². Because of a lack of doctors and hospitals, some trauma patients may be transported in excess of 2000 km over more than 24 hours to receive initial care. Investigators there developed an Accessibility/Remoteness Index of Australia (ARIA+) to reflect the ease or difficulty people face accessing services in nonmetropolitan areas of the country. The index is a continuous variable with values ranging from 0 (high accessibility) to 15 (high remoteness). Employing ARIA+, with Perth (the most isolated capital city in the world) as the reference point, they demonstrated that the remote rural trauma death rate is over four times the rate in major cities.^29,30

Rural, then, may be defined in accordance with census data based on metropolitan statistical areas, in terms of geography and distance, or by virtue of limited resources. In an analysis of the general surgery workforce, Thompson et al³¹ identified significant differences between communities with a population between 10,000 and 50,000 (large rural) and those with 2500–10,000 residents (small, or isolated rural). Large rural towns are far more likely to have the necessary resources such as general surgery, medical and surgical subspecialties, advanced life support (ALS) ambulance services, and essential equipment to provide prompt and sophisticated trauma care.

Environmental factors are also important as “rural trauma occurs in areas where geography, population density, weather, distance, or availability of professional and institutional resources combine to isolate the patient in an environment where access to definitive care is limited.”³² An alternate, somewhat more precise definition has been proposed as follows: “… A rural trauma region would be an area in which the population served is fewer than 2500, has a population density of fewer than 50 persons per square mile, has only basic life support prehospital care, has prehospital transport times that exceed 30 minutes on average, and is lacking in subspecialty coverage for specific injuries (such as a neurosurgeon to manage the patient with head injuries).”²⁴ In any event, though we may think we know it when we see it, it is apparent that “rural” is difficult to define.

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.”^24,33 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.³⁴ The relative risk of a rural victim dying in a motor vehicle crash is 15:1 compared with a victim of an urban crash,³⁵ and death from motor vehicle crashes is inversely related to population density.³⁶ 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.^37,38 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.^39,40 Finally, autopsy studies have suggested preventable trauma death rates of 20–30% in rural populations.^41,42,43,44 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 1.52.⁴⁵ Poor functional outcomes have been documented in patients with traumatic brain injury sustained in rural versus urban locales, also. What are the reasons for these differences?⁴⁶

In this chapter an attempt is made 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 more than 5 mm shift. No other injuries were identified. Following consultation with a neurosurgeon at the nearest level II center (150 air miles away), a general surgeon trained in emergency limited craniotomy (and following established local protocols) drilled a burr hole and enlarged it sufficiently to permit evacuation of the clot and to control the hemorrhage. The patient was transferred directly from the operating room to a helicopter, which flew him to the neurosurgeon for a formal craniotomy. He survived with a Glasgow Outcome Score of 4 and is now independent, although no longer able to function in his former capacity.

This true scenario could have any of the following plausible variables: unaccompanied victim hours or days to discovery, less accessible to rescuers, greater distance to hospital, lack of trauma team and trained surgeon, or adverse weather preventing air transport to level II trauma center. He might have been a hunter injured by firearm or animal, a backcountry skier caught in an avalanche, a rancher thrown from a horse, or the driver of a car on a remote rural road.

Remoteness, open farmlands, rugged beauty, and “nature” are powerful magnets for tourists, recreationists, and those seeking a quieter, less stressful lifestyle. Such visitors are often shocked to discover that medical services they take for granted at home are simply unavailable in a rural setting. In contrast, local residents tend to be independent, fatalistic and accepting of limitations, suspicious of outsiders, resistant to both change and regulations (helmet and seatbelt laws; gun control), and unaware of trauma as a public health problem because, in their limited experience, it is a rare event.^24,47

There are reasons why few people live in rural locations. The climate may be harsh, the terrain rugged and remote from services, the roads badly engineered and maintained, communications rudimentary, and the economy marginal. Career opportunities for the young are limited, so the young leave. As a result, significant segments of the population are elderly, poor, poorly educated, and in ill health. Population density (low) and personal income (also low) are the strongest predictors of per capita trauma death rates.²⁵ Nearly one-fourth of adults in this environment sustain some form of unintentional injury per year. The injuries are usually relatively minor, but they can be major and/or fatal. Binge drinking and depression are strongly associated comorbid factors, and suicide accounts for 10% of all rural trauma deaths.^24,48 Elderly rural patients tend to start out with a lower Injury Severity Score (ISS) and are less likely to die at the scene, but have higher complication rates and worse overall survival for comparable severity of injury. Based on data from the Major Trauma Outcome Study (MTOS), rural geriatric trauma patients fare less well than do those in an urban cohort.⁴⁹ In addition, older age and lower population density independently increase vehicle-related mortality.⁵⁰ A study by Wigglesworth⁵¹ compared two groups of five states each with the highest (group 1) and lowest (group 2) traffic death rates, respectively. Epidemiologic data from the Centers for Disease Control and Prevention (CDC) indicated that the fatality rates for falls, poisoning, drowning, fire, suffocation, homicide, and suicide conformed closely to the traffic death rates in the two groups of states. Group 1 states were rural, western, and below national averages for per capita income; group 2 states were urban, eastern, and financially well-off.⁵⁰ Overall, 60–70% of all trauma deaths occur in rural areas despite the fact that only 20–30% of the nation’s population lives in these areas.⁵²

Unintentional blunt injury comprises about 90% of cases, largely because of the prevalence of motor vehicle crashes and the paucity of injuries from firearms. The most common causes of fatal injury are motor vehicle crashes, suicide, homicide, and falls. For these and the next 10 most frequent causes, rural death rates exceed urban rates for all but poisonings. Some of the most hazardous occupations such as mining, logging, and farming are almost exclusively rural by their very nature.⁵³ Large animal injuries may occur on a farm or ranch in the course of daily work or in conjunction with such recreational pursuits as hunting, pleasure riding, or rodeo. Typical injuries are falls (horses), tramplings and gorings (bulls, wild game), and kicks (cows).⁵⁴ Travel on rural highways entails the additional hazard of motor vehicle crashes with wild animals (elk, deer, bear, or moose). As a mature moose weighs half a ton or more, a driver unfortunate enough to strike one risks significant injury to the brain or death.⁵⁵ Fatal accidents are significantly higher for loggers (140/100,000) than they are for workers in other industries (94/100,000), and are typically the result of being struck by falling trees, limbs, or snags. Crush injury between moving logs and encounters with heavy equipment are other common mechanisms, and access to care is often a problem.⁵⁶ Recreation provides endless opportunities for serious injury and death, also. Particularly dangerous are four-wheeled all-terrain vehicles (ATVs). In 2004, ATV crashes were shown to result in more than 136,000 injuries and 500 deaths and one-third of the deaths were in children. In Oregon, the rate of such injuries and deaths doubled between 2002 and 2005.⁵⁷ Small community hospitals bear the brunt of these misadventures, particularly when situated in proximity to ski hills, wilderness areas, national parks, and seashores or lakefronts.

Most people feel safe in rural setting as the risk of violent assault and penetrating trauma is very low as noted above. The low homicide rates, however, are negated by high suicide rates, particularly among adolescents and young adults.^58,59,60 Blunt trauma comprises 95% or more of the trauma case load at most rural community hospitals, 85% of which is minor or moderate (ISS <10) and can be treated without the need for transfer to a trauma center. Blunt trauma is less time dependent, which is fortunate since it is far more difficult to mount a rapid response in a small community hospital. It can be subtle, however, requiring experience and a high index of suspicion to avoid missed injuries.⁶¹ Although motor vehicle crashes cause the greatest number of trauma deaths in this country and in the rest of the world, they are sporadic events in small towns and the countryside.

In essence, the greatest problems confronting rural trauma care are access to the system and lack of resources. The challenge is to devise a system, ensure access, and make the most of limited resources.

Population Shifts

Population shifts in the coming years will have an impact on the problems of rural trauma. Although many parts of the Great Plains are becoming progressively depopulated, rural areas of the coastal regions, Rocky Mountains, Southwest, and Sunbelt states are experiencing an influx of young, active people who are tired of city life and eager for what small town America has to offer. Equipped with cell phones, modems, GPS-based equipment, and sport utility vehicles, these members of generations X and Y/Millennials (and their Baby Boom parents) are very much into hiking, camping, climbing, skiing, and other activities that are best pursued in rural and frontier settings. They are affluent and well-educated and accustomed to getting what they want. It is likely that, in order to support their desired lifestyles, they will expect or demand a trauma infrastructure that is sophisticated, efficient, effective, and comparable to what is available in a resource-rich environment. Whether they will be willing to pay for it through taxes or user fees is another matter. An important mission for rural systems will be convincing constituents of the importance of financial support for trauma activities.

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.

Transport

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.

Communications

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.