Wednesday, October 03, 2007

Don't Crash Your Car Outside a Big City

Big surprise. People think that this is due to lack of funding and certainly when we give stuff away for free money becomes a scarce. Wow. The reality also is, as we have stated here, that specialty surgeons (and trauma surgeons in particular) are in short supply. Besides that, due to the litigation climate and the demands on their time they would face being the one or two guys in town that do trauma, they absolutely do not want to practice in rural areas. Sometimes the best they can do outside a trauma center will not keep them out of court. Result? They leave for the big city. Go figure. Article citation below...

Transfer of trauma patients to appropriate emergency care often falls short.

The Wall Street Journal (10/3, D1, Landro) reports on a dangerous gap in emergency care, the lack of resources to transfer patients to the hospital best equipped to deal with them. Noting that "[t]rauma from injuries including accidents, falls, and violence is the leading cause of death for Americans under the age of 44, claiming more than 140,000 lives and permanently disabling 80,000 people annually," the Journal finds that "only one in four lives in an area served by a coordinated system to transfer patients to designated trauma centers from less-equipped hospitals, according to the American College of Surgeons, which sets standards for trauma care." And, "only eight state trauma systems met nationally recommended preparedness levels in a study by the federal government after the Sept. 11, 2001, terrorist attacks." The Journal adds that "[w]hile some progress has been made, many states remain woefully unprepared, trauma experts say." Furthermore, although "[e]fforts are under way to develop a national trauma system to ensure referral of severe injuries to qualified centers...funding is tight," with "the federal government...provid[ing] only about $34.1 million to help develop statewide trauma systems." In addition, the areas at "highest risk are...rural areas, where nearly 60% of trauma deaths occur even though such areas account for only 20% of the population."


  1. I guess it all depends on what your specific hospital is capable of treating. As I said in a previous post on another topic, I had a 74 yo male who fell off his bike and had 7 rib fx's, a pneumo, and a grade IV splenic lac.

    My hospital is a level III trauma center, but we have neurosurg/CT surg capabilities and function as a much larger hospital than we actually are. We've sent people with leaking aortas from blunt trauma straight to our OR with the CT surgeons rather than fly them out to the larger, level I center down the road because we can handle that, although granted, there are a fair amount of level III's that don't offer CT or neurosurg.

    I guess moral of the story is that not all trauma centers are created equal, even those within the same level of designation, and your real bellwether of care you'll receive is what the hospital can offer and what they can't.

  2. brian and jennifer.

    i can't argue with you but what i will say is that, just for example, i staff an ED in a town of about 350k. we have one hospital and no trauma designation. we have no trauma surgeons. we have no surgeons that will do trauma. the referral trauma center is so overwhelmed that we are getting blocked on some level 1 traumas now. the state has disallowed our EMS protocols that provide for direct transport to the trauma center from the scene. our state has lost two trauma centers in the past 5 years and now we have 4. not only can we not recruit a trauma surgeon, if we could, we would be unable to staff the OR accordingly nor could we handle the post op and rehab. town of 350k and growing and no plans for trauma.

    i know from friends across the country in the biz that they face similar problems.

    finally, if i'm a med student now, why in the world would i choose to go through the pain of a surgical residency and fellowship only to face a whole bunch of question marks 8 years down the road?

    derm for me baby!


  3. Well, it's pretty well known that statistically speaking, you're less likely to survive a crash on a rural road than in an urban area.

    While lack of rapid access to trauma care certainly contributes to this, there are other factors as well.

    On freeways and four-lanes, the traffic is at least moving in the same direction. On rural two-lanes there are bazillions of opportunities for someone to cross the center line, pull out into oncoming traffic to pass a slow vehicle, and so on. Lower traffic volumes can make people more complacent and less attentive about their driving. Plus many rural residents tend to treat the highway like their neighborhood street (well, it *is* their neighborhood street) and they'll casually pull into traffic or blow through a stop sign with tragic results.

    I don't know if this has ever been tracked or studied, but I wonder if a higher proportion of rural crash victims are killed outright and thus the question of access to trauma care is completely moot? I can think of triple and even quadruple fatals in my own county in just the past two years, in which all (or in some cases all but one) of the victims were dead at the scene.

    I can't cite statistics, but I wonder if rural residents are less likely to wear seat belts? Or more likely to drink and drive, especially if they are young adults? Or drive older cars that don't have airbags or aren't engineered as safely as many of the newer models? The biggest demographic for fatalities, btw, is young adult males who drive pickup trucks.

    Access to trauma care is just one piece of the puzzle here.

    But you're right, the level of care is very uneven, and many states aren't bothering to step up to the plate with a more coordinated, systematic approach.

  4. restricted access to trauma care in many areas is a terrible problem. I guess the question with regards to access is do we expand existing trauma centers and increase the transport system using the mentioned federal funding, or do we do more to lure trauma specialists to rural areas, which are not only lacking trauma physicians, but specialty doctors as well?

  5. 911,

    What exactly does "getting blocked" mean? does this put you in the position of being the trauma surgeon? And if so, what is your liability if you are forced to handle a case that should go to a trauma surgeon? You mentioned that your town has no surgeons who will do trauma....does this mean they respond to some calls but not others? How often does this kind of thing come up?

    Feel free to ignore any/all of this annoying list of questions.

  6. no,

    it's a great question. getting blocked means that i call the trauma center and based on my story or the patient's injuries they refuse transfer. my liability is not a concern because if i discharge my responsibilities according to the standard of care with my training i should not be liable for negligence. different story for a non trauma surgeon who does me a favor.

    the strategy at this point is evolving for me. there is one surgeon who is relatively new here that will help out in the stable patients who need observation for ruling out occult blunt abdominal trauma, but other than that i have been forced to rule these folks out here without the aid of a surgeon or observation unit.

    so far this has worked out okay but soon, here, someone will die because we have been refused transport intitially so proceed with the full workup including CT scanning from stem to stern. one day, and you will see this yourself, someone who comes in 'stable' from their MVA will pop the hematoma surrounding their spleen or liver and crash in the CT scanner. then the patient and i are up shit creek and then the trauma center will probably refuse because the patient is now 'unstable' and my surgeon will also be behind the 8 ball as he will be forced by law at that point to take the person to the OR where they will die.

    the reason they will die is that, especially at night, we do not have two surgeons on and packing the liver, getting exposure of injured abdominal organs etc... needs two surgeons and at least one who is familiar with the trauma procedure.

    so, many of us here have refused to start the scan workup and instead called for helicopter transport immediately emphasizing to the trauma center that this patient is beyond our capabilities to take care of. this usually works but from time to time the helicopter, staffed by trauma flight nurses who can do much life saving interventions, can't flie due to weather or mech. difficulties, or is 50 miles away on another call.

    obviously, at this point, putting him in a ambulance with one medic is a scary proposition, especially for the medic in the back.

    the only time i have to play trauma surgeon is for ER thoracotomies which are rare, done only with penetrating chest trauma with vitals lost at the door or on the bed and it almost never works.

    i am not busting on our trauma center. they are fantastic. they are, however, as of last week, taking care of over 90 trauma inpatients. there is a limit to what they can accept and, especially in the summer, they reach their limit.

    so, when they are full and their ORs are full, what the hell are they supposed to do?

    realize, trauma surgery is it's own subspecialty and there is trauma everywhere that there are people. centralization of any process or service is a great way to decrease efficiency whether we are talking about government or trauma care.

    again, because of the legal climate and because, after their killer training, trauma surgeons too want to have a life outside the hospital. if you sign on here as a trauma surgeon, and you are the only one, or even one of two, you will never sleep interupted, ever. or, if you can take call one out of 4 nights you are essentially only doing a little better than you have done in residency. the only solution for us is to get a trauma group in here and build the ORs to handle the trauma. there are no plans to do this and this is mostly a money issue.

    trauma used to pay, but it is a money loser now for reasons that are legion. again, to beat an almost dead horse, if these super specialists coming out of hell training are not rewarded then why do it in the first place and why go to a place where your life will continue to suck? better to go to a large trauma center and be on call once every two weeks and have residents do most of your work.

    this thing comes up often. tonight in fact. probably 5 times a week as people in our town like to drink and drive fast and the meth and crack folks tend to arm themselves with deadly weapons. my two cents.

  7. About 4 years ago, I worked at a rural hospital which had an excellent trauma program. The program was hemorrhaging money due to the low percentage of reimbursement in these patients.

    The hospital hadn't expected to make money on trauma, but had established the program in hopes of luring other transfers to the institution (such as cardiac patients with a relatively high percentage of paying patients). They made no secret of this intent to the referring hospitals in the area.

    The referring hospitals were happy to send us the trauma, but continued to send paying patients elsewhere. After 3 years, the trauma program had lost a bucket full of cash and was cancelled.

    Within two months of it's cancellation, I had two trauma patients die in my care (along with an inexperienced and frankly incompetant surgeon) while I was trying to transfer them. Neither should have died nor do I think would have died if I had the competant backup that I had enjoyed before.

    In both cases, all 3 trauma centers within 200 miles of me refused the transfers based on a lack of bed availability. One patient bled to death from a pelvic and bilateral femur fractures, the other bled to death from a splenic laceration.

    Few people understand how difficult it is to give 100% critical care to ONE patient whilest talking on the phone to multiple hospitals begging someone to accept a transfer, waiting for return calls, being placed on hold, being asked irrelevant questions, etc, etc. All the while, your department goes to hell as the other patients back up and start bitching.

    That was when I began to look for a new job!