Rural Trauma Victims Dying of the 'Golden' Rule

After an accident on Highway 111, near Biddeford, Maine
Photo: phooper [1]

The "golden hour" -- medically speaking "“ is the brief span of time just after a serious injury; survival usually depends on whether someone receives skilled critical care in those first 60 minutes. The Center for Excellence in Rural Safety reports that for motor vehicle injuries, there's even less "golden" time to spare [2]. "Crash victims are five to seven times more likely to die if arrival to a hospital exceeds 30 minutes."

But for many rural residents, and travelers injured in the countryside, trauma care isn't available within a "golden hour." A study of auto fatalities in Washington State [3], for example, comparing rural and urban trauma cases, found the "death rate in rural settings was three times that of the urban areas." And the number of "preventable deaths" was twice as high for rural accident victims. The same study found that it took six times longer for accident victims in rural areas to see a doctor and twice as long for them to reach a hospital.

At a meeting on rural trauma care [4] last month in Terre Haute, Indiana, Dr. Kayur V. Patel explained that, "If better first-hour care were provided, as many as 25 percent of deaths from serious injuries in the United States could (be) prevented."

So how can sparsely populated places, without a large hospital nearby, hope to deliver prompt trauma care? Dr. Erik Steele, a physician in Bangor, Maine, tells how Maine is making progress [5]. His excellent piece for the Bangor Daily News describes the predicament that rural Mainers and their doctors were in not so long ago, when turf battles, inefficient transport, and sluggish hospital admissions too often delayed patient care. Steele writes that conditions and results, too, have changed, since "EMTs, state government emergency medical system leaders, nurses, hospital leaders and physicians,... put their parochial interests aside and did the grinding work of building a trauma system for the people who live in, and visit, Maine." The state now has a helicopter system to transport accident victims and three trauma centers "“ in Lewiston [6], in Portland [7], and in Dr. Steele's own Bangor. [8]

[8]

"It is about all levels of the chain of survival" Steele writes, "from small hospitals to large, from local EMS crews to LOM (LifeFlight of Maine) crews, all doing what they do best and functioning as a system of caregivers rather than a collection of isolated heroes."

Wondering about the trauma care in your state? Check out this report card from the
American College of Emergency Physicians [10]. It ranks Utah, Idaho and Arkansas lowest, and gives California, Massachusetts, Connecticut and the District of Columbia the best scores on emergency facilities. (Notice any rural/urban differences here?) Overall the ACEP found the nation's critical health care system in poor shape, "characterized by overcrowding, declining access to care, soaring liability costs and a poor capacity to deal with natural and man-made disasters." Maine, by the way, received a decent B-.

Readers may also be interested to check on the Center for Excellence in Rural Safety's recent report on rural highway fatalities [11]. Even with the changes that Dr. Steele describes, Maine's rate of rural crash deaths is the highest in the nation (in part because such a large percentage of that state's roadways are rural). Maine's rural crash fatalities did decline 5% from 2004 to 2005. In the same period, Nevada and Michigan showed the greatest increases in deaths on rural roads. In 2005, 23,549 people died in rural highway accidents.

Interpreting the Rural Safety Center's study is tricky, as this commentator from Montana [13] makes clear. Still, the facts aren't in dispute. A 20-year report of traffic fatalities nationwide [12] found rural death rates from auto accidents were far higher. It cited a 1989 federal report "that 57% of all fatal crashes occurred in rural settings, and others have estimated that number to be as high as 65%. However, only about one-third of the vehicle miles traveled in the United States are on rural roads."

With these kinds of deadly discrepancies, all state policymakers and health officials should look at what's happening in Maine. Mainers are taking the "golden" rule seriously and making the changes to apply it to all citizens, urban and rural.