Overcoming barriers to improve time to definitive care after rural traumatic injury

May 07, 2022

When Henry J. Schiller, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, considers patients who've experienced traumatic injuries, he sees a trimodal distribution of survival:

  • Patients who die within minutes of injury and may not be able to be helped
  • Patients who die within 1 to 3 hours of injury in which rapid medical care can impact outcome
  • Patients who die several days following injury when the outcome is potentially modifiable

"If they die within minutes, we in the trauma center likely can't make an impact, but if we see the patient within 1 to 3 hours, we can help," says Dr. Schiller.

This time frame noted by Dr. Schiller coincides with the concept of the golden hour, which derives from cinematography's emphasis on using the hours occurring immediately after sunrise and immediately before sunset for videography, capturing their unique light qualities. For traumatic injury, rather than a key time to film, the golden hour is a crucial time for survival. It represents a defined time period in which life and death may hang in the balance after traumatic injury, requiring rapid transport to definitive care.

Location, location, location

A patient's location at time of injury can be a significant barrier for promptly receiving definitive care. Dr. Schiller notes that getting patients who've had a traumatic injury to definitive care in a major urban center is an entirely different situation from that for patients experiencing trauma in rural America.

"Rural trauma — defined as trauma care in which patients take longer than 60 minutes to arrive — inherently has delays to receiving definitive care," he says. "If someone is shot on the streets of Los Angeles, that person can be in an operating room within an hour. If you're in a field after a car crash in Southern Minnesota, you may be in the car several hours until someone discovers you."

In Southern Minnesota, crucial challenges exist in getting patients who've undergone trauma to definitive care:

  • Discovery: With a population density lower than that of a city such as Minneapolis, longer lengths of time can easily elapse before an injured individual is even found, much less transported to care.
  • Distance: It's not uncommon that an injury occurs far from the first available hospital.
  • Facility size: The system of care in the Southern Minnesota area includes multiple small hospitals staffed and equipped to provide stabilization but not definitive care. Thus, all critical patients require transfer.

"The average time to definitive care in our region is three hours if transfer is involved," says Dr. Schiller. "Delays naturally are introduced at each step of the way."

Key actions for rural trauma centers to ensure patients survive traumatic injury

The high level of stress in providing care for a critically injured patient can make it difficult for providers at any trauma center to process large amounts of information well in a complex situation, according to Dr. Schiller.

"Adrenaline makes you stupid," he says. "You can't remember things you knew to do. Adrenaline can cause time dilation where staff think they are moving faster than they are, and their ability to make complex plans goes down."

Thus, Dr. Schiller suggests a preprogrammed, team response for rural trauma centers, such as the response taught in the Rural Trauma Team Development Course (RTTDC), in which personnel don't have to make up anything as they go along.

Dr. Schiller highly recommends the RTTDC for all rural trauma personnel to ensure that individuals who may be part of a trauma response team are on the same page. He also suggests that trauma centers prepare for critically injured patients by:

  • Understanding the capabilities of the facility
  • Readying skills for stabilization and resuscitation
  • Determining team composition for a trauma case
  • Assigning roles and responsibilities when the prehospital report arrives for a patient with a traumatic injury
  • Determining transfer processes
  • Coordinating with the region's Level 1 Trauma Center, including jointly discussing improvement opportunities on a recent case or sharing protocols
  • Seeking continuous improvement opportunities, even if all cases have had positive outcomes

It's fine to recognize that a patient's needs exceed your facility's capabilities and call for transfer, says Dr. Schiller. He notes, however, that especially with a critical injury, increasing the pace can be crucial.

The main patient stabilization and resuscitation goals before transfer include:

  • Securing the airway with an endotracheal tube
  • Obtaining IV or interosseous access
  • Providing blood products for transfusion or alerting Mayo Clinic air ambulance of this need
  • Preventing further injury through techniques such as spine immobilization for a patient with a potential spine injury

RTTDC previously discouraged imaging while awaiting patient transport. However, with current electronic transmission capabilities, capturing and sending images can be feasible and efficient for the transferring facility and helpful to the receiving trauma team, says Dr. Schiller. He discourages imaging that delays transfer or is performed simply to provide comprehensive data for discussions with the Level 1 Trauma Center. If a transferring facility performs imaging, he says it's crucial to maintain a common imaging protocol for all trauma system facilities, such as avoiding extra radiation or contrast loads. He also suggests calling ahead to alert the Level 1 Trauma Center to look for the transmitted images.

"It's one thing if you have a broken leg and don't get care as quickly, but quite another if you have punctured lungs, loss of airway and hemorrhagic shock," he says. "Knowing an increase in mortality exists with more time to definitive care, you want to do everything you can do to shorten the time to that care, ensure the patient survives to arrive there and has better outcomes."

For more information

Refer a patient to Mayo Clinic.