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Urban-rural
differences in prehospital care of major trauma.
J Trauma 1997 Apr;42(4):723-9
Grossman DC, Kim A, Macdonald SC, Klein P, Copass MK, Maier RV.
Department of Pediatrics, University of Washington, Seattle, USA.
OBJECTIVES: To compare differences in response times, scene times, and
transport times by advanced life-support-trained paramedics to trauma incidents
in urban and rural locations. METHODS: This report was a prospective
cohort study of professional emergency medical services conducted in a
five-county area in the state of Washington. Ninety-eight percent of trauma
transports are provided by professional paramedics trained in advanced life
support. Subjects were included in this study if they qualified as a major
trauma victim and were transported or found dead at the scene by one of the
region's advanced life support transport agencies between August 1, 1991, and
January 31, 1992. The severity of injury was rated using the Prehospital Index.
Incident locations were defined as "rural" if they occurred in a US
Census division (a geographic area) in which more than 50% of the residents
resided in a rural location. RESULTS: During the 6-month data collection
period, advanced life support agencies responded to a total of 459 major trauma
victims in the region. A geographic locations was determined for 452 of these
subjects. Of these, 42% of subjects were injured in urban areas and the
remainder in rural areas. The severity of injuries, as determined both by the
triage classification (p = 0.17) and the distribution of Prehospital Index
scores (p = 0.92), was similar for urban and rural major trauma patients.
Twenty-six (5.7%) subjects died at the scene. About one quarter of both groups
had a severe injury, as indicated by Prehospital Index score of more than 3. The
mean response time for urban locations was 7.0 minutes (median = 6 minutes)
compared with 13.6 minutes (median = 12 minutes) for rural locations (p <
0.0001). The mean scene time in rural areas was slightly longer than in urban
areas (21.7 vs. 18.7 minutes, p = 0.015). Mean transport times from the scene to
the hospital were also significantly longer for rural incidents (17.2 minutes
vs. 8.2 minutes, p < 0.0001). Rural victims were over seven times more likely
to die before arrival (relative risk = 7.4, 95% confidence interval 2.4-22.8) if
the emergency medical services' response time was more than 30 minutes. CONCLUSIONS:
Response and transport times among professional, advanced life-support-trained
paramedics responding to major trauma incidents are longer in rural areas,
compared with urban areas.
A
survey of rural road fatalities.
Aust N Z J Surg 1994 Jul;64(7):479-83
Papadimitriou DG, Mathur MN, Hill DA.
Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales,
Australia.
This study is a retrospective case series analysis of all 82 road deaths
occurring in the Orana Area Health Service (OAHS) over the 2 year period
1989-90. The OAHS services a population of 112,800 in an area of 199,077 km2 in
north-west New South Wales. The aim of the study was to document timing, place
and cause of deaths, severity of injuries, pre-hospital management of victims,
and a TRISS analysis of outcome. This was done using ambulance, hospital, police
and autopsy reports. Seventy-two (88%) of the victims were motor vehicle
occupants, five (6%) were motorcyclists and four (5%) were pedestrians. The
median ambulance response time to the scene of the accident was 17 min (range
2-103 min). All deaths occurred within 24 h of injury with 65 (79%) of the
victims being dead at the scene, nine (11%) dying en-route and eight (10%)
reaching hospital alive. A TRISS analysis was performed on 51 deaths and 8%
(4/51) of these had a greater than 50% probability of survival. Of the victims
that had inevitable deaths according to TRISS, 11% (5/47) may have survived if
pre-hospital care arrived sooner. Reduction in the rural road toll is achievable
through preventative measures and strategies to improve access to care and
administration of pre-hospital care.
Wilderness
mortalities: a 13-year experience.
Ann Emerg Med 2001 Mar;37(3):279-83
Goodman T, Iserson KV, Strich H.
Section of Emergency Medicine, Department of Surgery, University of Arizona
College of Medicine, Tucson, AZ, USA. tgood808@lava.net
STUDY OBJECTIVE: To analyze the epidemiology of wilderness mortalities in
a localized area with diverse terrain. METHODS: We conducted a
retrospective review of the Pima County (Arizona) Sheriff's Office (PCSO) search
and rescue logs and case reports, hospital records, and autopsy reports for all
wilderness deaths from 1980 to 1992. The study group comprised all victims of
injury or illness in Pima County wilderness who died during a 13-year period in
a location remote enough so that standard ground-based emergency medical
services units could not extract the body. RESULTS: One hundred
fatalities occurred during the 13-year study period. There were 59 unintentional
traumas, 18 suicides, 9 homicides, 12 medically related deaths, and 2 deaths of
unknown causes. Toxicology tests performed on body fluids yielded positive
findings for alcohol in a total of 50 (50%) cases and positive findings for
drugs of abuse in 12 (12%) cases. It was estimated that alcohol was "a very
probable" or "a probable" causative factor in 23 (40%) of the 59
unintentional trauma deaths, and in 1 (8.3%) of the 12 medically related deaths.
Fifty-five (55%) deaths were witnessed events, with 45 (80%) of these victims
reported as dying immediately or before arrival of search and rescue personnel.
Ten (10%) victims received resuscitation in the field, and according to a review
of hospital charts and autopsy reports, only 2 victims had a potentially
survivable injury or illness. CONCLUSION: Many wilderness mortalities are
related to incidents involving alcohol. Once the accident or injury has
occurred, the majority of deaths are immediate, or at least before the arrival
of medical personnel. Higher levels of medical care would not have improved the
outcomes of those who did survive long enough to receive medical care.
Therefore, primary efforts to reduce mortalities in the wilderness should be
directed toward prevention, especially diminishing alcohol use in wilderness
areas.
Ann Emerg Med 2001 Sep;38(3):323-7
Williams JM, Ehrlich PF, Prescott JE.
Department of Emergency Medicine, West Virginia University, Morgantown, WV
26506-9151, USA. jwilliams@hsc.wvu.edu
The delivery of high-quality emergency care in a rural setting requires a
conceptual framework quite different from that required in urban and suburban
environments, given that available resources are limited in the rural setting.
The intermittent and episodic nature of seriously ill and injured patients who
present to rural emergency departments makes it difficult to plan, staff, and
equip in order to provide emergency medical care at the same level seen at
higher volume urban or suburban institutions. The objective of this article is
to describe the distinctive nature and widely unrecognized features of emergency
medicine in rural and remote areas, with a focus on clinical, workforce, and
economic issues. We present recommendations for a shift in thinking and a call
to action on behalf of all emergency medicine professionals that are based on a
realistic assessment of the current status of emergency medicine and that are
needed to develop and sustain high-quality emergency medical care in rural
America