Responding to the need for high quality emergency care in rural America

–Darrell Carter

Another cold blustery January night in northwestern Minnesota, and you hope everyone stays home and your hospital’s emergency department remains quiet. As the night charge nurse on duty, you are responsible for overseeing the care your night staff (one other RN and an LPN) gives to the twelve inpatients in your twenty-two bed Critical Access Hospital (CAH). These twelve patients include a mother and her hours-old newborn and an eighty-two-year-old female who is two days post-op after a hip pinning and who is exhibiting increased confusion and agitation. You hope to let your on-call doctor get some sleep since she was up much of last night delivering the baby in your nursery. The only other practicing physician in your community is gone for a much-deserved five-day break to Cancun.

 All has remained routine until 1:00 a.m. when the squawk from your ambulance paging radio disturbs your charting. The Basic Life Support ambulance is dispatched to a motor-vehicle-crash involving two vehicles and an unknown number of victims. At least two of the patients sound seriously injured. Reluctantly, you shift your role from more mundane tasks to organizing the team for the soon-to-be-busy emergency department.

 In the twenty-first century, seriously ill or injured patients benefit from a growing amount of advanced technology for diagnosis and treatment of their ailments or injuries. Highly trained specialists are now available to help manage a wide variety of complex conditions, and well-trained and highly skilled teams staff emergency departments. Unfortunately, this is true only in the larger population centers of the United States. Rural health care facilities do not have immediate access to this wide variety of specialists and frequently lack the more advanced equipment needed to diagnose or treat the seriously ill or injured patient. Rural providers frequently lack the organized team, knowledge, and skills to rapidly perform the life-saving procedures and treatments needed by the more seriously ill or injured patients. Extensive distances lengthen the time required to transport patients to specialized urban medical centers for life- or organ-saving procedures. It is little wonder that rural trauma victims have a higher mortality rate than their urban counterparts. In 2004 the Minnesota Statewide Trauma System reported that fewer than 30 percent of all motor vehicle crashes occurred in rural areas, but 70 percent of the fatal crashes are rural.

 There are many obstacles to our delivering the highest and most modern emergency and critical care to rural patients. However, the medical legal standards of care and the general public expect similar care to be delivered in both urban and rural communities. Disparity in the availability of advanced emergency care has adverse consequences. In rural areas, these include: higher rates of trauma deaths, increased burnout among providers, difficulty recruiting staff for existing health care facilities, and an increase in medical-legal risks for practitioners due to the inability to rapidly deliver emergency care or obtain easy consultation for some critically ill or injured patients.

 So what is the solution to this developing crisis in rural medicine? Some recommend more helicopters to rapidly transport the rural patients to urban centers. Others promote equipping rural communities with all the latest equipment, as well as hiring skilled specialists to respond to the infrequent events.  But is society willing to finance the cost of such solutions? Others claim living (and vacationing and driving) in the rural parts of our country is simply more dangerous, so if you elect to live in, or even venture into rural areas, then you need to accept the inherent risks.

(Excerpted from A Night in the Life of a Rural Emergency Care Team and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Darrell Carter and his colleagues responded to this need by starting CALS—comprehensive advanced life support.  http://www.calsprogram.org/

This innovative program combines ACLS, PALS, ALSO and ATLS with a rural focus and a team response approach. In the 21st century, many rural areas are filled with innovative ways to respond to the desire of health care providers and patients to provide and receive high quality care.  What is happening in the community where you are rotating?   Please share some innovations on this blog.

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