Optimal Resources for Rural Surgery.

BACKGROUND: Timely access to emergency general surgery services, including trauma, is a critical aspect of patient care. This study looks to identify resource availability at small rural hospitals in order to improve the quality of surgical care. METHODS: Forty-five nonteaching hospitals in West Virginia were divided into large community hospitals with multiple specialties (LCHs), small community hospitals with fewer specialties (SCHs), and critical access hospitals (CAHs). A 58-question survey on optimal resources for surgery was completed by 1 representative surgeon at each hospital. There were 8 LCHs, 18 SCHs, and 19 CAHs with survey response rates of 100%, 83%, and 89%, respectively. RESULTS: One hundred percent of hospitals surveyed had respiratory therapy and ventilator support, computerized tomography (CT) scanner and ultrasound, certified operating rooms, lab support, packed red blood cells (PRBC), and FFP accessible 24/7. Availability of cryoprecipitate, platelets, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) decreased from LCHs to CAHs. The majority had board-certified general surgeons; however, only 86% LCHs, 53% SCHs, and 50% CAHs had advanced trauma life support (ATLS) certification. One hundred percent of LCHs had operating room (OR) crew on call within 30 minutes, emergency cardiovascular equipment, critical care nursing, on-site pathologist, and biologic/synthetic mesh, whereas fewer SCHs and CAHs had these resources. One hundred percent of LCHs and SCHs had anesthesia availability 24/7 compared to 78% of CAHs. DISCUSSION: Improving access to the aforementioned resources is of utmost importance to patient outcomes. This will enhance rural surgical care and decrease emergency surgical transfers. Further education and research are necessary to support and improve rural trauma systems.

Disaster Ethics: Shifting Priorities in an Unstable and Dangerous Environment.

Emergency and critical care medicine are fraught with ethically challenging decision making for clinicians, patients, and families. Time and resource constraints, decisional-impaired patients, and emotionally overwhelmed family members make obtaining informed consent, discussing withholding or withdrawing of life-sustaining treatments, and respecting patient values and preferences difficult. When illness or trauma is secondary to disaster, ethical considerations increase and change based on number of casualties, type of disaster, and anticipated life cycle of the crisis. This article considers the ethical issues that arise when health providers are confronted with the challenges of caring for victims of disaster.

Does the rural trauma team development course shorten the interval from trauma patient arrival to decision to transfer?

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) was developed by the ad hoc Rural Trauma Committee of the American College of Surgeons, Committee on Trauma to address the increased mortality of the rural trauma patient. The effectiveness of the RTTDC in shortening the interval from patient arrival to decision to transfer and the effect on the transfer process of communication training emphasizing team building is the focus of this study. METHOD: Rural level III and level IV trauma centers (N=18) were enrolled in a multiinstitutional 3-month longitudinal study of transferred trauma patients. Results were compared with institutions having hosted RTTDC versus those institutions not yet exposed to the course. RESULTS: One-way analysis of variance was conducted. Results indicated that RTTDC training alone and RTTDC including communication training resulted in a statistically significantly shorter (p<0.05) time for decision to transfer. Transferring squad arrival time was also significantly reduced (p<0.01) as was the number of transferring squads contacted (p<0.01). No differences were observed among the trauma facilities and the number of receiving facilities contacted, (p=0.64) or in the time required to find an accepting facility (p=0.72). CONCLUSION: The RTTDC alone and with the embedded communication module significantly reduce delays in the transfer process of the rural trauma patient.