Despite the many changes in medicine over the past century, traumatic injury remains a surgical disease.
Trauma injury is a major public health concern in rural areas, where death rates from unintentional injuries are higher than in metropolitan areas (Am. J. Public Health 2004;10:1689-93). The rural surgeon sees more than his or her fair share of victims of automobile accidents, falls, unintentional firearms injuries, and occupational accidents (think tractor accidents and injuries involving machinery and animals).
Another reality of the rural areas of the United States is that the number of broadly trained general surgeons who can treat a wide variety of trauma injuries is shrinking. Aging and retirements of the “old school rural surgeons” are accelerating and precipitating a lack of surgical coverage crisis, including trauma, in rural areas (Arch. Surg. 2005;140:74-9).
These well-documented developments have combined to reduce the availability of rural surgeons to manage injured patients in planned and consistent ways. Because of the current training paradigm of increasing subspecialization, injured rural patients may be cared for at rural hospitals with reduced capabilities and by rural surgeons with limited trauma training and experience.
What is the action plan to help counteract these developments and to provide the highest-quality patient care at facilities staffed by surgeons who have sworn to “serve all with skill and fidelity”?
The most straightforward and well-established action plan to achieve those goals is the verification process developed by the ACS Verification, Review, and Consultation Program (VRC) in 1987 to help hospitals improve trauma care. The process involves a pre-review questionnaire, a site visit, and report of findings. Verification as a trauma center guarantees that the facility has the required resources listed in the current, evidence-based guide, Resources for Optimal Care of the Injured Patient (2014). If successful, the trauma center receives a certificate of verification that is valid for 3 years.
Most rural hospitals are designated as Level III and IV verified trauma centers on the basis of their available resources. ACS verification confirms that these centers have the commitments and capabilities to manage the initial care of injured patients by providing stabilization and instituting life-saving maneuvers. In addition, verification confirms that protocols and agreements with higher-level trauma centers within a system enable the safe and efficient transfer of injured patients.
During many years of practice in the rural hospitals verified as trauma centers, including being the medical director of a Level II and Level III facility, I provided care to injured patients who presented to the emergency departments (EDs). My experiences confirmed the unequivocal value of practicing in those facilities, and I can attest to the benefits of verification within a system, like Iowa’s state program.
The following case report validates such assertions. A helicopter, unable to complete the transfer to a Level I center for a deteriorating patient with a left chest gunshot wound, landed at my Level III hospital. There was a “Hot Off Load,” which was followed by a full trauma alert for the patient in profound shock. After placing a chest tube during a 20-minute ED stay, the patient transferred to the OR for further resuscitation, and stabilization with required operative treatment. With the patient stabilized and fully resuscitated, according to established agreements, I contacted the Level I center from the OR. After 3 hours, the patient returned to the helicopter and completed the transfer to the Level I trauma center. The patient survived because of the local trauma team’s commitment, organization, and skill brought about by the trauma center verification.
Most research to date has focused on higher-level trauma centers, but recent studies have shown that ACS verification was an independent predictor of survival of trauma patients at Level II centers (J. Trauma Acute Care Surg. 2013;75:44-9; J. Trauma Acute Care Surg. 2010;69:1362-6).
I have firsthand experience with the verification process. Following my involvement with the ACS Committee on Trauma, I became a national site surveyor for the ACSVRC. I became an Advanced Trauma Life Support (ATLS) instructor and then worked as a course director. ATLS is an essential component for trauma center verification. It supports the rural surgeon by giving the local trauma team a format for consistent, life-saving care for the most severely injured patients. I subsequently completed the ACS Advanced Trauma Operative Management course and elected to become an instructor.
I have made site visits to many rural hospitals as a part of the ACSVRC process and have met with a wide range of reactions from “Let’s show off how good we are” to “We really don’t know why we’re doing this” to “Just give us the merit badge and then get out of our hair.” I am gratified to note that ACS Fellows are uniformly supportive. They understand the need for organization, standards, and performance improvement.