Trauma center brings "golden hour" luster to rural health care

By Larry Dreiling

Auto collisions. ATV rollovers. Falls from the roof of a barn. Cattle chute mishaps. Accidents and injuries happen in rural America just as they do in big cities.

The question is: Can rural people survive injuries as well as people in big cities? Studies indicate that where one lives can be important to how one lives or dies.

In the medical field, injury is called trauma. Many experts in the field of trauma care consider the first 60 minutes after an injury to be a so-called "golden hour" when trauma care is most effective in saving lives.

Given that the risk of death for severely injured patients rises significantly after one hour, trauma systems strive to offer access within that time period, from the receipt of an initial emergency call to arrival at a trauma center.

The best place for injured people to go for help are Level I and II trauma centers. As defined by the American College of Surgeons, a Level I center is defined a facility often attached to a medical school, charity or municipality.

Level II facilities are often private, community or voluntary hospitals that have made a commitment to trauma care.

Level I and II trauma centers, taken as a whole, provide comprehensive care for the most critically ill patients and have immediate availability of trauma surgeons, anesthesiologists and other physician specialists.

Lack of services

According to a study, led by Dr. Charles Branas, an epidemiologist at the University of Pennsylvania School of Medicine, and published in a 2005 issue of the Journal of the American Medical Association, 85 percent of the overall U.S. population is covered by a Level I or II trauma center. It is in rural areas where the need for such care facilities is most acute.

"The geographic distribution of trauma centers varies widely across states and regions," the study noted. "Many areas of the country are not well-served by trauma centers, while other areas may have a surplus of centers, possibly leading to inefficiencies, lower patient volumes per center, and reduced quality of care."

The results of the study indicate that 32 percent of the population of Iowa, 37 percent of Kansas, 63 percent of Oklahoma, as well as 68 percent of South Dakota and Wyoming do not have access to the advanced and speedy care of a Level I or II trauma center needed to meet the "golden hour." (See map.)

Other states in the High Plains have done much better. Colorado, at 87 percent, is the first state in the nation to use hospital-based helicopters to transport injured patients. And Nebraska, with a heavily coordinated systems approach to trauma care, is at 74 percent.

One man, one vision

Perhaps the leading reason for Nebraska's high access rate is the vision of one man.

Dr. Lloyd Westerbuhr was a general surgeon based at Regional West Medical Center, Scottsbluff, Neb. Now retired and living in Arizona, he is credited by colleagues as having the vision to develop a trauma system for the Nebraska Panhandle region, and further, the rest of the state.

"Dr. Westerbuhr had the vision. He was the driving force behind what we have today," said Boni Carrell, a registered nurse on the trauma service at Regional West, a hospital that saw more than 1,200 patients in its emergency room last year, with about 325 of them transported via helicopter.

Over 100 physicians are on staff or have privileges at Regional West. An effort is underway to grow the medical staff an additional 25 percent in the next three years, according to Holly Anderson, marketing and public relations specialist. Many of the physicians will work in outreach clinics in outlying communities as well as in Scottsbluff.

Regional West is a Level II trauma center. Through a sophisticated communications network initiated by Westerbuhr, it is connected to the emergency rooms of 11 smaller hospitals in the Panhandle. Also using the network is a multitude of local first responders and emergency medical services (EMS) operations.

Improving outcomes

When a trauma call comes into an outlying emergency phone system, local first responders are dispatched. Being highly trained, they make an assessment in the field. Through that assessment, a decision on how to quickly move the injured person to the proper care facility is made. That patient could be transported to Scottsbluff or even further, to as far away as Denver, depending on the nature of the situation.

"We have the right people in the right places that really care about the people of this region. It's not just about us here," said Randy Meininger, director of Valley Ambulance Services, the primary provider of ground ambulance service in Scottsbluff. Meininger also currently serves as mayor of the City of Scottsbluff.

Even now, the team at the hospital is concerned about improving outcomes even further.

"The term 'golden hour' might be used too much. It was meant for metro areas for the time of incident to surgical intervention," Meininger said. "For the size of territory we cover, it doesn't always happen that way. We may be an hour from the time of incident to the time we arrive on the scene. We have to work better than those systems."

"This has also improved our outcomes for stroke and cardiac care, as well. It's done wonders in many other areas, not to take anything away from trauma."

Fixing frustrations

Still, it takes a vision to have developed the system. Westerbuhr's vision for developing the Regional West trauma operation stemmed from his days as a young intern.

"In my training days, I trained at a big city charity-type hospital where you see trauma all of the time," Westerbuhr said in a phone conversation. "Small town hospitals deal with trauma whether it's planned or not. You are the only act in town. We'd dealt with trauma for many years and there were so many things that were frustrating. I felt like we needed a better way of dealing with it."

In the early 1990s, the concept of a system-type approach to trauma care was in its infancy. The state of Washington was developing a statewide system at the time and the American College of Surgeons rating system started a few years before that. The rating system showed that with this approach patient outcomes could be vastly improved.

"All this information was out there and I was very frustrated with what was going on in our own hospital. There were a couple of sentinel events that precipitated my dedication, if you will," Westerbuhr said. "One of our ward secretaries came in after an auto accident on a Saturday night. She was admitted to the intensive care unit by a family physician that really had no expertise in trauma at all. I was called in Sunday morning.

"By the time I saw her, she was in extremis. It took a huge effort to save her. I got to thinking that here was a family doc who would call me if he thought someone in the emergency room had appendicitis but he didn't feel any hesitation to admit a severely injured patient to an ICU under his care. He was a good guy; he didn't mean any harm; he just didn't know any better and there was no system.

"That was the kind of thing that spurred me into thinking that we needed a new approach to do things. I proposed that we develop a system for trauma care. I used as a model the ACS system."

One of the key components of the Regional West trauma system is the communication system, installed in 1994.

"It absolutely is a huge part of this. My view was to be sure our own hospital had a system in place that did the very best job they could once the patient got there," Westerbuhr said. "We then needed to have a way to get the patient there as quickly and as safely as we could from the time the call came in to the EMS people until the time the patient arrived at the hospital."

Foundation commitment

Before the system was installed, communication was a very big deficiency, Westerbuhr said.

"We had ambulances in the northern part of the area that couldn't talk to us in Scottsbluff because there were hills blocking radio communications until they got into the valley," Westerbuhr said. "They couldn't tell us what was coming or when.

"That led to the focus of our hospital's foundation to install our communications system. It was a huge boost to trauma care in the area. To serve the whole region, to install repeaters and everything else in every ambulance cost well over $500,000. The system allows doctors to talk to doctors, ambulances to ambulances, and ambulances to hospitals. All the prehospital units in the Panhandle were involved."

As a result, the hospital's foundation changed from looking at only the local facility to a regional approach.

"It was a huge commitment," Westerbuhr said, "but it created a lot of enthusiasm once the project got going."

"It also meant we had to step up our educational focus to the first responders and advanced life support personnel in the region. We added all these new training programs where people would come in from the outlying area and learn together. That means doctors, nurses, all the way down to volunteer first responders. We made sure the training was uniform. It all comes together with this communications system that links everyone together."

Big changes

One of the good things about this new approach to education was that people were able to network through the programs and get to know each other.

"A huge spinoff of this was we were able to break down a lot of barriers to make it better. We learned that each of us out here couldn't be a little island to do it," Westerbuhr said. The thing that frightens little hospital emergency rooms--the kind without surgeons--more than anything else is the idea that a really bad trauma patient comes in there and they really don't know what to do with it.

"By having the system with good communications, they have a better idea of if a patient comes in with a certain injury, they'll know what they need to do with that patient at their hospital and how to get them transferred to the appropriate specialty hospital. We developed a transfer plan for all kinds of patients to expedite transport when any one facility exceeds their ability, even ours."

The next thing Westerbuhr and the hospital needed to improve trauma outcomes was a helicopter. He recalls it as a hard sell at first.

"At the time, our helicopter studies showed that for our size of population a helicopter wouldn't make sense, since there weren't enough people. That flies in the face of what is needed. If there is any place that absolutely needs a helicopter, it's a place like the Panhandle of Nebraska because when someone gets injured, say, in the Sandhills, it could be five hours in a ground ambulance before a patient could arrive at the appropriate facility," Westerbuhr said.

"The hospital administrator, at the time, and I spent a lot of time talking about it. He finally committed to do it. We worked out some ways to make it work by working with Flight For Life at what used to be known as Presbyterian Hospital in Denver. They helped us some financially because they got just about all of our cardiac patients at that time. So, it was to their benefit.

"By the time we were in the air, a year later, we knew it was going to work. It just took off from there. Every piece took a long time to get together."

Helicopter works

One of the things Westerbuhr learned in developing the trauma system for his region was that small town ambulances will not leave their immediate area. A major trauma case would require an ambulance to come up from the bigger city to pick up that patient.

A helicopter changes that.

"As soon as a helicopter lands in the field, the skill level of care for the patient increases immediately," Westerbuhr said. "The crew on the helicopter is so well trained that they exceed the skills of the people at most of those little hospitals out there."

By developing the trauma system, Regional West in January 1996 earned its designation as a Level II trauma center.

"At the time, we were one of the smallest hospitals in the country to receive it," Westerbuhr said.

Another piece of the trauma system pie, which Westerbuhr calls a marvel of statewide cooperation, is the development of a state trauma system, which started from the grassroots. Westerbuhr credits trauma directors at hospitals in Kearney and Lincoln with working together to create state legislation to improve coordination of patient care.

"You need transportation and communications systems, but you also need a network that coordinates everything. The last thing I put in place before I retired--we put in place a way to improve the quality of service and hopefully patient outcomes," Westerbuhr said. "Everyone comes together as a region. That would have never happened before we put the system in place. This was unheard of years ago."

Team effort

Westerbuhr emphasized the importance of commitment by hospital administration, medical staff, nursing staff and especially EMS providers in the development of a system of trauma care.

"In our institution Jim McHugh, our administrator; Shermaine Sterkel, nurse coordinator, and Randy Meininger, as well as the hospital foundation were all instrumental in our success."

To anyone interested in improving the health of rural parts of the country, Westerbuhr offers one piece of advice.

"The way it has to start is with a physician advocate," he said. "The hospital has to be committed, but there needs to be a physician, preferably a surgeon, as an advocate."

Larry Dreiling can be reached by phone at 785-628-1117 or by e-mail at ldreiling@aol.com.

THE GOLDEN HOUR--This map shows areas of the continental U.S. with access to Level I or II trauma centers within 60 minutes of an ambulance or helicopter. While there are few places in rural America with such access, taking a system approach to trauma care, such as the system developed for far western Nebraska and anchored b Regional West Medical Center, Scottsbluff, Neb., have reduced what had been access times of as much as five hours to times that can be considered more reasonable. (Map courtesy Dr. Charels Branas, University of Pennsylvania School of Medicine and the American Trauma Society.)

9/15/08
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Date: 9/11/08

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