Rural Trauma, a Race Against Time

Rural Trauma Road Traffic Accident in SW Washington State Case Study

This young man was the sole occupant in a car at an intersection, when his car was “t-boned” by another vehicle with a drunk driver. The accident was witnessed by other drivers who called on their cell phones to get help. Rural EMTs are mostly volunteers who work and have to be called in. The EMTs arrive at the scene approximately 30 minutes after the accident. The patient was trapped in his vehicle. The EMTs needed the Jaws of Life to extricate from the vehicle, at least another 30 minutes. Upon extrication, the patient lost pulses and consciousness. The EMTs start a peripheral IV, do CPR and give intravenously cardiac resuscitation drugs, resulting in a slow return of vital signs. They transport the patient to the nearest hospital, Columbia Memorial Hospital (CMH) with surgical capability in Astoria, Oregon, a fifteen minute transport from scene to hospital. 

The patient has another cardiac arrest as he arrives in the emergency department. The surgeon on call happened to be a retired academic general and trauma surgeon who inserts more IVs, gives two units of type specific blood, and inserts two chest tubes, with return of the patient’s vital signs. What to do next?  Stabilize then transfer vs. transfer the patient and stabilize at the trauma center where all advanced technology is immediately at hand? This is a classic example of making decisions that save time to save lives, even though it goes against what is recommended by trauma experts.

This situation now poses a major dilemma. The Advanced Trauma Life Support Course advocated that a rural trauma patient should be stabilized before being transferred. 
For a rural hospital with limited resources, trauma experience, and blood bank, providing immediate surgery is not possible, the OR nursing staff, surgeon, anesthetist has to be called in, causing another 30 minutes (minimum) in delay of operative care. This patient having had two episodes of loss of vital signs, is at risk for having a 3rd episode of loss of vital signs at the rural hospital while waiting for the rural OR team to respond and be ready to do surgery at the rural hospital. The other dilemma is the capability of the rural blood bank and coagulation lab to provide massive transfusion if, upon opening the abdomen, the surgeon encounters massive bleeding from an injury.

This academic surgeon reasoned that the Life Flight helicopter waiting on the rural hospital’s helipad could have this patient on the OR table at Emanuel in less time than the surgeon could start surgery at CMH. He chose the latter, and transferred the patient by helicopter to Emanuel. He took the precaution of sending two units of blood with the transfer team. On arrival in the Trauma OR at Emanuel, the patient had another cardiac arrest, and was revived with massive transfusions of blood and blood products and surgical control (splenectomy) of bleeding from a shattered spleen.

The patient did well, as other less significant injuries were addressed. He was transferred to Rehabilitation, then home. He completed college, went to Seminary School and became a pastor.

Medical Clarifications:
1. On the surfaces of bones (periosteum) are small arteries which contribute to the amount of bleeding which cause a significant amount of blood from fracture sites.
2. For a transfusion consisting of 1 unit of packed red blood cells, 1 unit of fresh frozen plasma, and one liter of saline or Ringers lactate, it gives you a total of two liters.
3. The ACSCOT and ACEP white paper states that resuscitation of blunt trauma patients in cardiac arrest in the prehospital time period is futile, not when the patient arrives in the ED in cardiac arrest.
4. The prehospital time was at least one hour. 

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