Don’t get into a car accident on a two-lane country road, miles from town.
Of course, it might happen. But the fatality rate for car accidents is three to 10 times higher in rural areas than in cities, according to a 2017 report from the Centers for Disease Control and Prevention.
A car crash isn’t the only type of accident that’s far more dangerous in the country. On-the-job trauma, accidental drowning, firearm injuries, residential fires and electrocutions also boast disproportionately high rural fatality rates. Overall, the CDC says, about 12,000 rural Americans die from unintentional injuries every year, making fatal accidents almost twice as likely for rural residents as urban dwellers. In fact, according to the National Center for Health Statistics, population density is the strongest predictor of trauma death rates in the U.S.
One significant factor in this trend is time. For optimal outcomes, patients with critical injuries need to get medical attention within 60 minutes, according to anecdotal evidence and military research. If this “golden hour” runs out, death becomes much more likely.
“What we know in trauma is that the sooner you get to a surgeon with all the resources and testing capabilities, survival outcomes increase dramatically,” said Andy Gienapp, director of the Wyoming office of Emergency Medical Services. “But in a small community or wilderness parts of America without ambulance service, if you have a bad injury, heart attack or stroke, it’s going to be a while until someone gets to you.”
Up in mountain towns, across swaths of farmland, in barren stretches of desert and deep on country roads, there’s no shortage of barriers to timely treatment for serious injuries. Medical facilities are short on both doctors and vital resources like blood. Emergency response services are underfunded and understaffed. Designated trauma centers are few and far between. Yet experts say that promising new advances in telemedicine and increased emphasis on community-based healthcare can help address some of these gaps in care.
Twenty percent of Americans live in rural areas, but fewer than 10 percent of physicians practice there. Many doctors flock to cities, where jobs at top hospitals and competitive practices are professionally and financially rewarding. Yet for other medical professionals, there’s something to be said for the connections a small-town doctor forms with patients. The obligation to furnish high-level care stems both from professional duty and personal investment.
Now primarily a clinical professor of surgery at the University of Kansas School of Medicine, Tyler Hughes worked in rural America in elective and emergency surgery for more than two decades, after spending the first 12 years of his career at a general surgery practice in Dallas.
“Over the course of 20-plus years, you see generations of people,” said Hughes, who operated on the children of patients he knew as children. While Hughes enjoyed working in a close-knit community, he acknowledges inherent challenges in rural medicine. “Rural surgery is a lot like playing chess, as far as the lack of resources and the distances involved,” he said. “You have to think seven moves ahead, like a chess player.”
Traveling for trauma care
Everywhere in the U.S., survivors of serious accidents like fires, car crashes and shootings are supposed to be treated at regionally designated trauma centers that are staffed and stocked for the situation. Trauma centers are classified as Level I through Level V, with a separate scale for pediatric care and strokes. Level I and II trauma centers are equipped to handle worst-case scenarios. Level V centers can provide life support and stabilization before patients are transferred to higher-tier facilities.
Most states have at least one Level I trauma center: Georgia has two; New York has 12. But some states, such as Wyoming and South Dakota, don’t have any. Idaho doesn’t even have a Level II center. Legally, that’s fine — there are no federal requirements for states to have higher-tier trauma centers. But it does mean that patients in need of specialized or life-saving care need to be airlifted across state lines.
In cities, 35 percent of emergency departments are level I, II or III trauma centers. In the country, that number drops to 2.4 percent, according to the Agency for Healthcare Research and Quality. Meanwhile, closures of rural hospitals — with and without trauma designations — have accelerated, per an August 2018 report from the University of North Carolina Cecil B. Sheps Center for Health Services Research. Eighty-seven have closed in recent years, and more are on the chopping block.
The small facilities that dominate rural hospital care aren’t an ideal destination for critically injured patients. “To stabilize, a patient needs rapid, confident and aggressive emergency treatment,” Gienapp said. “But if you have a physician who hasn’t put in a chest tube in two or three years, they may not feel confident about doing something like that, when it’s needed to save a life.”
What’s needed, Hughes says, is a “vigilant” emergency management system. “In rural trauma,” he explained, “dying at the scene is more common.”
Emergency services in danger
In rural communities, ambulances aren’t in heavy rotation like they are in cities, so it’s more expensive to send one out. Historically, rural emergency medical services have depended on a mix of private and public funding to cover the cost of operating in large service areas. They also save money by relying on a volunteer workforce.
When the volunteers driving those ambulances get called on, they typically need to leave their day job and drive up to 30 minutes just to pick up the ambulance. From there, they head to the trauma site. In cases of multiple injuries, backup may be called in from much farther away.
“Ambulance services respond to a primary care area of up to 135 miles, so if you’re a person having heart attack, that’s a long wait,” said Gary Wingrove, a longtime rural paramedic now living in Crescent City, Florida. “If you’re traveling 135 miles to get to that trauma victim, the golden hour has already passed before you’ve reached them.”
Wingrove has been on the front lines of rural emergency response for decades. Growing up in small-town Iowa, he began volunteering as an ambulance attendant during his senior year of high school. “I got to leave school to go on ambulance runs,” he said. He later worked as a paramedic in Minnesota, eventually becoming the first paramedic to be president of a state rural health association.
“Rural paramedics need to be among the most competent of the ambulance workforce, because they’re with patients for a longer period of time.”
Paramedic expertise is critical when facing longer distances. Though the term “paramedic” is commonly used to mean any ambulance personnel, there are actually multiple levels of emergency responders, with titles and certification requirements that vary by state. In general, those certified to do basic EMS work can assess patients and furnish life-support assistance, like CPR. Advanced responders can perform more complicated life-saving procedures, like IV insertion. At the top are paramedics, who are trained in a wider array of medical skills, like reading X-rays, administering drugs and performing manual defibrillation.
“A person has to train 120 to 150 hours to get a basic EMS license,” said Roger Wells, a physician assistant at the Howard County Medical Center in Nebraska. Paramedic training is a heavier load. As a volunteer pursuit, paramedic certification is a lot to take on.
“Rural paramedics need to be among the most competent of the ambulance workforce,” Wingrove said, “because they’re with patients for a longer period of time.”
“The requirements are outstripping the ability of local communities,” Wells said. “EMTs are rarely appreciated, within the healthcare system, by communities or by the patients for the time, dedication and effort that is required to complete their duties in mostly volunteer rural system.”
Where treatment is concerned, “it’s seen as not sexy or relevant,” Gienapp says, of emergency services. Firefighters carrying people out of the World Trade Center offers a powerful image, but dialing up 911 for a medical emergency won’t necessarily get you an immediate response. “People don’t think about it,” he said. “They just call 911 and are surprised when the ambulance takes 30 or 40 minutes to arrive.”
In larger communities, an ambulance can choose between a hospital specializing in heart or trauma-related issues. There’s often no such choice in smaller towns, where first responders must quickly decide between immediate air transport and driving to a local regional hospital or a facility where the patient can be “packaged” and airlifted to a higher-level center.
In microcommunities that max out at populations of 100 or 200, it may not make financial sense to run an emergency service. But Gienapp points out that even small towns can plan for emergencies, such as by having an automatic defibrillator, or AED, to jumpstart hearts, providing CPR training for community members and pairing up with larger neighboring communities to provide emergency services.
A better-coordinated state and federal infrastructure for emergency response is needed, Gienapp says, noting that few federal dollars go to EMS organizations. While communities may overwhelmingly recognize the need for fire departments, they’re not as certain about EMS organizations.
In smaller areas, two 24/7 hospitals aren’t necessary, Hughes says. There needs to be less competition and more coordination. “Most traumas can be handled locally,” Hughes said. “A good trauma system reduces the number of unnecessary transfers to cities or other states, saves money and saves lives.”
Rescuing emergency care
“Providing new community-based services can be more challenging for rural agencies,” Wingrove said. “In a town of 3,000, if you have a for-profit ambulance service with paid staff, you’re in a small town without much volume,” he said. “As the owner of ambulance service, you’re rightfully concerned about to your ability to generate revenue.”
Some healthcare companies and ambulance services are looking to a newer model of emergency care, called community paramedicine. This shift could both reduce emergency visits and provide stable employment for paramedics, lessening reliance on volunteers.
The basic idea is that community paramedics furnish a broader range of healthcare services than paramedics otherwise would. They might provide home healthcare services for homebound patients, or fill in for physicians in urgent but not emergency situations during their off hours. In one Minnesota county, paramedics also provide care at county jails, Wingrove says, and in another, they provide basic, vital care for nursing home patients who don’t have primary care physicians.
This model of healthcare also helps reduce unnecessary, expensive ER trips, which can clog the response system by taking up beds, resources and time. Community paramedics can conduct home visits for people who’ve been relying on 911 and the ER for lower-risk health issues. Paramedics are trained to determine when patients can’t be cared for at home.
“Headaches, belly pain and anxiety are the vast majority of ER visits,” said James Bush, medical director at the Wyoming Department of Health. “We’d rather pay paramedics to keep patients in the home.”
Wyoming also works with telehealth services, which use videoconferencing and mobile apps to diagnose, monitor, treat and manage patients remotely. These telehealth services have enabled thousands of “virtual visits” over the past 10 years, Bush says. Patients with urgent conditions, such as an ear infection, can use encrypted Internet connections (as required by federal health privacy law) to contact their physicians, reducing strain on emergency care facilities.
Telehealth services can assist immediate stabilization efforts as well. For example, if a child with a severe burn is taken to a hospital without a burn center or a pediatric center, physicians can consult specialists for help with triage and any immediate treatment needs before transferring the patient to a burn center. Two 2018 studies found an association between telemedicine consultations and faster door-to-care provider time, faster transfers and decreased emergency department stays for severely injured patients. Of course, access to broadband service, which is necessary for high-quality video-conferencing, is still scarce in many remote locations.
Samaritans saving lives
In rural America, bystanders are also being trained to help at the scene of an accident, such as a road collision or farm equipment injury, according to Stop the Bleed, an American College of Surgeons public education program. The program’s goal is twofold: to place bleeding-control kits in every public venue and to train passersby to stop emergency bleeding until professional help arrives.
“We’re training laypeople to stabilize and stop hemorrhage,” Hughes said, “and that’s going to make a huge difference in whether people are going to survive or not.”
Many of the program’s techniques, such as blood vessel compression and tourniquet use, are based on military research from the Afghanistan and Iraq wars. As of 2018, at least 124,350 people have been trained to “stop the bleed.”
Telehealth services and bystander-assistance measures can help fill in treatment gaps. But Gienapp says we still need to improve rural emergency care if we want to see the injury fatality rate come down. “Emergency care is in trouble,” Gienapp said. “Rural, critical-access hospitals are on the edge of being able to stay afloat, and emergency medical services agencies are understaffed.”
Addressing the problem, Gienapp says, will take “creative people with different solutions” acknowledging what’s going on in rural America. “If we keep sticking our heads in the sand and saying that it’s not a problem,” he said, “we’ll soon find out how big a problem it really is.”