Good results from advanced trauma care in rural areas

THE Rural High North has a high rate of fatal injuries and pre-hospital deaths, with almost nine of 10 trauma-related deaths occurring in the prehospital phase. Early detection of head injury, protection of the airway, control of external bleeding, treatment of hypotension and hypoxemia, fast transport to a hospital with neurosurgical facilities, prompt evacuation of intracranial hematomas, followed by advanced neurointensive care and rehabilitation are cornerstones in modern neurotrauma management. In urban areas, where most studies have been performed, a decrease in mortality and morbidity has been proven after implementing the Brain Trauma Foundation guidelines. In their study of patients with traumatic brain injury (TBI) from the rural northern Sweden, Brorsson et al. have shown that such results can also be achieved in vast rural areas with only one university Level I Trauma center. Even though the study population is small, and some of the conclusions are debatable, we congratulate the researchers for their successful efforts to document the effects and results in their rural trauma system, which is one part of a widespread regional emergency medical services system (EMS). The results of this study also challenge the concept of direct transport from the accident scene, bypassing the local hospitals, to the Level I Trauma center, as suggested in other studies. It is possible to establish and maintain a robust ‘chain of survival’ for the acute TBI patients by focusing on the basic principles of airway control and perfusion of the brain if the guidelines and practice are clear, simple and consistent. In remote areas, depending on many tiers in the ‘chain of survival,’ a well-coordinated trauma system is needed. The study from rural northern Sweden is most of all an example of such a well-designed and quality-controlled EMS system with qualified medical personnel responsible for each tier. A balanced, wellrehearsed and targeted use of local ground ambulances, local hospitals, air ambulances and Level I Trauma center can deliver optimal care to trauma patients, despite very long prehospital distances. Efficient trauma systems can be organized well in remote areas including local hospitals as an integral part of the ‘chain of survival’ to definitive treatment at a Level I Trauma center. Some important factors must be in place to achieve optimal care. The local population must be trained and have basic first aid skills so that the first (lay) person(s) on scene will be able and willing to perform basic life support. Equal and fast access by phone 24/365 to EMS through a well-known emergency number, properly staffed at a professional emergency medical dispatch center, must be established. Ground ambulances with EMS personnel and necessary emergency medical equipment, monitors and drugs must be available at short prehospital response times to arrive at the scene of the accident early. The local hospitals must spend limited time on resuscitation and diagnostic procedures before transferring the patient to the Level I Trauma center via a suitable, mixed ground and air ambulance system. Teleradiological image transfer to the trauma center will shorten the total time consumption before emergency surgery. Most important, probably, is that every tier in the chain has to follow the same principles and protocols of emergency medical treatment of the TBI patient. Even with long pre-hospital evacuation lines, a rapidly responding, integrated ambulance system can delivery TBI patients timely and quickly to the Level I Trauma center. The hospital infrastructure for such a trauma system is present in Scandinavia today. An optimal utilization of the infrastructure is often a challenge in many regions. Experiences from other life-threatening pre-hospital emergencies in rural environments with long