The dawning of the twentieth century brought with it a major transformation in American society. There began a massive exodus of the traditional agrarian population to the growing urban centers across the country. The appearance of the automobile and a myriad of other technological advances further encouraged this shift and provided Americans with a plethora of powerful and efficient tools. At the same time, those very advances provided more powerful and efficient sources of injury and death. By the 1950s, trauma had become a significant cause of death and serious disability across the U.S. and in many communities, both rural and urban, survival of such injuries became the exception rather than the rule.

In 1966, the National Academy of Science published a scathing report entitled “Accidental Death and Disability: The Neglected Disease of Modern Society” [1]. The expose quickly captured the attention of the press, the public, the medical establishment, and Congress and as a result the Emergency Medical System (EMS) was conceived. Soon the concept of regionalized trauma centers , standardized protocols for the management of the severely injured patient and a nationwide 911 access network emerged. As a consequence of such efforts, victims of trauma now received efficient and timely treatment and survival became the rule rather than the exception.

A half century later, America’s trauma system continues to thrive as designated trauma centers throughout the American landscape are staffed by board certified emergency room physicians, fellowship trained trauma surgeons, and critical care intensivists who man highly sophisticated and specialized ICUs. These frontline physicians are supported by air and ground transport teams which essentially bring the emergency room to the trauma victim while still in the field. Despite the widespread establishment of such networks there remains a significant population of our citizens who are well beyond the reach of one of these lifesaving institutions.

Patients in remote and rural areas often find that their local hospitals have a paucity of specialty coverage and limited access to the technological advances that most of us take for granted. How can these patients be best served when in need of competent care as a result of a major traumatic event? What options are open to provide lifesaving treatments in environments that have inadequate resources? The answers to these and other questions are the responsibility of not only the providers in the austere communities, but also of those of us who are integrated in the greater trauma care networks. In addition, successful solutions require the commitment of local, regional, and national political decision-makers.

First and foremost, it is essential to educate the physicians and mid-level practitioners who most often provide the care in remote facilities. It is the responsibility of the tertiary specialist to initiate the lines of communication between the rural providers and the larger facilities and to assure that the care the patient receives at the local hospital is appropriate. As a neurosurgeon, I have often times visited the medical staffs of outlying hospitals and lectured on the stabilization of the head or spinal cord injured patient. Discussing a common nomenclature such as the Glasgow Coma Score or advising when to give Mannitol or Methylprednisolone can be of enormous value to a physician or nurse practitioner inexperienced in treating severely traumatized patients. As important however, can be sharing with these colleagues what not to do in these situations as the principle “primum non nocere” must prevail.

On the other hand, it is incumbent upon the local practitioners to be open to these educational opportunities and willing to provide the expertise to stabilize the patient until transfer can be arranged. I attempt to make these first line providers competent in performing a brief but meaningful neurological examination and comfortable with initiating therapies which may keep open the window of opportunity for more sophisticated intervention as the “golden hour” is extended.

As regional medical centers become increasingly burdened with an influx of victims of traumatic injury we are finding more and more of these institutions unable to accept appropriate transfers because of bed availability. For this reason it is essential that the smaller facilities take a more active role in the management of less critically injured patients who may not require such tertiary care. Unfortunately, many of the providers in remote emergency rooms have learned the magic catch phrase “we don’t feel comfortable” managing a given trauma patient and thus the Emergency Medical Treatment and Active Labor Act (EMTALA) compels hospitals and physicians to accept in transfer a patient who could be well managed in their home facility [2].

For the system to function appropriately, smaller hospitals in remote and rural regions must accept the responsibility for the care of those patients. This “culture change” requires a strengthening of the relationship among the regional hospital and its many smaller referring facilities. The first piece of such a relationship is the educational component discussed in the previous paragraphs. But making them comfortable requires much more than sharing with them when to give an osmotic diuretic or how to calculate the Glasgow Coma Score. One of the major concerns of providers in remote regions is the rare patient who does deteriorate beyond the capabilities of the local hospital. The fear, not totally unfounded, is that when they call back asking for transfer they will find that now there are no beds available or that since the victim is now an “inpatient” and no longer in the emergency room EMTALA does not apply and the receiving consultant is free to refuse the transfer.

In those institutions with which we have attempted to establish a more symbiotic relationship, we have assured the providers that if a patient they have agreed to manage locally deteriorates, we guarantee that we will accept the immediate transfer regardless of bed availability. The problem justifiably becomes ours to solve and thus offers a degree of assurance that the local provider is not left managing a patient beyond his or her capability because they agreed to our advice to keep the patient initially. This policy is not an easy one to establish and requires a degree of trust on both sides that often takes years of familiarity and experience to emerge.

An additional piece of the puzzle that is essential for such a relationship to work is access by the regional trauma center to the diagnostic studies, however, limited of the outside institutions. Not infrequently, patients are transferred with a diagnosis that is not supported once the patient has been helicoptered in and the “outside” CT scan is reviewed locally. I have had patients airlifted to our institution with an “interhemispheric subdural hematoma ” only to find simply a calcified falx cerebri misread at the outside facility. Another elderly female, wide awake and asymptomatic after a fall, was transferred with a “6 cm epidural hematoma” when in fact she harbored a calcified meningioma that was present and unchanged on a CT scan 5 years prior. Having access to the PACS system of the referring hospital would have spared these patients an unnecessary transfer. Recently, my partners and I have been meeting with our referring hospitals’ radiology departments and obtaining access to their internal PACS systems on our home desktop computers. This allows us to view the X-rays and CT scans from several (but not all) of our feeding hospitals and can often times result in a local hospital admission and preclude transfer to a tertiary facility.

Rural practitioners can now be greatly aided with the emergence of telemedicine as an option to any facility with access to a computer. The definition of “telemedicine” is used rather broadly in the medical literature and most often refers primarily to “tele radiology”—the ability to review radiological studies over web based platforms. In the preceding paragraph I described our experience with “telemedicine” but the potential goes far beyond reviewing CT or MRI scans remotely and giving advice as to the necessity of transferring the patient to a tertiary center [3, 4]. For years, cardiologists and dermatologists have utilized real time technologies, to meet remotely with patients, render a diagnosis and prescribe a treatment plan. Using computer interfaces for live treadmill testing, cardiac auscultation, and real time images of patients has resulted in specialty access for individuals who previously were unable to obtain such consultations without long travel that many found prohibitive [5, 6].