This issue was prepared by EAST Rural and Community Care Committee Members Ariel Santos, MD, MPH and Tyler Johnson, DO.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Rural Surgery
Scroll down to see summaries of these articles
Article 1 reviewed by Erin Burton, MD and Ariel Santos, MD, MPHRural Trauma Team Development Course Positively Impacts its Desired Objectives. Bauman ZM, Khan H, Raposo-Hadley A, Daubert T, Hamill ME, Kemp K, Evans CH, Terzian WTH, Waibel B, Cantrell E.
Am Surg. 2024 Jun;90(6):1250-1254.
Article 2 reviewed by Erin Burton, MD and Ariel Santos, MD, MPHInnovative blood transfusion strategies to address global blood deserts: a consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition. Raykar NP, Raguveer V, Abdella YE, Ali-Awadh A, Arora H, Asamoah-Akuoko L, Barnes LS, Cap AP, Chowdhury A, Cooper Z, Delaney M, DelSignore M, Inam S, Ismavel VA, Jensen K, Kumar N, Lokoel G, Mammen JJ, Nathani P, Nisingizwe MP, Puyana JC, Riviello R, Roy N, Salim A, Tayou-Tagny C, Virk S, Wangamati CW.
Lancet Glob Health. 2024 Mar;12(3):e522-e529.
Article 3 reviewed by Tyler Johnson, DO, Joshua Bennett, MD, MPH and Madison Clements, DOThe pulmonary contusion score: Development of a simple scoring system for blunt lung injury. Torlle LJ, McNickle AG, Feery D, Mohammed S, Chestovich PJ, Batra K, Fraser DR.
Surgery in Practice and Science. 2024 June
.Article 4 reviewed by Tyler Johnson, DO, Joshua Bennett, MD, MPH and Madison Clements, DOHemodynamic deterioration of trauma patients undergoing interhospital transfer. Michos L, Whitehorn GL, Seamon M, Cannon JW, Yelon J, Kim P, Hatchimonji JS, Song J, Kaufman EJ.
J Surg Res. 2024 Jun:298:119-127.
Article 1
Rural Trauma Team Development Course Positively Impacts its Desired Objectives. Bauman ZM, Khan H, Raposo-Hadley A, Daubert T, Hamill ME, Kemp K, Evans CH, Terzian WTH, Waibel B, Cantrell E. Am Surg. 2024 Jun;90(6):1250-1254.
Many rural hospitals are unequipped to handle acute trauma patients, take longer time to transfer to higher level of care and tend to obtain numerous amounts of imaging studies prior to transfer. By focusing on improving the locoregional trauma centers, we are able to save more lives, improve cost efficiency, and increase quality of life of trauma survivors.
The Rural Trauma Team Development Course (RTTDC) was created by the ACS Committee on Trauma in 1998 and is composed of an eight-hour course aimed at improving rural trauma centers focusing on quick identification of a severely injured trauma patient and expedited transfer to a higher level of care.
This is a prospective, observational study from 2015 – 2021 that analyzed RTTDC. Patient cohorts were obtained before and after the course was given to rural hospitals. Emergency department dwell time, decision to transfer time, number of total images obtained, and mortality were all evaluated. The data collection involved 16 hospitals in Nebraska and Western Iowa and a total of 472 patient transfers (240 before the course and 232 after the course was instructed). The authors found that ED dwell time was significantly reduced by 64 minutes, decision to transfer time was cut by 62 minutes, and that the average total number of imaging obtained prior to transfer was reduced. Mortality was unaffected by implementation of the RTTDC. This study is limited by being a single center study and not all staff at the hospitals participated.
Results of the study further emphasized the goals of RTTDC which include quickly stabilizing patients, recognize when a patient needs to be transferred based on facility resources, and to not delay transfer by getting images prior to transfer. It should be the goal of all Level 1 and 2 trauma centers to promote RTTDC to all rural hospitals in their catchment areas.
Article 2
Innovative blood transfusion strategies to address global blood deserts: a consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition. Raykar NP, Raguveer V, Abdella YE, Ali-Awadh A, Arora H, Asamoah-Akuoko L, Barnes LS, Cap AP, Chowdhury A, Cooper Z, Delaney M, DelSignore M, Inam S, Ismavel VA, Jensen K, Kumar N, Lokoel G, Mammen JJ, Nathani P, Nisingizwe MP, Puyana JC, Riviello R, Roy N, Salim A, Tayou-Tagny C, Virk S, Wangamati CW. Lancet Glob Health. 2024 Mar;12(3):e522-e529.
Access to blood transfusion is a major issue in many rural communities across the globe. Blood transfusion is a critical component of many aspects of healthcare, including trauma related injuries, obstetric hemorrhages, nutritional and hereditary anemias, and surgical care. In low- and middle-income countries, there is a 102 million annual unit blood shortage. The term blood desert refers to areas of the world where there is no reliable access to blood transfusion where essential clinical demand for blood components cannot be met at the point of care in a timely and affordable fashion, in at least 75% of cases where transfusion is needed. A panel was held in Jan and April 2023 comprised of physicians from low- and high-income countries from multiple specialties including surgery, OB, general practice, and military transfusion medicine, along with industry experts, researchers, and patient advocates. The panel identified three emerging strategies to help alleviate the crisis in blood deserts: walking civilian blood banks (WBB), intraoperative autotransfusion (IAT), and drone-based blood delivery (DBD).
Walking blood banks refers to mobilizing donors in times of emergency in which blood is collected and screened for antibodies and infections when available, and universal donor or type specific fresh whole blood is transfused to patients with emergent needs.
Intraoperative autotransfusion such as cell saver, is currently used in many academic centers, however is not thoroughly utilized in blood deserts. This reduces the need for allogenic transfusion, the risk of introducing new infection, and the need for typing and therefore shortens the time to transfusion. This should be considered as a salvage therapy when the patient is at risk of imminent death or disability from hemorrhage (as deemed by the operating surgeon), or planned operations with expected large volume blood loss without GI spillage.
Drone based blood delivery would help expedite delivery to the blood desert areas while being able to access a well-stocked storage hub. Drone based blood delivery helps eliminate delivery factors such as manpower or terrain difficulties and has been used in USA, Switzerland, Rwanda, Haiti, etc. However, drone implementation would need to be supported by increasing the donation blood supply to keep up with the ability to deliver to previously difficult areas to reach as well as effective blood management at the hub.
The aim of this paper was not to recreate or replace the current blood banking system, which is continually a work in progress. The three pillars evaluated in this paper were to help improve access to blood while continuing to build well established, high quality, sustainable, context-appropriate blood banking systems worldwide. It helps bring to light a major deficit that is occurring worldwide that many clinicians are unaware of and offers three interesting and prospective techniques that we could utilize to help improve this issue. By continuing to evolve our blood bank, and blood delivery processes globally, we would be able to alleviate the deaths and disabilities that occur to patients as a direct result of lack of access to proper blood products. Blood alternatives as well blood conservation practices though not discussed in this paper should also be considered.
Article 3
The pulmonary contusion score: Development of a simple scoring system for blunt lung injury. Torlle LJ, McNickle AG, Feery D, Mohammed S, Chestovich PJ, Batra K, Fraser DR. Surgery in Practice and Science. 2024 June.
Clinical recognition of the severity of blunt pulmonary injury after chest wall trauma is an important factor in the ultimate outcome of the rural trauma patient. Pulmonary contusions are known to be a driving factor in clinical deterioration requiring intubation and prolonged ventilatory support. For rural hospitals providing initial surgical resuscitation and stabilization, recognizing a severe blunt lung injury through common imaging modalities could be crucial in early transfer to a facility which has the capacity to provide specialized intensive care, or deciding to continue care for the patient at their facility. Most rural trauma centers have ready access to a computerized tomography (CT) scanner which can be used to diagnose pulmonary contusion.
Previous pulmonary contusion grading scales have been proposed but require the use of three-dimensional reconstructive computer programs to quantify severity. These are not available at all hospitals, especially critical access hospitals and rural trauma centers. To simplify severity stratification, the authors developed a novel scoring system known as the Pulmonary Contusion Score (PCS). The scoring system evaluates each lung lobe for contusion and is a simple sum, with a maximum of 10 points. 0 points are assigned for no contusion present in a lung lobe, 1 point assigned for contusion volume of 50% or less, and 2 points for contusions greater than 50% of a lobe. A PCS ≥ 4 was noted to correlate with a need for mechanical ventilation for more than 48 hours.
This was a retrospective review of adult trauma patients that analyzed the sensitivity and specificity of the PCS in predicting the need for mechanical ventilation after blunt lung injury. They included 217 patients age 18 years old and above who presented to their level 1 trauma center after blunt injury with resulting pulmonary contusion identified on CT in the year 2020. They excluded patients who died within 24 hours of arrival or had a head abbreviated injury score greater than 3. Their primary endpoints were duration of mechanical ventilation, procedures, and outcomes. The analysis revealed patients with a PCS < 4 were unlikely to need prolonged mechanical ventilation with a 93% specificity and 93% negative predictive value. One weakness of this study is that a significant number of patients with PCS ≥ 4 required ventilation for management of severe TBI, potentially confounding these results.
The results of this investigation reinforce the importance of a reliable scoring system in the initial management of the trauma patient with lung injury. Rapid quantification of the severity of contusion has important implications in the decision making process when considering early transfer from a rural center to a higher level of care. By utilizing this system, providers could quickly decide to arrange transfer if the level of expected care outweighs their resources, or be reassured in keeping patients with lower scores, which prevents transfer overload to urban trauma centers and allows for safe treatment of patients in their own community. This assessment of the PCS provides evidence supporting its use and should be incorporated in the practice of rural trauma providers.
Article 4
Hemodynamic deterioration of trauma patients undergoing interhospital transfer. Michos L, Whitehorn GL, Seamon M, Cannon JW, Yelon J, Kim P, Hatchimonji JS, Song J, Kaufman EJ. J Surg Res. 2024 Jun:298:119-127.
Well organized trauma systems reduce morbidity and mortality by providing appropriate and expedient care for time-sensitive injuries. Rapid transport to high-level trauma centers is preferred, but not every injury occurs in a geographic location that makes this possible, this is particularly true in rural areas. Interhospital transfers therefore represent a crucial element of trauma system function. Level I and II trauma centers that provide comprehensive injury care receive injured patients in transfer from lower level and non trauma centers. Common indications for transfer include patients with a high-energy mechanism, multisystem injuries, or injuries involving the brain. Although transfers are essential for appropriately selected patients,the process can be fraught with adverse events, delays in treatment, and limited resources en route. The goal of the authors research was to characterize patients at risk for hemodynamic deterioration (HDD) in interhospital transfer. Their hypothesis was that despite initial stability, patients whose hemodynamics deteriorated between hospitals would have worse outcomes than those who remained stable on transfer.
This was a retrospective cohort study that utilized the Pennsylvania Trauma Outcomes Study (PTOS), which includes all accredited trauma centers in Pennsylvania. The inclusion criteria was defined as; Patients aged >16 years were included if they were designated as transferred into a Pennsylvania trauma center, from 2011 to 2018, and if they were hemodynamically stable (HDS) on initial presentation to the referring center. Children aged less than < 16 years were excluded to avoid transfers to pediatric centers solely based on patient age and to simplify assessment of vital signs. HDS was defined as heart rate (HR) <100 beats per minute and systolic blood pressure(SBP) >100mmHG. Patients were excluded if transfer occurred 24 h after presentation. Outcomes of interest included in-hospital mortality, length of stay, and complications, as well as disposition from the emergency department. 52, 919 patients met inclusion criteria over the study period.
Of the patients with HDD, 4440(83.5%) had normal blood pressure but elevated heart rate on arrival at the receiving center. 813 (15.2%) were hypotensive with a normal heart rate. 63 (1.2%) were both hypotensive and tachycardic. Of the patients with HDD, 124 (2.5%) had an SBP of < 80 mmHg on arrival to the receiving center. 740 (13.9%) had a heart rate > 120 bpm on arrival to the receiving center. Of 52,911 included patients, 10,160 (19.2%) had an elevated shock index on arrival to the receiving center. Patients with elevated shock index had high mortality rates (3.1% versus 2.3%, P < 0.001), longer length of stay (4 versus 3 days, P < 0.001), and higher rate of complications (14.1% versus 7.1%, P < 0.001). HDD patients were more often moderately-severely injured (injury severity score 9-15). Injured in motor vehicle collision or gunshot wound (GSW), with extremity or torso injuries. The time between arrival to the referring center and the receiving center were similar for both groups. A greater proportion of patients who developed HDD en route received more blood products and were transported to the ICU, OR or IR than their HDS counterparts. Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable.
This is a very interesting topic particularly for the rural trauma provider but for receiving facilities as well. They identified a population (1/10 patients) that were HDS initially but decompensated during transfer and had worse outcomes. The authors note that nearly 90% of patients were transferred from non trauma centers and those patients were at higher risk of HDD than those transferred from lower level trauma designated facilities. Showing there is room for both improvement and further study. It could be inferred that expanding Level III and IV systems may improve outcomes for this subset of trauma patients given the worse outcomes for non trauma designated centers or expanding training/resources opportunities at non trauma centers, While the authors did elucidate factors that contributed to HDD, further study could be directed at specific factors that lead to HDD and potential interventions low resource facilities could provide prior to transfer. This could improve patient outcomes and aid receiving facilities in reducing resource utilization while identifying patients at high risk for intervention on arrival. They highlight the importance of two way communication between transferring and referring facilities, as well as new frontiers in the utilization of telehealth. The authors recognized the limitations of their study to include its retrospective registry based nature, survival/selection bias and their broad definition of HDD. The authors should be commended for their work with this difficult to study patient population.
