Appalachian Health and Well-Being

10. Trauma

209 10 Trauma Levi D. Procter, Andrew C. Bernard, Paul A. Kearney, and Julia F. Costich This chapter addresses the problem of injury in rural areas of Appalachia, including the role of trauma systems in caring for the injured and the inadequacies of these systems in rural areas. Because systems for collecting data on injury are fragmented and limited in scope, the precise analysis of injury data in Appalachia remains impossible, even in the twenty-first century. Therefore, injury data from three Appalachian states are used as a surrogate for other rural areas in Appalachia. This chapter outlines specific deficiencies and concludes with recommendations for future research and policy initiatives. Epidemiology Trauma is the number-one cause of death in the first four decades of life in developed countries. Nearly 9 million people worldwide are injured annually , 300,000 of whom suffer permanent disability.1 Unintentional injury (UI) is the term for injury that is not caused by the human intent to harm oneself or another person.2 UI accounts for more than 100,000 deaths in the United States each year and is the fourth leading cause of death in all age groups.1, 3, 4 Major traumatic injury and death are much more common for men than for women, with men representing approximately two-thirds of the total population injured. Motor vehicle crashes (MVCs) are the leading cause of UI, accounting for more than 1 million injuries worldwide annually. Falls are the second most common cause of UI in those aged 45 to 75 years and the leading cause of unintentional death in persons older than 75 years, followed by poisoning, drowning, 210 Procter, Bernard, Kearney, and Costich and burns.1 In 2005 fatal and nonfatal UIs resulted in $625 billion in U.S. health care costs. Injury in Rural America Rural populations across the United States have significantly worse outcomes from UIs than their urban counterparts. Only 30 percent of the U.S. population lives in rural areas, but nearly 70 percent of injury-related deaths occur there.5, 6 In rural America a pedestrian struck by an automobile is three to four times more likely to die than one injured in an urban area,7 and the risk of death from MVCs is fifteen times as high.8 The likelihood of death from UIs in rural areas is inversely proportional to population density.9–12 In addition, injured rural patients are typically older and frequently die at the scene with lesser degrees of injury.13 Rutledge and coworkers13 found that injured rural patients who survived at least twenty-four hours were older, had more comorbidities, had less overall injury, and were more likely to die from multiple organ system failure when compared with similarly matched urban patients. In rural areas lacking trauma systems, UI-related deaths are distributed in a trimodal pattern—immediate, early, and late—which is also the basis for trauma system design.14 The first sixty minutes after injury—the “golden hour” of trauma—account for the highest number of deaths.15, 16 In the classic statement by Dr. R. Adams Cowley, “there is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later—but something has happened in your body that is irreparable .”16 Some 45 to 50 percent of those severely injured die immediately or very soon after injury.14, 17 The early mode is between one and four hours after injury, representing some 24 percent of deaths, and the late mode includes deaths occurring more than one week after injury due to multiple organ failure.14, 17 Late deaths now account for only 7.6 percent of all trauma deaths in areas with established trauma systems, reflecting improvements in critical care and resuscitation.17 Immediate deaths point to the need for better trauma prevention initiatives and education.Improvements in prevention are critical to lessening injury severity and mortality. For instance, trauma prevention programs Trauma 211 that focus on safe workplaces, use of seat belts, alcohol and substance abuse deterrence, proper helmet usage, and firearm safety offer the greatest potential benefit in terms of preventing immediate deaths. The severely injured who do not die immediately represent a sizable injured population for whom appropriate trauma care, if delivered quickly and...