Rural trauma deaths would decline if ambulances could bill insurance companies for delivering blood on way to hospital

A fire-district ambulance on a dirt road after a training exercise near Fruita, Colo., last April. The West and parts of the South pose big challenges for rural emergency medical services. (Photo by Smiley Pool, Dallas Morning News)

In 2020, a traumatic injury killed an American every 31½ minutes, and such injuries are the top killer of children and adults under 45. Those statistics could be better if more ambulances carried blood and could bill insurance companies for administrering it, Lauren Caruba of the Dallas Morning News reports in a package with the San Antonio Express-News focused on rural America.

The problem is worst in the sparsely populated West, but "parts of the South performed worse compared with the coasts," Caruba reports. The package focuses on western Colorado and has an interactive map showing how far every location in the 48 contiguous states is from a trauma center.

"The vast majority of emergency medical providers . . . are unequipped and underfunded, leaving them unprepared to fully treat patients with severe internal bleeding," Caruba writes. "Across the country, bleeding patients receive drastically different care depending on where they are injured and the emergency providers who treat them." Awareness of the issue "has been mostly confined to medical journals and discussions within the medical community, leaving the general public largely uninformed about the extent of the epidemic."

"The solution is straightforward: If paramedics widely carried blood, as military medics have done for years, tens of thousands of lives could be spared annually. But the country’s fragmented health-care system does not allow for an easy fix. . . . Despite repeated pleas from specialists, the federal government has not prioritized or properly invested in the plight of injured Americans."

With each minute that passes after a potentially fatal injury, the possibility of death increases, "especially within the first half-hour, when severe bleeding deaths peak," Caruba notes, citing research. "An estimated quarter of all Americans live further than a 30-minute drive from Level I or II trauma centers, which provide the highest level of care to injured patients."

The Defense Department has greatly improved combat death rates with faster evacuation, "increased tourniquet use and administered blood on the way to the hospital," Caruba notes. "No such overhaul has happened in U.S. health care, and efforts have not been made to broadly adopt the military’s best practices, particularly before patients reach a hospital."

In 2019, fewer that 1% of trauma patients "received blood products of any kind on the way to the hospital, even when they displayed clear warning signs of bleeding out," Caruba reports, citing research by the University of Alabama-Birmingham. She notes that there is relatively little research into trauma deaths, and that the federal government doesn't even track them. But a federal report in 2016 estimated that 20,000 to 30,000 trauma deaths a year were potentially avoidable.

The U.S. has more than 23,000 emergency medical services, but only about 100 ground services have blood, "trauma advocates have found in recent surveys. While most air ambulance companies carry blood products, they treat only a small fraction of injured patients," Caruba reports. "Blood is a costly, limited resource, and most emergency medical providers lack relationships with blood banks. They also face regulatory and logistical hurdles, like maintaining blood refrigeration temperatures in the field and creating a system where unused units do not go to waste."

The Prehospital Blood Transfusion Initiative Coalition is focusing on the servcies' "inability to bill insurers for the cost of the blood and the rules in some states that prevent paramedics from starting transfusions," Caruba reports. "The group hopes to present recommendations to Congress and the National Association of State EMS Officials next year. Their goal is that every patient with major bleeding — including the injured and those hemorrhaging from medical complications — will receive blood if they need it."

Staffing issues put one-third of rural ambulance services in jeopardy, National Rural Health Association says

A Tri-State ambulance (Image from WEAU-TV)

One-third of rural emergency medical services are so short-staffed that they are in "immediate operational jeopardy," posing risks to rural residents who rely on them as a health-care safety net, says a policy brief from the National Rural Health Association.

"Dwindling population, losses in the volunteer workforce, and decreased reimbursement threaten continued access to these services," says the the brief by Nikki King, Marcus Pigman, Sarah Huling and Brian Hanson.

"One of the largest contributing factors to the disparity in mortality rate from traumas, such as overdose, for rural residents (discussed above) is travel time and distance to trauma centers," they write. "Rural residents are significantly more likely than non-rural residents to die following traumatic injury."

Hayley Spitler of WEAU-TV in Eau Claire, Wis., cited the brief in a story that featured Kent Stein, operations manger of Tri-State Ambulance. "We're experiencing the same thing that companies are experiencing nationwide, both volunteer and professional companies. We sometimes can run into a challenge finding EMTs and medics out of school."

Study finds that adverse childhood experiences increase risk of opioid addiction, relapse after treatment

A newly published study quantifies how trauma experienced during childhood, called adverse childhood experiences, can lead rural people to become addicted to opioids. Common ACEs include having an alcoholic or depressed parent, and being abused or neglected.

Researchers from the University of Tennessee and the University of Memphis conducted an in-depth study of 87 patients seeking opioid addiction treatment at a rural medical clinic. All the patients were white and 75 percent were male; almost half of them reported four or more adverse childhood events. A higher number of ACEs correlated to an increased risk of addiction relapse: every additional ACE increased the odds of relapse by 17%, according to the study.

On he other hand, each treatment visit reduced the odds of a relapse by 2%. Relapses occurred in 54% of patients, and the highest relapse rate happened after the first clinic.

Lead author Karen Derefinko said the study shows the lasting impact of ACEs, Jane Stevens reports for ACEs Connection.

"This study will help practitioners understand the importance of providing trauma-informed treatment," Derefinko told Stevens. "Because of the stigma associated with drug use, it’s hindered health care workers’ understanding of why people use drugs and has led to an assumption that they’re bad people. This shows that trauma-informed care and providing resources does impact how well people can do. It’s also validating for patients and gives them a lot of hope."

Childhood trauma can cause long-lasting harm to rural adults; help less available in rural areas

People living in rural areas are more likely to deal with poor physical and mental health; the reasons are a complicated web of interconnected factors such as smoking or drug use, workplace hazards, lack of access to physical or mental health care, poverty, and despair. But another reason for poor health is adverse childhood experiences, which are "significant disturbances in a child’s life that affect their security and ability to function in healthy ways. ACEs include all forms of child abuse (emotional, physical, or sexual), neglect (physical or emotional), or household dysfunction (divorce, violence, incarceration, substance abuse, or mental illness)," Jenn Lukens reports for the Rural Health Information Hub. ACEs can cause a self-perpetuating cycle of poor life outcomes that in turn create more ACEs for the next generation.

ACE exposure in rural adults. (Source)

According to a 1998 study by insurer Kaiser Permanente and the Centers for Disease Control and Prevention, the more ACEs a child experiences, the more likely he or she is to experience chronic health conditions, anxiety disorders, a lack of accomplishment in life (career, etc.) and even early death. Subsequent studies confirmed that research and found that "because the central nervous system closely interacts with the body’s immune, hormone, and clotting systems, adverse experiences in a child’s life, especially repeated ones, can change how the organ systems function later on. This process is known as 'biological embedding' and could take years or even decades before symptoms start to show," Lukens reports. And rural children are more likely to experience certain ACEs such as poverty, living with a mentally ill person, and living with a person who abuses drugs or alcohol.

Dr. Jean Talbot of the Maine Rural Health Research Center led research for a 2016 study that looked at how ACEs affect adults in both rural and urban areas. "ACEs cluster together. People who report having an ACE are more likely to have more than one," Talbot told Lukens. "It’s easy to think of ways that this could happen. For example, if a parent experiences incarceration or mental illness, this in itself is an ACE for the children in the family, but it can also impair the adult’s ability to care for kids. So it may open up the fault line exposing children to other types of adversity."

Helping kids deal with ACEs could have a big impact on rural health. "We know that ACEs are linked to high-risk health behaviors like smoking and alcohol abuse," Talbot said. "These, in turn, contribute to health outcomes like heart disease, lung cancer, and diabetes – some of the major causes of the widening rural-urban mortality gap. So, if we want to close this gap, we may need to address rural ACEs as part of that effort."

Some rural community clinics and school districts are trying to address ACEs with programs that train teachers to watch for kids facing adverse conditions, and other programs that help children process trauma. Pediatricians are often the first professionals to see that a rural child has had an adverse experience, so the CDC and some nonprofit groups are raising awareness with doctors about the importance of keeping an eye out for them.

Rural patients less likely to go to trauma centers, more likely to die in first 24 hours, says study

Triage sensitivity and specificity estimates for rural
patients (OHSU chart; click on it for a larger version)

Critical trauma patients from rural areas in the Pacific Northwest are far less likely than urban patients to be taken to a major trauma center. That's not surprising, but an apparent effect is more important: Rural trauma patients are more likely to die within the first 24 hours, says a study by Oregon Health & Science University published in JAMA Surgery.

Researchers found that 29.4 percent of rural patients needing critical care were initially transported to a trauma center, compared to 88.7 percent of urban patients. When accounting for transfers, 39.8 percent of rural patients were cared for in trauma centers, compared to 88.7 percent of urban patients. While overall mortality rates were similar, 89.6 percent of rural deaths occurred in the first 24 hours, compared to 64 percent of urban deaths.

Not only do rural patients have longer distances to travel to a major trauma center, they may choose to be hospitalized closer to home, OHSU doctor Craig Newgard, the lead author of the study, Sue Vorenberg of the Portland Business Journal. Many high-risk rural patients “never make it to a major trauma center. And the explanation for that is kind of complicated. There’s no one easy thing to point to,” Newgard said. “We may need a culture change by providers, recognizing that seriously injured patients in rural areas need to be transferred to a major trauma center more quickly.”

The study looked at 2011 data from 67,047 people (1,971 of them rural) transported by EMS to 28 hospitals in Oregon and Washington. "Among the 53,487 patients transported by EMS, a stratified probability sample of 17,633 patients (1,438 rural and 16,195 urban) was created to track hospital outcomes (78.9 percent with in-hospital follow-up)."

Study of teens' concussions shows a wide range of symptoms, some of them with cause and effect

University of Kentucky researchers have discovered surprising differences in symptoms student athletes experience following a concussion, a particular concern as high-school football season nears.

Lisa Koehl, a doctoral candidate in the university's Department of Psychology, and Dan Han, director of the Multidisciplinary Concussion Program at UK HealthCare, drew from a UK database of patients with brain injury and drew a sample of 37 athletes aged 12 to 17.

Koehl said in a press release that 22 of the 37 participants had emotional symptoms after suffering concussions. Among those with such symptoms, 23 percent also had sensitivity to light, while 14 percent had sensitivity to noise. Of the teens who did not have emotional symptoms, 13 percent had light sensitivity, but none of them had noise sensitivity.

Han said said participants who reported anxiety were 55 percent more inclined to have attention difficulties than those who didn't report anxiety. Teens who were irritable or aggressive were 35 percent more likely to report issues with attention those those who were not irritable.

The two groups did not show differences in how many experienced "loss of consciousness, amnesia, nausea and/or headaches, indicating that the groups were likely comparable in the level of the severity of concussion," the press release says.

Koehl said the research helped them understand how physical and emotional symptoms in concussion patients interact, with each causing the other in different cases. "Identifying factors that affect a teen's experience after concussion may help in planning for the appropriate treatment and in making decisions about when to return to play and what accommodations are needed at school during recovery," Han said. (Read more)

Youth athletes more at risk for head injuries; small-town sports editor localizes the issue

College football instituted a controversial new rule this year called targeting, in which a player who creates a head-to-head collision is ejected from the game and the first half of the next game, plus a 15-yard penalty for his team. For years, professional football has adjusted its rules to protect players from head injuries, and several retired players have suffered so much pain from multiple concussions that they have asked for their brains to be studied then they die. 

Youth football practice in Hopkinsville, Ky. (Ky. New Era)

But what about younger athletes? The Institute of Medicine of the National Academies released a report this week that looked at concussions in sports for athletes ages 5 to 21, finding that concussion rates are higher for high-school football players than those in college, according to a press release. The study found that the number of athletes under 20 treated for concussions and other brain injuries increased from 150,000 in 2001 to 250,000 in 2009. The most dangerous sports for boys are football, ice hockey, lacrosse, wrestling and soccer; for girls they are soccer, lacrosse and basketball. (Read more)

Youth football players "are at an even greater risk than players at other levels, according to Dr. Robert Cantu, co-founder and medical director of the Sports Legacy Institute," reports Les Johns, recently appointed sports editor of the Kentucky New Era in Hopkinsville. Cantu told Johns, “The reason it’s more dangerous to the brain is that brains at that age are not nearly fully myelinated — which is the coating of nerve fibers, like coating of a telephone wire, which gives it better transmission and better strength. The young child’s brain fibers are much more easily torn than they are as adults.”

Cantu, who believes tackle football should be banned for players under 14, said it doesn't matter if they don't hit each other with the same ferociousness as college and pro athletes, Johns writes. Cantu told him, “That youngster’s brain is lighter than an adult brain, and it takes less acceleration for it to violently shake inside the skull. There’s less inertia than an adult brain would have. It is also housed in a very weak neck attached to a very big head. That ‘bobble-head’ affect also puts it at great risk.” Cantu also said studies have shown that "youth recover more slowly than adults from head trauma, especially those who suffer repetitive brain injuries."

Youth leagues are making changes to create a safer environment, Johns writes. Terrence Davis, commissioner of Bud Hudson Youth Football in Hopkinsville, told him, “We have two high-school certified referees on the field, so they’re over all health issues.” Cantu was skeptical, saying “God bless ‘em if it’s true, but I doubt it. They don’t have doctors at those games, unless it’s a parent. They don’t have medics or athletic trainers. They don’t have anybody that could recognize a concussion, or is trained to do it.”

Mark Graham, a former high school football player, who has been a league referee for 20 years, told Johns, “The coaches are ultimately responsible for the kids, but the officials here are licensed with the [Kentucky High School Athletic Association]. We get extensive training through the state of Kentucky to recognize what a concussion is. If we see it as an official, we can determine that he sit out until he gets a medical release.” (Read more) What are youth coaches in your area doing?

The numbers tell the stories: Rural trauma is more likely fatal, and rural health has chronic problems

Here are stories that can be told in almost any state, just with different data: Georgia Rural Health Association Executive Director Matt Caseman writes that you are more likely to die if you suffer a traumatic injury in rural Georgia than if it's in a metropolitan area. He says 67 of Georgia's 159 counties do not have a surgeon, and 115 do not have a neurologist.

"More than 1 million Georgians live at least 50 miles from a Level 1 trauma center — the kind that handles the most serious cases. That distance makes it virtually impossible to get them to such a facility within the 'golden hour' — the period after a major trauma accident when emergency responders have the greatest chance to save a life," Caseman writes for Georgia's Saporta Report. "In metro Atlanta, there’s one fatality in every 339 accidents. In rural Georgia, it’s one fatality in every 74 accidents."

More broadly, Caseman also notes that 65 Georgia counties don't have a pediatrician, 68 don't have a gynecologist, and rural Georgians are more likely to be uninsured or under-insured and suffer from heart disease, diabetes, obesity and cancer. He explains that rural populations are older, so they have greater health care needs, and rural Georgians are more likely self-employed, so they pay more for health insurance and don't go to the doctor so often. And more rural Georgians are on Medicaid.

Caseman has counterparts in every state, and they are members of the National Rural Health Association. All are good sources of information about rural health; so is the federal Office of Rural Health Policy.

Injury hospitalization rate is higher in rural areas

Injuries requiring hospitalization occur at a significantly higher rates in rural areas, according to a study that researchers say is the first of its kind.

“As the population density decreases, the risk continues to increase,” said Dr. Jeffrey H. Coben of the Injury Control Research Center at West Virginia University. “If you just look at violence – person against person – the rates are higher in urban areas. But for virtually every other cause of trauma, the risks are substantially greater in rural areas.”

Previous studies found that death rates from injuries are higher in rural areas. This study examined all injuries that prompted admissions to U.S. hospitals in 2004. Hospitalization rates for injuries were 35 percent higher in sparsely populated rural counties and 27 percent higher in more populated rural counties. (The release from Newswise, a research-reporting service, didn't make clear whether the comparisons were with metropolitan-area counties or the U.S. as a whole.) The study is published in the January issue of the American Journal of Preventive Medicine.

Why is rural riskier? In addition to promptness of care, other factors include higher-risk occupations such as farming, longer commuting distances, and a host of other possible factors. "Previous studies have shown that people who live in rural areas are more likely to take part in risky behaviors such as recreational drug use, drunken driving or failing to use seatbelts," Newswise reports. "Plus a culture of self-reliance may cause people to undertake household fix-up chores that are inherently dangerous, such as roof repairs." (Read more)

Association of Health Care Journalists holds its first Rural Health Journalism Workshop

We're live-blogging today from the first Rural Health Journalism Workshop, being held by the Association of Health Care Journalists at the University of Missouri in Columbia, Mo. We're just hitting the high points, but the sessions are being recorded and will eventually be posted on the association's Web site.

The workshop began yesterday with an overview of rural America and its health-care system, moderated by your blogger. The panelists were Charles Fluharty, director of policy and director emeritus of the Rural Policy Research Institute; Dennis Berens, director of rural health for the state of Nebraska and former weekly newspaper publisher; and Patricia Thomas, who holds the Knight chair in health and medical journalism at the University of Georgia. One unexpected focus of the discussion was trauma care. It's always been an issue in rural areas, but is being complicated by the declining state of volunteer ambulance services in many rural communities, Berens said.

Today's first session was on diabetes, which almost one in 10 Americans have. Many rural areas have high rates of the disorder, which can lead to many other medical complications and disease; most diabetics live 10 to 14 fewer years than non-diabetics, said Dr. David Gardner of the University of Missouri.

Dave Templeton of the Pittsburgh Post-Gazette was not only the moderator but an example. He said he is a Type 1 diabetic who was diagnosed at 11 and has lived all his life in a rural county, but "Not once was I ever asked to take a diabetes education course. . . . Diabetes requires self-management."

The other panelists were Dr. Edwin Fisher of the University of North Carolina, who talked about diabetes self-management in rural communities, including Richland County. Mont., on the North Dakota border, and among migrant farmworkers in southwestern Arizona; and Patty Johnson, a nurse and diabetes educator in three rural counties in the southwest corner of Pennsylvania that have high rates of amputation resulting from diabetes.

Fisher said the best diabetes care is community-based, with support groups and activities to encourage self-management. We think rural journalists should think of themselves as part of the community effort, because many people with diabetes resist doing much about it. Gardner cited what he called "the law of halves:" Half the people with diabetes accept intervention, half of those who accept intervention follow the advice, and it works for only half of those, equaling only one-eighth of the diabetic population. For Fisher's help in covering diabetes, you can e-mail him here.

We think one of the most important roles journalists can play in combating diabetes is helping people avoid Type 2 diabetes, the most common form, in which the body becomes insensitive to the insulin in produces to process sugar in the blood. The major steps are losing weight and being more physically active. One way to approach this would be to find someone who has been diagnosed as pre-diabetic (high blood sugar but not high enough to be diabetic), has friends or relatives with diabetes, and has successfully avoided the disease by taking appropriate measures.

Gardner emphasized the role of genetics in the development of diabetes, and noted that it is a disorder, not a disease, and is not just related to blood sugar; other factors that need treatment include blood pressure, cholesterol and other compounds that harm the body. "it's important that we recognize this as a genetic disease made worse by our environment -- too much food, not enough exercise," he said, adding that it's also the wrong kind of food; Gardner said the closing of supermarkets in rural areas has made proper food harder to find and reduced the quality of diets. He said too many stories over-emphasize the role of obesity in diabetes: "Don't blame the patients in your stories, and at the very least, show the patients hope."

Legislator filing bill to create trauma system for Kentucky hospitals; will rural hospitals support it?

We reported here three weeks ago that rural Americans are dying because their states lack systems to designate hospitals to treat traumatic situations. One of those states is Kentucky, but maybe not for long, if advocates can overcome a tough budget situation -- and maybe opposition from rural hospitals. Yes, you read that right. Rural hospitals. Read on.

"State Rep. Bob DeWeese (R-Louisville), a surgeon, said he expects to file legislation early this week that would create a statewide trauma system," reports Karla Ward of the Lexington Herald-Leader. "The system would provide more education for doctors, nurses and paramedics to care for and assess severely injured patients, so that they are taken to the most appropriate facility as quickly as possible. ... The legislation would also encourage more community hospitals to seek designation as trauma centers, and would enable statewide guidelines and protocols on where patients should be taken for triage."

Dr. Jeffrey Coughenour, a trauma surgeon at the University of Kentucky, told Ward that states with mature trauma systems have seen a 15 to 20 percent fewer deaths from traumatic injuries. A bill to create a system in Kentucky passed the state House last year but died in the Senate. The bill's price tag is $2.8 million, which will probably be tough to get at a time when the state budget is being cut. DeWeese said the Kentucky Hospital Association supports his bill; however, that doesn't necessarily mean that all its members do.

Ward reports, "Smaller hospitals have balked at the idea because of competition -- they fear that the hospital in the next county will look better if it becomes a trauma center and they don't, Coughenour said. There's also the concern that a trauma system will cause small community hospitals to lose patients to the larger trauma centers." Coughenour told Ward that his university, which has one of the two top trauma centers in the state, gets many patients who would be as well served closer to home and has no interest in taking patients from smaller hospitals. "We don't want everybody," he said. "We're too busy here as it is." (Read more)

Lack of state trauma systems kills rural Americans

Rural Americans are dying from accidents because their states lack systems to designate hospitals to treat trauma victims, Laura Ungar reports today in The Courier-Journal.

"Trauma systems are designed to get injured patients the care they need as quickly as possible within a 'golden hour' in which survival is more likely," Ungar writes for the Louisville newspaper. "In states with trauma systems, more hospitals are encouraged to develop certain levels of expertise, paramedics and emergency medical technicians are trained in where to take patients, medical professionals coordinate services and a registry tracks trends."

States without trauma systems are Arizona, Idaho, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Ohio, Rhode Island, South Dakota, Vermont and Wisconsin. Indiana and Alabama recently started state systems. For a detailed, state-by-state rundown from the American College of Surgeons, click here.

Ungar reports that a bill to start a system in Kentucky "faces obstacles -- legislators wary of spending the millions it would require, rural hospitals concerned about the costs of becoming trauma centers and already-overburdened rural doctors worried that their on-call workloads would increase." (Read more)