One in eight Americans live in urban areas, but 60 percent of deaths from trauma occur in rural areas. In Iowa, most rural emergency rooms are only equipped for basic emergencies -- and have limited budgets for staff and equipment. But a course led by trauma specialists is helping small ERs prepare for big emergencies.
In the Manning Regional Healthcare Center’s emergency room, a team of about a half dozen nurses crowded around a young woman stretched out on a hospital bed.
Nurse Taya Vonnahme read off her status.
"We have a 28-year-old female. ATV rollover. Left chest in abdominal pain. Heart rate at 120," she said. Vonnahme then quickly assigned everyone a role. "So I’m on crash cart. Robyn’s on IVs. You’re on oxygen. You’re on procedures," she said.
This may sound scary -- but it wasn't actually a real emergency. It was an exercise set up by Rick Sidwell, a trauma surgeon at Iowa Methodist Medical Center in Des Moines.
On a summer day, Sidwell was in Manning, a town of about 1,500 located 90 miles west of Des Moines.
He was teaching a course called rural trauma team development. Through exercises like this, he showed the staff efficient ways for dealing with fast-paced trauma cases -- like checking for airway or neurological issues, applying a tourniquet -- and even using a checklist. This is something he does at his hospital.
“We even have one up on our wall, just when we know a trauma’s coming in, this is the stuff we’re getting out,” Sidwell said.
For more than two decades, Sidwell has travelled to hospitals nationally -- and even internationally -- to teach this class.
"It’s a course that's been translated into French, into Spanish because this is a need that is is a universal need -- not just Iowa," he said.
Iowa is where the class started, Sidwell said, when nearly three decades ago, a Marshalltown surgeon realized many trauma concepts were geared towards urban hospitals with lots of resources.
According to Sidwell, the class is about helping ERs in rural places, like Manning Regional -- which has just 17 beds -- and is the first place many patients end up following a heart attack or hunting accident.
"It's all about how are we going to take care of injured people at the local center, knowing that that's completely different than how things occur at a big urban trauma center," he said.
That can be a matter of life and death — especially in rural areas. Research shows people in rural areas are 14 percent more likely to die from traumatic injuries than those in urban areas.
Nurse Brian Feist, who also teaches the course and works at Iowa Methodist Medical Center in Des Moines, said small hospitals know how to help patients. They just face other barriers.
"The problem they have is they don't have the necessary equipment because it doesn't happen that often for them," said Feist. "A lack of frequency is tough to justify for a $10,000 rapid infuser."
That’s why Feist said a large part of the class is focused on how to prepare patients for transfer larger facilities -- like the one he works at -- by ambulance or air.
"A huge amount of our injured patients come to us as transfers," he said, "so the better prepared we can get our critical access hospitals, the better that patient has for longevity in a great outcome."
This was one of the reasons that Manning’s ER trauma coordinator Boni Johnson was interested in the course.
Johnson said about 50 percent of their patients have to go to places like Des Moines or Iowa City.
"A lot of them are, you know, cardiology, orthopedics," she said. "We just don't have a lot of those resources right here. And not only within our facility, but within the facilities around us."
Many of the nation’s rural hospitals are under intense financial pressure. More than 100 have closed in the last nine years -- though none have closed in Iowa -- and others have cut back on services like delivering babies.
Johnson said she’s impressed that the course’s instructors seem to really understand the importance of rural providers -- and their dwindling resources.
"You are a jack of all trades, master of none, you can be asked to run a cardiac drip one minute and be taking care of an orthopedic patient next," she said.
Sidwell said the course is also about addressing the importance of rural trauma care.
"If we really want to as a state, if we really want to as a country, eliminate unnecessary disability and death from injury, then we have to address the important role that the rural environment plays," he said.
The course is provided free of charge to hospitals through the Iowa Department of Public Health.