XI. URBAN VS. RURAL TRAUMA DEATHS:
There are many factors that increase the chances that a patient will not survive a motor vehicle crash in rural America:
THE RURAL ROAD SYSTEM:
The rural road system is much more hazardous than urban roads. Even though modern freeways are designed to conduct traffic at a mere 15 miles per hour faster, they have many built-in protections that rural roads do not.
The rural road system is designed to usher motorists comfortably down a smooth, narrow corridor at speeds in excess of 50 miles per hour, not for vehicles that lose control. Rural roads are fine as long as nothing happens to interrupt the smooth progress of a vehicle down a twelve-foot wide lane of pavement. Unfortunately there are many things that can interrupt this smooth motion. High-speed rural roadways are unforgiving when a vehicle crosses the centerline or leaves the asphalt. There are no barriers that separate us from going head-on with opposing traffic. Wide, flat shoulders that provide a safe reentry to the traffic lane and barriers that protect us from hurtling off course into a fixed object, a body of water, or an extended rollover crash are literally "hit and miss". Once any vehicle is out of control for even a brief moment, the rural highway ceases to be a safe, comfortable place and suddenly becomes a potential death trap.
Driving at highway speeds on a smooth road surface, insulated in our climate-controlled, quiet, comfortable vehicle, we can easily forget that opposing traffic is blasting by on our left at a combined speed of over 100 miles per hour. We can placidly ignore the fact that if our vehicle drifts gently off the road, what awaits us is an uneven, soft, rutted, slick or sloped surface that can jerk us violently out of control in a split-second, resulting in an abrupt over-correction and a high speed impact with opposing traffic, an extended rollover, or a violent smash up into a solid object. Or, we may go hurtling off course, completely at the whim of chance, the presence of hazards nearby and our built-up kinetic energy.
ROADWAY HAZARDS:
Adjacent to rural roads, there are often unprotected solid objects; these include embankments, ditches, culverts, poles, large rocks, etc. Debris and potholes may litter the traffic lanes. Wild and domestic animals wander the roadway and dart out. People walk and bicycle along the sides of the highway in the dark, with no sidewalks or curbs to separate them from the passing traffic and no lighting to illuminate them. Signage and roadway markings are sparse and sometimes in poor repair or obscured by greenery. Greenery growing up along the roadside can increasingly obscure approaching traffic until sight lines become dangerously inadequate. Concealed, unlighted, uncontrolled driveways are common.
Turning lanes are only found in the more built-up areas. Traffic stopping abruptly on the highway to negotiate a 90-degree turn presents an obstruction to through traffic and a risk of a sudden high speed rear-end or angled collision. Sharp curves are frequent and sometimes off camber and deceptive. Gradients change often and abruptly. Water standing in low spots in the road or running across the surface is common. Ice and snow can build up rapidly in the mountainous regions where the roads are long, removal services are sparse and the highways are steep and crooked. Standing deep water often abuts the roadway. (A bumper sticker that used to be popular in the mountains of Humboldt County said "Pray for me, I drive highway 299". I often wanted to have one made that said in reply, "Don’t bother! I drive highway 96.")
People who drive rural roads every day often become complacent and frequently travel speeds considerably higher than the posted speed limits, vastly increasing the risks and the potential for fatal injuries. Kinetic energy increases with the square of velocity, therefore a vehicle going 60 miles per hour will impact with a force four-times greater than one traveling 30.
EMS:
The differences between urban and rural EMS calls:
A one-hour response to an vehicle crash with an entrapped driver and a head injured child; an extended on-scene time while extrication is performed; and a one-hour transport with a non-breathing pediatric patient and a hypotensive, vomiting adult over mountainous country roads will try the skills (and stomach) of any ambulance attendant. Many rural EMT’s in this situation would consider themselves lucky to have a third crewman along, scavenged from the on scene volunteer fire department that can follow instructions and bag the child.
To an urban EMT whose response times and transport times are usually less than 15 minutes, who have all the mutual aid that they need from numerous emergency services, who frequently respond with an extra EMT on board and who may have to negotiate a traffic jam or a few overpasses enroute to the nearest trauma center, the above scenario is almost unthinkable. To an EMT in rural America, it is common.
The definition of a "Good call":
It always amuses me when I share war stories with urban EMT’s how their eyes often get big and they exclaim "Damn! That sounds cool!" "We never get any good calls!" If the definition of a good call is spending hours with unstable patients, speeding down dangerous roads, using every skill you possess just trying not to lose ground and wondering how long it’s going to be before you have to start CPR on another dead body, rural EMTs get lots of "good calls".
In rural America, under favorable conditions, the amount of time from the inception of a critical trauma call until the patient arrives at a facility capable of emergency surgery is frequently over four hours. It is no wonder that when we hear the term, "The golden hour" (the theoretical amount of time a critical trauma patient has before shock begins to cause irreversible damage), rural EMTs often laugh. In Hoopa EMS, we laughingly referred to the golden hour as "The golden half-day". (Even so, our "Limited Advanced Life Support" program did save many lives.)
THE LIMITATIONS OF RURAL EMS: