Rural trauma crisis involves falls more than crashes

There’s a crisis in trauma care for rural areas, including those in New Hampshire, but it’s not the crisis you think it is.

“Most people’s perception of trauma, from the news and TV, is car crashes, stabbings,” said  Dr. Steve DeWitt, an emergency department physician at Concord Hospital. “For trauma, those sorts of injuries are higher in urban areas but not for rural trauma.”

So what’s the biggest cause of sudden injuries in small towns and the countryside?

“Surprisingly to most people, it’s the falls from standing height,” said Dewitt.

In other words, the biggest issue is people falling over — not falling off of something tall like a ladder, but just falling over.

They trip over a loose rug, slip in the shower, miss the first step on the stairs, roll out of bed or stumble on nothing in particular. Suddenly, they are dealing with cracked bones or torn ligaments or internal bleeding. Even if the fall results only in bruising, cuts and pain, it can ruin life for weeks, months or years.

The prevalence of this situation comes as a surprise not just to lay folk but even to some health-care providers, Dewitt said. He’ll be making this point as part of a panel discussion on rural trauma on Thursday, Oct. 23, as part of the hospital’s annual Trauma Conference at Southern New Hampshire University.

The session, which provides continuing education credits, includes topics like pediatric trauma, fatal collision investigations and one called “Lower Extremity Injuries: The Car Always Wins.”

Dewitt said that 40% of traumas seen across the three hospitals in the Concord Hospital Health System — Concord, Franklin and Laconia — are due to “falls from standing.” The problem is compounded by age demographic, since New Hampshire is one of the oldest states in the country.

eniors are more likely to be hurt by what seems to be a minor accident like tripping or slipping. Dewitt said these kinds of falls can carry a “higher injury burden and higher mortality.”

That leads to the second issue for providers: Diagnosis.

A problem can be plain to see when a patient is bleeding heavily after a car crash but far less obvious when a patient is lying on their living room floor complaining of unlocalized pain. EMTs have protocols to make sure the condition isn’t worsened while they’re transported, but once at the hospital, it can get more complicated.

“The trickier piece comes when the patient comes to the ER and you have to tease out those problems,” Dewitt said, “There are a a lot of subtleties that can be missed.”

Older patients are often on multiple medications that can do things like lower their heart rate or blood pressure. They also “may have mild dementia, making it tough to determine what’s going on,” he said.

Technology, such as more sensitive CT scanners and newer portable ultrasounds, can help “to pick up subtle potentially important and intervenable traumas (like) internal bleeding, lacerations of organs or bleeding around the brain.”

Treatment of the elderly can frequently take much longer, involving specialties like physical therapy and requiring transfer to long-term care or nursing facilities.

That leads to the final problem in rural trauma care, one that is common in most of health care: Staffing and facilities.

“This is considerably short-staffed,” he said. “There’s a major nursing staff shortage, and also paramedics, EMTs, technicians … therapists.”

Training and certification in geriatric trauma is available but not common.

New Hampshire’s only Level 1 trauma center, the highest designation, is at Dartmouth-Hitchcock Medical Center in Lebanon. It also has the only Level 2 trauma center for pediatrics.

Concord Hospital has a Level 2 trauma center. Otherwise, the only Level 2 or Level 3 trauma centers are all in Hillsborough or Merrimack counties, leaving the state’s rural areas badly underserved.

The hospital in Franklin, for example, has no general surgeon, no anesthesiologist. “Trauma patients may show up at our door, we have to stabilize them and send them to Concord,” Dewitt said.

That is improving, he said, with specialty services such as interventional radiology traveling from trauma centers to other facilities on certain days, and technological upgrades “trickling down from trauma centers to rural hospitals.”

What this means, Dewitt said, is that seniors should take extra care to avoid simple slips and trips that can lead to big problems, working on things like balanced gait or regularly using strength and flexibility exercises.

“Education is key,” he said.