Trauma

Jan. 17, 2024

Mariah K. Raabe, R.N., a trauma/safety/stroke coordinator at Mayo Clinic Health System in St. James, Minnesota, understands the circumstances encountered by Advanced Trauma Life Support (ATLS) developer James K. Styner, M.D., FACS, when the family's plane crashed in rural Nebraska. The crash killed his wife and prompted Dr. Styner to seek immediate trauma care for his three injured children. Raabe, too, is in a more remote, rural area, located in Watonwan County, Minnesota. Mayo Clinic Health System in St. James with its Level IV trauma center serve a town of fewer than 5,000 residents, approximately 40 miles from Fairmont or Mankato in Minnesota.

Raabe is not alone. Minnesota is dotted with rural Level III and IV trauma centers and few Level I and II trauma centers.

Making the most of finite resources

Raabe is accustomed to providing trauma care with limited staff and resources. One emergency department physician and one nurse staff the St. James emergency department and trauma bay. During the day, one pharmacist and one X-ray technician also are present. A social worker works remotely — no longer in the hospital from 8 to 4 p.m. — and respiratory therapists are nonexistent. After hours, no pharmacist is present.

"It's hard to portray how limited we are," says Raabe. "But I'd say we're doing a great job with what we have. Our nursing and physician staff serve as jacks-of-all-trades. So much falls on the one ED and trauma bay nurse or the float nurse shared between the emergency department and hospital."

She explains that many services are a phone call away, which is "better than nothing." When a patient requires intubation, the physician and nurse oblige, with no specialist on hand. All healthcare professionals at a facility like St. James wear many hats, she says. For example, often the nurse serves as admitting registrar as well as providing care for patients with traumatic injuries.

The small team finds TeleEM, an emergency telemedicine consult service, helpful. It allows St. James staff to consult with any physician, pharmacist or respiratory therapist about a given injury. But at times the lack of additional physically present teammates presents a challenge.

"Sometimes we really need more hands, but financially, we can't," says Raabe, commenting that her team is resilient, has exceptional teamwork and relies on one another. "Our team really cares about others. We do the best we can for our patients to get them as stabilized as possible."

Occasionally the trauma population is higher than usual and staff must hustle to meet patients' needs, Raabe indicates it is difficult to staff a hospital well amid unpredictability. Hours or days later, the trauma population may be extremely low.

Though the hospital does not typically care for patients needing ICU-level care for periods as long as eight hours, this has occurred occasionally, prompting a human resource challenge because the patient requires one-on-one care.

Ambulance service presents another hurdle in a rural area such as St. James. Raabe says her team is grateful for its local volunteer ambulance service.

However, as the service has no trained paramedics licensed to care for patients who are intubated or receiving IV medications, for example, the service may transport any patient to St. James. Yet it cannot transport all patients to a higher care level following care at St. James, when needed.

How RTTDC came to St. James

Gwen D. Meyer, M.S.N., R.N., a Mayo Clinic trauma education and outreach coordinator, has a passion for Level 3 and 4 trauma centers in limited-resource environments. Meyer is the coordinator of the Rural Trauma Team Development Course (RTTDC) sponsored by the American College of Surgeons. Meyer takes the RTTDC on the road to regional critical access hospitals with Mayo Clinic trauma surgeons. She also visits Level III and IV trauma centers and responds to patient care questions from regional trauma centers by phone. Meyer is aware that lack of human resources is the largest challenge for Level III and IV centers and is cognizant of the expense for smaller centers needing to stock expensive, yet expiring, trauma care equipment.

"Training's extraordinary for our trauma facilities, especially Level 3 and 4 centers," says Meyer. "Our trauma staff from Mayo Clinic who provide the training, in turn, are impressed by the knowledge level of and care provided by trauma professionals from these smaller facilities."

Meyer approached Raabe at a Southern Minnesota Regional Trauma Advisory Committee meeting to offer an on-site Rural Trauma Team Development Course (RTTDC) for St. James. This course is based on concepts from the ATLS course Dr. Styner developed, yet it's tailored to the rural trauma care environment.

How RTTDC training helped St. James

The free, eight-hour RTTDC held in St. James included 25 personnel from trauma and the city-owned ambulance service. Raabe and Meyer planned the course months in advance. Though not paid for their time, ambulance volunteers attended the course anyway, wanting to learn, says Raabe.

Benefits Raabe noted from the RTTDC held in St. James include:

• Training by in-person experts. Raabe states that face-to-face education was a great experience for St. James staff. She appreciated seeing the faces of trauma professionals from Rochester, Minnesota, and interacting with them and their staff on-location. She found the RTTDC instructors to be effective teachers.
• Review of trauma care's systematic approach. RTTDC discussed trauma care's sequential order of steps and prioritization — which Raabe sees as crucial to avoid missing anything — for a limited or full team. The course also reviewed on-site supply locations and how to use the facility's trauma care equipment to save lives.
• Relationship-building for hospital and EMS personnel. The course encouraged building strong working relationships between these groups. Raabe reports these bonds and resulting collaboration grew through attending the course together. She also notes that seeing one another face-to face promoted compassion and grace between hospital staff and EMS personnel.
• An opportunity to speak up. Raabe says RTTDC offered a chance for the St. James trauma professionals to provide input and speak their minds.

"It's great to have our voices heard at these smaller facilities," she says.

Meyer highly suggests requesting the RTTDC for your center, which trauma professionals, police officers and other community trauma service personnel may attend. The course provides a mix of didactic and scenario-based training that instructors customize for the environment at the local trauma care base.

"RTTDC has been well received over the years," says Meyer. "All you have to do is request it." If you are interested in requesting an RTTDC, please contact Meyer at meyer.gwen@mayo.edu.

For more information

Refer a patient to Mayo Clinic.