September 11, 2001, revisited: a review of the data

HYPOTHESIS: The September 11, 2001, World Trade Center (WTC) attack was a disaster of epic proportion in New York City, NY. It was unprecedented in terms of the number of people who were killed in the bombings, as well as in terms of the volume of patients received at local (New York City) hospitals. The strain on local emergency medical services, hospitals, and the citywide trauma system is still felt today as the hospitals, physicians, and agencies involved struggle to train for similar events that may occur in the future, cope with the psychological and social aftermath, and even pay for the response to the bombing. The objective of this review of the data was to determine the major causes of morbidity (ie, hospital visits) during the hours immediately after the September 11, 2001, WTC attack, as well as to detail the costs involved in the medical response to a disaster of this scale and to identify some lessons learned with respect to the hospital's response to an event of this magnitude. DESIGN: Review of records and cost data submitted by Saint Vincent's Hospital, Manhattan, NY, to the state of New York and federal sources for financial relief from the September 11, 2001, WTC attack. SETTING: Saint Vincent's Hospital is an academic medical center of New York Medical College and a New York City-designated level I trauma center. PATIENTS: All medical records for the patients registered at Saint Vincent's Hospital on September 11, 2001, after 8:50 am were reviewed. RESULTS: The major cause of morbidity for the September 11, 2001, patients was smoke inhalation (30.0%); followed closely by chemical conjunctivitis and corneal abrasions (16%); lacerations, abrasions, and soft-tissue injuries (15.5%); isolated orthopedic complaints (12%); and psychiatric complaints (10%). Multiple-trauma patients were 3% of the patients seen. There were 5 fatalities at Saint Vincent's Hospital. CONCLUSIONS: The WTC disaster was a source of major morbidity and mortality to the people of New York City. The possibility that Saint Vincent's will again serve in that role is in the forefront of the minds of everyone involved in updating our contingency plan.     

Media use by children and adolescents from New York City 6 months after the WTC attack

Six months after the World Trade Center (WTC) attacks of September 11, 2001 (9/11), a representative sample of New York City students (N = 8,236) in Grades 4 through 12 reported their use of TV, Web, and combined radio and print media regarding the WTC attack. Demographic factors, WTC exposure, other exposure to trauma, and probable posttraumatic stress disorder (PTSD) were used to predict intensive use of the 3 types of media. Intensive use was associated with direct exposure to the WTC attack (with the exception of Web use) and to having reported symptoms of PTSD. Stratified analyses indicated that the association between probable PTSD and intensive media use was more consistently present among those who had no direct or familial exposure to the WTC attack. As well, media, particularly TV, was intensively used by children after the WTC attack. Variations existed in the factors associated with intensive media use, which should be considered when planning postdisaster media coverage and advising families.     

Use of a state-wide administrative database in assessing a regional trauma system: the New York City experience

BACKGROUND: A successful regional trauma care system should concentrate severely injured patients within trauma centers, and should improve severity-adjusted outcomes. We compared injured patients' outcomes in New York City's level 1 trauma centers and nontrauma centers. STUDY DESIGN: We analyzed 1998-2000 New York Statewide Planning and Cooperative Research System (SPARCS) data for 103,725 adult discharges from 70 New York City hospitals (15 level I trauma centers), using ICD-9CM codes 800-950. Their 227 DRG's were aggregated into 7 clinical injury classes. A severity index was extracted from each refined DRG, and deaths, age, and gender were analyzed. Regression analysis predicted death from age, gender, severity index, and trauma center discharge, with separate analyses of the three largest clinical classes, and estimated excess mortality because of trauma center discharge. RESULTS: Level 1 trauma centers discharged 48.2% of injured patients, with higher mean annual discharges per hospital (1,046 discharges per TC vs. 437 per NTC, p < 0.001). Trauma centers discharged more than half the central nervous system, general/gastrointestinal, cardiothoracic, and vascular injuries. Trauma center patients were 12.5 years younger than NTC patients (p < 0.0005), and were disproportionately men (64.7% TC vs. 47.2% NTC, p < 0.0005). For the entire patient cohort, and for central nervous system, orthopaedic and general/gastrointestinal injuries, severity, age, and gender adjusted mortality risk was significantly greater at trauma centers than nontrauma centers. CONCLUSIONS: New York City's trauma system concentrates injured patients in trauma centers on the basis of injury class rather than severity, but does not produce improved adjusted mortality outcomes for injured patients.     

Motor vehicle crashes in New York State: importance of accounting for emergency department deaths when assessing differences in in-hospital mortality by level of care.

BACKGROUND: Motor vehicle crashes (MVCs) are one of the leading causes of death in the nation and in New York State, particularly among younger adult males. It is important to study how to reduce mortality from MVCs. METHODS: Hospitalized victims of motor vehicle crashes in the 1994-1995 New York State Trauma Registry were identified for the study. A statistical model was used to calculate risk-adjusted mortality rates for groups of hospitals constituting each level of care (regional trauma center, area trauma center, noncenter). Levels of care were also compared with respect to the location of deaths in the hospital (emergency department, inpatient), and the time between emergency department admission and death for patients dying in the hospital. RESULTS: The risk-adjusted mortality rate for MVCs in patients in regional centers was higher, although not significantly higher (6.91%; 95% confidence interval [CI], 6.18%-7.70%) than for area centers (5.53%; 95% CI, 4.43%-6.82%) or for noncenters (5.83%; 95% CI, 4.70%-7.15%). However, regional centers admitted seriously injured trauma patients from the emergency department much more quickly than other levels of care. Whereas only 18% of all in-hospital deaths occurred in emergency departments of regional centers, the comparable percentages for area centers and noncenters were 39% and 46%, respectively. Also, 43% of all deaths in regional centers occurred within 24 hours of presentation to the emergency department, compared with 15% in area centers and 21% in noncenters. CONCLUSION: Risk-adjusted inpatient mortality rates for victims of MVCs may not yield a fair comparison of performance for different levels of care or for different hospitals because of differences in how quickly emergency department patients are admitted to the hospital. A more equitable way to assess hospital mortality rates may be to include emergency department deaths in addition to inpatient deaths.     

A descriptive analysis of injury triage, surge of medical demand, and resource use in an university hospital after 8.12 Tianjin Port Explosion, China

Objective: The 8.12 Tianjin Port Explosion in 2015 caused heavy casualties. Pingjin Hospital, an affiliated college hospital in Tianjin, China participated in the rescue activities. This study aims to analyze the emergency medical response to this event and share experience with trauma physicians to optimize the use of medical resource and reduce mortality of critical patients. Methods: As a trauma centre at the accident city, our hospital treated 298 patients. We retrospectively analyzed the data of emergency medical response, including injury triage, injury type, ICU patient flow, and medical resource use. Results: There were totally 165 deaths, 8 missing, and 797 non-fatal injuries in this explosion. Our hospital treated 298 casualties in two surges of medical demand. The first one appeared at 1 h after explosion when 147 wounded were received and the second one at 4 h when 31 seriously injured patients were received, among whom 29 were transferred from Tianjin Emergency Center which was responsible for the scene injury triage. After reexamination and triage, only 11 cases were defined as critical ill patients. The over-triage rate reached as high as 62.07%. Seventeen patients underwent surgery and 17 patients were admitted to the intensive care unit. Conclusions: The present pre-hospital system is incomplete and may induce two surges of medical demand. The first one has a much larger number of casualties than predicted but the injury level is mild; while the second one has less wounded but almost all of them are critical patients. The over-triage rate is high. The hospital emergency response can be improved by an effective re-triage and implementation of a hospital-wide damage control.     

A history of hand surgery in New York City

The origins of Hand Surgery in New York City are temporally centered around World War II. Arthur J. Barsky, MD, Condict W. Cutler, Jr, MD and Emanuel B. Kaplan, MD laid the groundwork for our regional specialty prior to the War. J. William Littler, MD, Robert E. Carroll, MD, served in the Armed Forces and were instrumental in the development of the specialty in the second half of the 20th century. Hand services evolved in each of the major academic centers in New York including those led by Lee Ramsey Straub, MD, at the Hospital for Special Surgery, Richard J. Smith, MD at the Hospital for Joint Disease, Robert W. Beasley, MD at New York University and Berish Strauch, MD, and Morton Spinner, MD, at Albert Einstein and Montefiore. Several surgeons who worked with or were trained by these masters formed the nucleus of the next generation of leaders including Richard G. Eaton, MD, Martin A. Posner, MD, Harold M. Dick, MD, and Charles Melone, MD. Their proteges and a relatively small number of surgeons trained elsewhere, like Andrew J. Weiland, MD, and Robert Hotchkiss, MD, make up the current leadership of Hand Surgery in New York City.     

Triage in a Bomb Disaster with 166 Casualties

Abstract Background: We describe the surgical response of the Helsinki University Hospitals to a bomb disaster with 166 casualties. According to the Helsinki Area Disaster Plan, severely injured patients were transported to several hospitals with emergency facilities to avoid overtriage. Methods: The patient data were gathered from hospitals, health centers and other doctor visit/ appointments records. Injury Severity Scores (ISS), critical mortality rate and death/wounded ratio were calculated. Results: Of the 166 injured patients, 5 died immediately at the bombing site. Sixty-six patients were transported to the six affiliated hospitals. The mean ISS score for survivors was 12. Seventeen percent of the acute survivors were critically injured (ISS>15). The critical mortality rate was 8%. There were no later deaths; the dead/wounded ratio was 4.4. Operative treatment was performed for 38% of the patients treated in surgical emergency departments. Conclusion: The bombing attack in Myyrmanni shopping center led to 166 casualties, of whom 66 patients were received at six affiliated hospitals in Helsinki and Uusimaa Area. The critical mortality rate was low. A local disaster plan was implemented. The surgical response was rapid and well coordinated. In a mass casualty disaster not all disaster victims need to go to a trauma center.     

The Hospital for Special Surgery Affiliates with Cornell University Medical College and New York Hospital, 1951; Philip D. Wilson Retires as Surgeon-in-Chief, 1955

When World War II ended in 1945, the Hospital for Special Surgery (HSS), the oldest orthopedic hospital in the country, was entering its eighth decade. Only 5 years previously, its name was changed from the Hospital for the Ruptured and Crippled (R &; C). In 1934, Dr. Philip D. Wilson (1886–1969) had been recruited to fill the office of the fifth Surgeon-in-Chief with a key charge to restore the hospital as the leading orthopedic institution in our country, a role it originally held for over half a century since its founding in 1863. Wilson believed that a close affiliation with a university center having a medical school and hospital, while maintaining independence, was vital to achieve this objective. In 1948, negotiations between representatives of the Board of the New York Society for the Relief of the Ruptured and Crippled and representatives of the Society of the New York Hospital and Cornell Medical Center began and a preliminary written agreement was reached in March, the next year. The affiliation called for construction of a new building to house approximately 170 inpatient beds for orthopedics and arthritis. The land on the East River between 70th and 71st Streets, owned by New York Hospital, was to be given, without monetary exchange, to the Hospital for Special Surgery for construction of its new hospital. Finally, on November 1, 1951, a new non-proximate agreement was ratified. On May 25, 1955, after 43 years at 321 East 42nd Street, the Hospital for Special Surgery moved to its new six million dollar building at 535 East 70th Street where it formally became affiliated with New York Hospital–Cornell Medical Center. Two months later, on July 1, 1955, Philip D. Wilson retired as Surgeon-in-Chief to become the Hospital for Special Surgery’s new Director of Research and Surgeon-in-Chief Emeritus.     

Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2-3 years after the September 11, 2001 terrorist attacks

Manhattan residents living near the World Trade Center may have been particularly vulnerable to posttraumatic stress disorder (PTSD) after the September 11, 2001 (9/11) terrorist attacks. In 2003-2004, the authors administered the PTSD Checklist to 11,037 adults who lived south of Canal Street in New York City on 9/11. The prevalence of probable PTSD was 12.6% and associated with older age, female gender, Hispanic ethnicity, low education and income, and divorce. Injury, witnessing horror, and dust cloud exposure on 9/11 increased risk for chronic PTSD. Postdisaster risk factors included evacuation and rescue and recovery work. The results indicate that PTSD is a continued health problem in the local community. The relationship between socioeconomic status and PTSD suggests services must target marginalized populations. Followup is necessary on the course and long-term consequences of PTSD.     

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND: Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters. STUDY DESIGN: Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance. RESULTS: Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85). CONCLUSIONS: In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.     

Maximizing reimbursement from trauma response fees (UB-92: 68X) - lessons learned from a hospital comparison

BACKGROUND: The trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers' performance in collecting this fee help define methodologies that can enhance reimbursement. METHODS: Our trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center. RESULTS: Out of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars) CONCLUSIONS: Enhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.     

The impact of resource loss and traumatic growth on probable PTSD and depression following terrorist attacks

The authors interviewed by phone 2,752 randomly selected individuals in New York City within 6 to 9 months after the attacks of September 11, 2001 on the World Trade Center, and 1,939 of these were reinterviewed at a 12- to 16-month follow-up. It was hypothesized that resource loss would significantly predict probable posttraumatic stress disorder (PTSD) and probable depression since September 11, and that resource loss's impact would be independent of previously identified predictors relating to individuals' demographic characteristics, history of stressful event exposure, prior trauma history, peritraumatic experience, and social support. Second, it was predicted that reported traumatic growth would be related to greater, not lesser, psychological distress. The authors' findings supported their hypotheses for resource loss, but traumatic growth was unrelated to psychological outcomes when other predictors were controlled.     

Posttraumatic stress in children with first responders in their families

High levels of exposure and occupational stress of first responders may have caused children in first-responder families to become traumatized following the September 11th, 2001 terrorist attacks. New York City public school children (N = 8,236) participated in a study examining mental health problems 6 months after the World Trade Center attack. Results revealed that children with emergency medical technician (EMT) family members had a high prevalence of probable posttraumatic stress disorder (PTSD; 18.9%). Differences in rates of probable PTSD among EMTs' and firefighters' children were explained by demographic characteristics. Where EMTs are drawn from disadvantaged groups, one implication of this study is to target EMT families in any mental health interventions for children of first responders.     

Relative importance of designation and accreditation of trauma centers during evolution of a regional trauma system

BACKGROUND: Improved survival after injury has been demonstrated with trauma system implementation and designation of trauma centers. Local designating health authorities or national verification (United States) or accreditation (Canada) programs audit trauma center performance. The relative importance of designation versus accreditation with respect to improved outcomes is not clear. The purpose of this study was to measure outcomes within a single regional trauma system after designation of trauma centers and to compare outcomes in the one accredited center to the nonaccredited centers. METHODS: Data from three trauma centers were studied. All were large, university-affiliated regional medical centers, integrated into a regional trauma system and served by a single ambulance service. The study period was 1992 to 1999, immediately after trauma center designation in 1991. The British Columbia Trauma Registry was used to identify trauma patients, mechanism of injury, length of stay, case mix, case volume, acuity, pediatric caseload, and proportion of transfers at each center. A questionnaire was circulated to each hospital to determine the level of institutional support and programmatic development for trauma. The Trauma Registry was used to calculate z scores (TRISS methodology) for each center and TRISS-adjusted mortality odds ratios between institutions. Differences in covariables were controlled for in subgroup analysis. RESULTS: Two centers (hospitals A and C) had a high trauma caseload; one (hospital B) had a small and diminishing caseload. Only one center (hospital A) developed a trauma program consistent with Canadian accreditation criteria; z scores for center A were consistently better than at hospital B or C and survival odds ratios were significant. This finding applied to the total trauma population, blunt adult trauma patients (whether or not transfers and hip fracture patients were excluded), and in the more severely injured blunt trauma subgroups. There were no differences between hospitals for the relatively small number of patients with penetrating trauma. CONCLUSION: Differences between hospitals were apparent from the outset of the trauma system. However, designation as a trauma center does not appear to necessarily improve survival in large regional medical centers. Development of a trauma program and commitment to meeting national guidelines through the accreditation process does appear to be associated with improved outcome after injury.     

Implementation of CBT for youth affected by the World Trade Center disaster: matching need to treatment intensity and reducing trauma symptoms

An implementation study of cognitive-behavioral therapies (CBT) was conducted for traumatized youth in a postdisaster context. Headed by the New York State Office of Mental Health, the study targeted youth (N = 306) ages 5-21 affected by the World Trade Center disaster. They received either trauma-specific CBT or brief CBT skills depending upon the severity of trauma symptoms. Clinicians were trained to deliver these interventions and received monthly consultation. A regression discontinuity design was used to assess optimal strategies for matching need to service intensity. At 6-months postbaseline, both groups had improved. Rate of change was similar despite differences in severity of need. The implications for the implementation of evidence-based treatments postdisaster are discussed.     

Adolescent exposure to the World Trade Center attacks, PTSD symptomatology, and suicidal ideation

This study examined the associations between different types of trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation among New York City adolescents 1 year after the World Trade Center attacks. A sample of 817 adolescents, aged 13-18, was drawn from 2 Jewish parochial high schools (97% participation rate). We assessed 3 types of trauma exposure, current (within the past month) and past (within the past year) suicidal ideation, and current PTSD symptoms. Findings indicated that probable PTSD was associated with increased risk for suicidal ideation. Exposure to attack-related traumatic events increased risk for both suicidal ideation and PTSD. However, specific types of trauma exposure differentially predicted suicidal ideation and PTSD: knowing someone who was killed increased risk for PTSD, but not for suicidal ideation, and having a family member who was hurt but not killed, increased risk for suicidal ideation, but not for PTSD. This study extends findings from the adult literature showing associations between trauma exposure, PTSD, and increased suicidal ideation in adolescents.     

Can we improve trauma mortality in a state with a voluntary trauma system

BACKGROUND: Arizona has no organized statewide trauma system. We looked at the 1997 and the 1998 Uniform Hospital Discharge Data Set (UHDDS) for the State of Arizona, and examined the trauma mortality data at both trauma hospitals and nontrauma hospitals. METHODS: All qualifying mortalities based on hospital data from 1997 through 1998 were reviewed for the State of Arizona. Trauma deaths from 32 nontrauma hospitals were examined and compared with that of 7 level 1 trauma centers within the state. RESULTS: In this time period, there were 375 qualified mortalities from nontrauma centers and 761 qualified mortalities from level 1 trauma facilities. Only 29 (8%) of nontrauma hospital deaths were found to be due to motor vehicle accidents. Only 8 (4%) mortalities at nontrauma centers were due to firearms. CONCLUSION: The data suggest that patients are arriving at the appropriate facility for definitive care despite the absence of a formal statewide trauma system.     

The Integrated Trauma Program: a model for cooperative trauma triage.

The Integrated Trauma Program (ITP) is the cooperative trauma triage service of the University of Toronto trauma and burn hospitals and the Ontario Ministry of Health. It provides physicians in referring hospitals direct access to a trauma team leader (TTL) in one of several trauma centers through a single phone number. Three adult trauma centers, one pediatric trauma center, and one burn center, all affiliated with the University of Toronto, participate in this program. This article describes the system during the first two years of operation. From July 1989 to June 1991, 1530 requests for patient transfers from a total of 97 hospitals were processed. Of these transfer requests, 77% were accepted by the TTL to a trauma service as multiple trauma cases, 16% were accepted directly to a surgical service without involving the trauma team, 4% were refused by the TTL as inappropriate referrals, and 3% of requests were cancelled by the referring physician. The transfer requests are distributed to a specific trauma center by request of the referring physician (10%), according to a rotation (70%), or as selected by the ITP (20%) when the scheduled hospital is not readily available. Closure of all adult trauma centers occurred on 43 occasions. During these closures, 48 patients bypassed the Toronto trauma centers and were transferred to other cities. The ITP office also keeps an ongoing data base of patients transferred. The mechanism of injury in the majority of cases is vehicular crashes. The mean Injury Severity Score is 24 for adults and 17 for children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcomes after ruptured abdominal aortic aneurysms: the "halo effect" of trauma center designation

BACKGROUND: Trauma centers have an array of services available around the clock that help reduce mortality in injured patients. Having such services available can benefit patients other than those who are injured. We set out to determine whether patients hospitalized with ruptured abdominal aortic aneurysms experience lower morbidity and mortality at regional trauma centers than at other acute care hospitals. STUDY DESIGN: We conducted a retrospective cohort study with the exposure being care at a trauma center and outcomes either mortality or organ failure. We evaluated all patients 40 to 84 years of age with a diagnosis of a ruptured abdominal aortic aneurysm who underwent operation during 2001 in 20 US states with organized systems of trauma care. We determined the relative risk of either death or organ failure at regional trauma centers compared with nondesignated centers. RESULTS: Of 2,450 patients hospitalized for ruptured abdominal aortic aneurysm, 867 (35%) hospitalizations occurred at regional trauma centers. At trauma centers, 41.4% of patients died before hospital discharge, compared with 45.2% of patients at nondesignated hospitals (odds ratio [OR], 0.85; 95% CI, 0.71-1.02). After adjusting for payor, hospital beds, annual hospital admissions, annual inpatient operations, affiliation with a vascular surgery fellowship, and comorbid illnesses, the likelihood of death or organ failure was lower at trauma centers (OR, 0.72; 95% CI, 0.55-0.93). CONCLUSIONS: Care at regional trauma centers after operative repair of ruptured abdominal aortic aneurysm is associated with improved outcomes. We postulate that these benefits reflect the ability of both vascular and general surgeons to immediately mobilize resources for care of the patient requiring urgent operative intervention. The beneficial effects of trauma center designation might extend beyond caring for the critically injured.     

Tertiary trauma care in a rural state

Trauma patients in rural areas usually have no access to regional trauma systems or designated trauma centers. Efforts to provide quality trauma care in small hospitals may seriously overextend local capabilities. The urban trauma center retains an important role in trauma care even when the initial care must be provided at the local level. Twenty-five trauma patients were transferred to University Hospital between 1985 and 1988 after definitive care was initiated in community hospitals. During the same time period, a total of 147 trauma patients were transferred to the trauma service. No information was available on the total incidence of trauma. Medical records were reviewed to determine the reasons for transfer. Major reasons included the need for further complex surgery, better critical care support, and inadequate blood banks. Trauma centers serving rural areas provide a valuable resource well beyond the initial 24 hours.