The design of this study allowed for comparisons within a geographic region serviced by a mature trauma system. Previous studies have suggested poorer outcomes for rural TBI patients. Analysis confirmed that the profile of severe TBI patients in Victoria is similar to that reported in the existing literature, and that patient demographics and injury causation factors, rather than rurality, were more likely to influence functional outcomes for survivors. The collective results show that a holistic approach to trauma system design and development is required in order to achieve optimal patient outcomes across broad geographical areas. 

The frequent use of experienced HEMS paramedics in rural areas raises the possibility that paramedic exposure and experience may be important. Analysis indicated that clinical confidence can decrease even amongst experienced paramedics, and that alternative strategies may be required to enhance and maintain skills, knowledge and confidence in rural areas. Lessons gained from understanding the relationship between experience, exposure and confidence are likely to have applications for other high-acuity case types, and may translate well to other craft groups required to manage such cases particularly in rural and remote areas. 

These findings have implications in the Australian setting where a large proportion of rural and remote communities remain isolated in regards to access to emergency medical care. Initial intervention strategies may be crucial in these settings, where access to higher level trauma care may be many hours away. These findings may also have implications for developing countries where the high rate and burden of traumatic injuries is evident. Understanding differences between rural and urban trauma profiles, enhanced pre-hospital intervention strategies, and the process of regionalising trauma expertise provides a framework for development in areas lacking integrated trauma care services. Ultimately, improvements may enhance the standard of trauma care and ensure optimal patient outcomes following severe injury.