Rural medicine reminds physicians of their value

Recently, while on a locums assignment in a very small, rural hospital, I cared for a gentleman with chest pain.  His discomfort seemed classic for an MI, but his EKG did not. So I treated him as normal with aspirin and nitrates, and waited for his cardiac markers to come back from the lab.  In the interim, his chest pain worsened.  Sure enough, he developed an anterior MI.  The tombstones of tombstones, you might say.

Well, this wonderful facility did not have a cardiologist on staff, much less a cardiac cath lab.  So, I went “old-school.”  I gave him a thrombolytic.  I know, seems pretty Stone Age, doesn’t it? But it was the right thing to do.  There was no interventional cardiologist in the area; in fact, the patient would ultimately be transferred by fixed-wing aircraft to the nearest cardiac care center.

While he had one brief episode of ventricular fibrillation (responsive to one shock), his event was otherwise unremarkable and his EKG normalized before the flight crew ever arrived.  He was pain free and grateful as he was loaded for his trip to the referral center.

Afterward, two things became evident. First of all, the charge nurse thanked me for making a decision quickly. Apparently, she had experienced some locums physicians who were uncomfortable simply making the call on their own. They inevitably wanted to show their patient’s EKG’s to cardiologists and have discussions.  I looked and acted.  Second of all, I realized yet again how much fun it is to be … important!

We live in an era of specialists and subspecialists and sub-sub-specialists.  In large cities, the job of the emergency physician is to order the EKG as quickly as possible (hopefully before the patient arrives it seems), and call the right interventional specialist in something like a nano-second.  In some places, we serve as facilitators, almost brokers.  But in the small centers of America, where the advanced technology of medicine isn’t always immediately available, our job becomes absolutely critical.

I find that refreshing. And exhilarating!  Too many young emergency physicians have grown up in the long shadows of never-ending back-up. But a few short miles out of the city, an airplane flight over a mountain, a drive along a jagged coast and one may discover that he or she, as an emergency physician, is the truly the last, best hope for patients who populate the remote parts of America, doing hard work in hard industries.  We are needed by farmers and timber-workers, miners and fisherman, hunting guides and raft guides, truck drivers and oil-well workers and all their precious loved ones.

I encourage physicians to reach out and work in the remote places.  Take the chance and take your skills out to the places where they are truly precious.  If you are older, your experience will be priceless.  And if you are younger, well be bold and do your best.  And learn to make decisions ‘all by your lonesome.’

You may find that working in those out of the way places is just the thing you need to remember how very special, and very valuable, your skills and experience really are. And why worry?  Help is only a fixed-wing flight away.

Edwin Leap is an emergency physician who blogs at and is the author of The Practice Test. This article originally appeared in The Barton Blog.

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  • Ron Smith

    Hi, Edwin.

    Great post!

    It reminds of my Pediatrics residency some thirty years ago now. I was at the University of Oklahoma in Tulsa at St. Francis, also known as ‘the pink palace.’ It was a 1,000 bed facility but there was no Pediatric Intensivist…heck I am not sure there were any such fellowships then to be honest?

    I remember the child that came in with a sodium of 175. Vomiting and diarrhea prompted their local and rural physician to get them started on a rehydration fluid. The thing was he told them how to make it rather than just go buy Pedialyte for some reason.

    As you can guess, the child’s mother was cramming too much sodium in the solution and hypernatremia ensued. I had never seen a sodium that high. At the time, I’m a third year Pediatric resident in a hospital where even the ER docs stepped back and let us take over as soon as we arrived for a Pediatric code.

    I’m a third year in the program so when we rotated through the pink palace, we *were* the intensivist. Sure it was a community based program in a large part with only 8 or so full time faculty and some 70 or 80 clinical practitioners professors who we worked with mostly.

    The first twenty-four hours were harrowing to be sure. Careful calculations about how much more salt to introduce into the IV fluids to keep the sodium raised were done and redone. Even so, lowering the sodium from 175 to 169 resulted in seizures and a partial brainstem herniation. I stuck to the plan of carefully supporting the sodium so as not to let it drop more than 10 per day.

    And it worked! Despite the partial herniation and the seizures, this little girl survived. Years later the parents called me after I had gone back home to Arkansas to practice to thank me. She was a normal child. That little girl had everything going against her, but by gum, I wasn’t consigned to that.

    Her case, and many, many other like it served me well these past thirty years, and continue to keep me relevant. To be sure, if I don’t know something, I do know where to find the information or people that I need to solve the problems.

    Leadership…well, it leads.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • buzzkillerjsmith

    I did a locums in Kodiak AK a long time ago. A fishing boat turned over and a several hypothermic pts in arrest came in. I think the Coast Guard pulled them out. The subspecialty care was in Anchorage, a long flight away.

    Things were so bad that the radiologist was running one of the codes. Interesting experience.

  • meyati

    I agree- I think the main thing is that the doctors learn to think deeply and quickly– It creates a more hands on type of doctor.

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