“So tell me why you think you you’re having a stroke?”
The nice lady, mid 40s, sat on the ER exam table in work-clothes, an anxious look on her face. “Well, I was working the cattle up in the timber, and when I got back to my 4-wheeler my heart was racing, and I was short of breath. My arms were tingling, and so was my face. I’m concerned it might have been the start of a stroke.” Before I could go much further, her sister chimed in: “tell the doctor what else happened, go ahead!”
My eyes went from sister back to the patient as I waited for the tale to unfold. “The thing is, a black bear sow chased me when I got between her and her cub. Do you think that could have made me feel badly?”
“Yes ma’am! Maybe you were just hyperventilating.” (I certainly would have.)
It was the sort of situation that isn’t really surprising in rural emergency departments across America. Although I saw my “bear-chasing” victim in Colorado, most of my practice has been in South Appalachia. Rural Southerners have the same standard health issues as all Americans. However, while their assorted afflictions are often the same as those suffered by urban or suburban dwellers, there are unique problems, often involving nature, that bring patients to the rural ER. Hardly a summer goes by that I’m not giving someone anti-venin for a snake-bite from a copperhead. The last person I gave it to was a seven-year-old boy who was bit walking along a river with his family.
When physicians work in rural areas, we become comfortable with certain behaviors and patterns of injury. When a man walks in with dozens of tiny holes in his back, in April, the standard question is, “Did you get a turkey?”
Falls from tree stands elicit appropriate queries like, “Were you knocked out, does your neck or back hurt?” and the slightly accusing, “Were you wearing a safety harness?”
I have spent a lot of time suturing lacerations from chainsaws, machetes and pocket knives. I have treated patients whose hands were crushed in log splitters. I have removed fish-hooks from assorted body parts (including the eyelid of a two-year-old) and seen innumerable bites from insects and other creatures. I have also had to reassure frantic, visiting urbanites that all those red marks probably don’t reflect Lyme disease but more likely come from mosquitos. I have cared for more than my share of hypothermia, hyperthermia and no small number of drownings and near-drownings.
Thanks to rural life and work, I know what a log-skidder is, and what it means to hear that a tree or saw “kicked back.” I know to be very worried when I hear that the local rodeo is sending someone kicked in the face by a horse, and I was not surprised to see a man who shot himself in the leg while re-holstering his .44 Magnum after killing a wild hog.
The challenges of the rural ER, however, extend beyond pathology and into problems with resources. We have few specialists. A rural hospital with a decent ER, some family physicians, an obstetrician and a general surgeon, is rich indeed. Typically there is no cardiologist, no neurologist, no pediatrician, no trauma team; no heart center, no stroke center.
But it gets more challenging. To many Americans, the answer would simply be, “Well, if they’re very sick, just call the helicopter!” But rain, wind, fog, snow, ice and smoke from wildfires often keep us helicopter free. Even ambulance transfers are challenging, as most counties have only two ambulances and only one can be away at any time.
In addition, transfers to big centers can be confusing when physicians on the other end, in the big hospital, simply can’t fathom the fact that the small town doesn’t have things they take for granted, like an intensive care unit, a neurosurgeon or even an MRI.
The reality of medicine in rural America is often very different from the way the profession looks on medical dramas, which are usually set in well-stocked, well-staffed urban centers. Rural hospitals have plenty of struggles, and those troubles are growing. But what we lack in money, equipment and personnel we more than makeup for in rewarding work, challenging situations, grateful patients, and awesome stories.
City or country, a doctor can’t ask for much more than that.
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