Rural Medicine: Reaching the Limits

The world of Critical Access Medicine is unknown to most physicians.  Lots of reasons exist to explain this.  Most physicians come from rather privileged backgrounds – read urban/suburban/well-educated.  Outside of vacation, their exposure to Rural America is very limited.  They simply do not know what is out here.

Medical training largely does nothing to address this lack of familiarity.  In general, medical training concentrates physicians in large cities right at the time time they are beginning to have families and start careers.  This makes moving somewhere else after training even less likely.

The culture of large teaching centers glorifies the specialist and high-tech, high intensity medicine. Physicians who teach in these centers often denigrate “community practice” as somehow behind or inferior.  Moreover, physicians who practice in urban areas often cite the lack of resources as an impediment to good care.

I have met physicians who have all or some of these biases against rural medicine.  The lack of resources, however, is absolutely a real issue.  I run into it on a regular basis.  I understand other physician’s frustration.

Multiple times on my last shift, I ran headlong into barriers to providing care.

Making Do

On a recent shift, a woman came in with the complaint of weakness and slurred speech.  Upon seeing her, I immediately called a stoke alert.  I do not work in any hospitals with a neurologist, let alone a “stroke team.”  Some have telemedicine robots so a stroke neurologist can evaluate a patient remotely.

This hospital does not even have the robot.

In most Critical Access Hospitals, lab and X-ray are not in house until you call them.  So, we worked on getting things started: drawing blood, placing IVs, etc.  I did an NIH stroke scale, 11.  The score met diagnostic criteria to consider tPA, if her other factors didn’t disqualify her.

Finally,  tech X-ray tech arrives.

“I need a stat CT of her head.” I initially received only a blank, sheepish stare in response.

She looked at me, at the patient, and back to me.  The X-ray tech leaned towards me and asked under her breath, “How how much does she weigh?”

The bed scale registered an astounding 472 lbs.

I turned to the X-ray tech, “That is above your scanner limit, isn’t it?”  She nodded up and down.  I knew the next closest CT scanner was 30 miles away, the hospital is slightly bigger (they have surgery capability and visiting specialists).

“Call Otherton and see what their CT scanner can hold.” The X-ray tech ran off to call and ask.  The one room ED was milling with people –  family, EMTs, nurses.  None of them doing much at that point, save for the lone nurse struggling to get an IV in the patient’s difficult habitus.  This was the most exciting thing to happen in this down for weeks.

After a few minutes, she returned.  “Their limit is lower than hours.”

“Of Course it is.” At this point, I had already accepted this is not going to go my, nor the patient’s.  I grabbed the phone to call the nearest stroke center, almost 3 hours away.

The long distance consult/transfer conversation follows a script.  Patient’s name, brief past medical history, brief story of what has happened.  In the case of a stroke, special attention to presenting physical findings and last known normal is the expected.  Then, I get to the meat of my call:

“So, the real struggle right now is she is well over the weight limit for our CT scanner and the next closest CT scanner is 30 minutes away and apparently has a lower weight limit than ours.”

Then, I heard something I have never heard from another physician on the consult line.  The stroke neurologist offered a simple line.

“I’m sorry.” This was quickly followed by, “Yeah, let’s just get here as fast as we can.  She is already out of the tPA window, we’ll finish her evaluation here.”

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

The next day, an ambulance arrived with a 40s male, actively seizing for 20-30 minutes after the police arrested him.  No IV’s were placed in the field, he is completely unresponsive.  We quickly placed an IV and began the rounds of diazepam.  Finally, after three rounds, his seizure activity stopped.  He was still unresponsive.  GCS of 7, even after watching for any post-ictal improvement.

I have learned at this point it is more effective to ask for certain items rural EDs keep in bundles rather than what you would, ideally, prefer.  So, I didn’t as for my preferred induction agent, paralytic, etc.  I just asked them to bring their RSI kit, video laryngoscope (if they have one) and regular laryngscope.

“While we are getting ready to intubate, can someone get some IV keppra ready.”

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

“What other IV anti-epileptic medications do you have other than benzodiazepines?”

“I don’t know, maybe ketamine?”

Practicing medicine in a Critical Access setting is not a smorgasbord.  It is an 8th grade cafeteria line.

You can have whatever you want as long as it is Salisbury steak.

I proceed to intubate.  Afterwards, he was thankfully easy to bag and maintained end tidal CO2 and Oxygen levels in desirable ranges.  I asked if we have a ventilator.  An eager EMT piped up.

“Oh yeah, it is right over there.”  He pointed to a machine sitting on a crash cart with a big red sticker on it, “Out of Service.”

“Oh, I guess not.” He sheepishly admitted.

“Okay, bag him, make sure not to hyperventilate.”

Luckily, we have already called the local Medevac crew for critical care transport. They arrived and hooked patient onto their ventilator.  Carefully, they moved him with all his the sedation drips and IV fluids to their stretcher and flew him off to somewhere with an ICU.

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

I have talked to a fair number of EM residency trained ED docs and I often get the response of, “Oh, practicing out there would terrify me.”

I have no MD back up, no specialist support other than what can be obtained over the phone.  The EDs are often minimally staffed and under-provisioned.  On the other hand, my shifts are rarely so eventful as this.  Usually, it is Urgent Care level work ups. Often times it is downright boring – 24 hours without a patient sometimes.

But, that is the thing with an ED, anything can show up, even if it usually doesn’t.

I think a lot of quaternary care center trained physicians bristle at the resource limitation.  “I just wouldn’t feel like I am doing a good job.” is another statement I have heard.

I actually understand these concerns, no one likes to feel like they are providing less than the best care.  My response is simple.  The patients I see can’t call 911 and get dropped off at a Level 1 trauma center.  They are 2.5 hours from a level II, 30 minutes from a level III, minimum.

You can only take care of patients where they are.  Patients in Rural America need medical care just like patient in Urban America, but that isn’t where they are.  It’s called Critical Access for a reason.  Doing what is possible when you must is often more meaningful to the patient as doing everything because you can.

Time is of the essence in so much of what we do.  Waiting 20 minutes for a BLS ambulance to arrive and then driving another 30-45 minutes to the next closest Emergency Department could have meant serious brain damage for the man that man.

Could I offer him everything?  Of course not.  But I offered him a hell of lot better than 30 minutes of seizing in ambulance.

The famed bank robber Willy Sutton once answered the question, “Why do you rob banks?” with a simple, “Because that’s where the money is.”

I suppose, in the end, my answer is just as simple.

Why do I do this job?  Because it’s where the patients are.

Featured Image: The British Army in the United Kingdom 1939-45 Soldiers from 24th Battalion, Hampshire Regiment scale an obstacle during ‘toughening up’ training in wintry conditions at Wateringbury in Kent, 20 January 1942.

 

 

What is Being Present Worth to You?

…Memories of presence…the intensity of interacting with another human being that animates being there for, and with, that person.

Arthur Kleinman, The Lancet, Vol 389 June 24, 2017 Pg 2466.

“Doc”

“What do you have?” I ask the paramedic with the clipboard standing in front of me. The ED is rather busy. I am trying to arrange transfer of a man with an intra-abdominal abscess and one with neutropenic fevers. The prospect of more work does not excite.

Hank, an older paramedic who really enjoys the “medicine” part of his job, launches into his presentation.

“Rex Mayfair is a mid-forties man with a history of metastatic prostate cancer, Stage IV presents with urinary retention since this morning. This happens occasional for him and he comes in and we place a foley and have him follow up later. I already bladder scanned him, 570ml, and our scanner has been underestimating lately. Can I place the foley? He’s hurting.”

“Any fevers, weakness, blood in his urine?”

“A little bit of blood earlier, none now. Otherwise no changes from his baseline. He is not currently undergoing treatment for cancer, but is not on hospice. Can I place the foley?”

“Sure, go ahead. I’ll be in a bit.” I am relieved he has such a simple complaint. Something straightforward. Shouldn’t slow us down too much.

I return to organizing antibiotics and transfers for my other two patients.

Cancer Just Sucks

Eventually, after I tie up some loose strings, I make my way to Rex’s room. By the time I get into his room, Hank has already placed the foley, 1000ml out, and Rex is feeling better. My participation is really only procedural – a physician needs to physically see every ED patient.

I have a confession to make, I hate cancer. I hate how all consuming it is. As someone who initially trained in family medicine, cancer makes me feel as though I have already failed. The time for prevention was long ago. Now we sit at the mercy of the tumors.

Bad cancer makes me feel helpless. Doctor’s hate feeling helpless. Rex had bad cancer, and he was young.

Walking into the room, seeing Rex’s young, gaunt face makes me want wrap this up as quickly as possible. I only need to make sure there is no reason to suspect this is something other than swelling related to the cancer and I can rush him on his way. This should be quick…

To be Present or…not

“Hi, Rex, I am Dr. HighPlains, are you feeling any better after the foley?”

“Oh yeah,” Rex says in a defeated sigh. “It is better now.”

He just looks so damn tired and weak. I inhale deeply, but shallow enough so Rex didn’t notice. I sit down in a chair, recline slightly, and prepare to be here for a while.

After a few perfunctory ED questions, I asked Rex how things were going otherwise.

“It sucks, y’know, it just sucks.” He admitted.

“I can only imaging how much it sucks.” My patterned doctor-speech.

“I hurt all the time, cancer is in my bones. My hips and back, they ache all the time and then trigger muscle spasms.”

Without probing, he tells me how his urologist diagnosed him after 8 months of treatment for prostatitis. He describes how he was on hospice for a bit, but didn’t want to have a catheter permanently yet, so now he is not on hospice, but not pursuing curative treatment.

I simply nod in silence. His eyes are sunken and tired, but whenever he looks up, mine are there to greet his and hold his gaze as long as he desires it. He pauses frequently, but never seems done.

He continues, again without probing. He decided not have chemo because he has a form of muscular dystrophy. His oncologists told him the chemo would render him bed-bound from weakness.

“I would’ve had no quality of life…it just sucks, y’know.” He trails off into silence.

“Yes, it does.”

You Don’t Have to Ask a Dying Man

What do you say to make someone who is dying feel better?

It is a trick question, of course. Not because there is nothing to make them feel better, rather the thing involves no speaking. The answer, it turns out, is simple: you listen.

You listen. Even when it makes your own heart break, you listen. You listen through the descriptions of pain which makes you wilt. You don’t have to ask a dying man anything.

If you listen, he will tell you everything he wants you to know.

Rex isn’t done. He tells me about the facebook groups he’s found, which have been helpful to fight the isolation of living in the middle of nowhere with end-stage cancer.

He describes how much he used to enjoy driving the bus which took local elderly to events in the city and hearing their stories.

He misses that.

He tells me again about the pain. He tells me how his doctor prescribed him oxycodone for the pain, but he doesn’t like taking it. It makes his sleepy.

He has two little girls. When he took the oxycodone he just slept all day. His voice trails off, but I hear the implication.

He would rather be awake in pain with his daughters than sleep away whatever time he had left with them.

“It just sucks y’know, I’m only my forties, not an old man. Shouldn’t have to have a tube up there….it just sucks….” He bows his head, the brim of his baseball cap hiding those eyes, deep-set in his sallow, bony cheeks.

At that moment, it was a good thing I was listening, I couldn’t have said anything if I’d tried. I was speechless. My mind whorled in appreciation for the beauty of his simple statement.

“I have two little girls, I just slept all the time.”

This man, who has all the right in the world to numb himself from the pain of his situation had decided being present with his family was worth the pain.

Maybe when someone tells you the name of the thing which will probably kill you, time becomes palpably more dear. I don’t know.

What would I suffer through to give my daughter better memories of her father? What would I suffer through to have those memories and make more for as long as I could?

Few of us face a choice so stark, but in some way or another, we all face Rex’s choice. We can choose to be present in our lives and in pain, or choose to chase numbness.

I sat in a room with courage that day. I sat in a room with a man who chose to live his life rather than run from death.

Occasionally, if we let ourselves, we can awed by those we see through our practices But, we have to let ourselves sit in acceptance and receive the gift. I could have easily kept moving and had Rex on his way.

Instead, I sat down, and I am richer for it.

Featured Image: The Artist’s Father in His Sick Bed, Lovis Corinth, 1888.

Down the Canyon and Up the Mountain

Ten years ago this summer, I started a journey.  I made a decision to climb a mountain.  The path is well travelled and well marked, but supposedly so arduous few are allowed to start the journey.

Setting off to summit this peak, I first had to descend into the depths of a canyon.  Others had told me of this canyon.  They did not, however, explain its diabolical nature.  They did not warn me the sides of the canyon are loose scree fields, easy to get down, very difficult to get up. 

Going down wasn’t too bad, and everyone around said it would be worth it on top of the mountain.  The scree seemed to let me almost surf the way down.  However, the bottom of the canyon was dark, cold, and filled with sharp brush which abused the body. 

“You’ll get through,” they told me. “You’ll survive.”

Finally, though, after I reached the bottom, I began the journey back up.  I waded the cold creek.  I took a brief rest.  Then, I set out on a long hard climb up.  I could see neither the canyon rim, nor the original peak I had envisioned climbing.  

The loose scree gave way under me and sent backwards, 6-7% with every step.  It seems as though every possible handhold belied some danger: thorns, scorpions, snakes, and the like. 

Finally, after a long slog, I have reached to the canyon rim.  From the rim I can now look up and see the mountain that had been my goal.  I am tired, hot, sweaty, and forever changed from who I was before I descended into the dark of the canyon.  

I gaze longingly up at the mountain, it is visible, yet still so far away.  I turn around, and realize I am at the exact same elevation I started at, 10 years before, just a chasm of time away.  I am closer to the mountain, yes, but no further away from my starting point. 

This is what it feels like to reach Zero Net Worth after 10 years of medical training and working as a physician.   So much has changed, and yet, financially, I am only back where I started. 

10 Years Back to Zero

My net worth was barely above zero prior to medical school, but it was positive. That was the last time I had a positive net worth. The massive debt of medical school sent my net worth south of negative $300,000 at its lowest.

I recently calculated my net worth and, I have officially reached a positive net worth.

10 years later

Technically, somewhere in the last 6 months I reached Zero Net Worth. It took me a few months shy of a decade, but I have crawled back from the financial hole medical education put me in.

To be clear, I am not debt free. All of my assets just now officially outweigh my debt.

Getting back to zero is a necessary part of building wealth as a physician (assuming you took out loans for medical school). Nonetheless, the idea of 10 years of hard work, missed sleep, and sacrificing time with family and friends leading only getting me back to even is depressing.

Accounting for Life

Of course, money is a poor way to track life’s ups and downs. The value I place on different periods of my life over the last ten years correlates very poorly with their contributions to my net worth.

Medical School

The most striking example of this is medical school. By far the most expensive part of my life up to this point. I feel, at best, neutral about my medical school experience. It was okay, but certainly not worth the money it cost (from an experience standpoint).

I learned a lot in medical school, relatively little of it has much bearing on the actual practice of medicine or my life today. In my opinion, medical school is merely the price of admission to medicine, not much more.

By far the most significant value add to my life that came out of medical school was my wife. Meeting her is the great redeeming factor of my time in medical school, and worth it all.

Residency

My financial footing in residency probably changed little overall. I saved some money in Roth and traditional IRA, so the cost of my interest on my loans was probably offset by this.

On the other hand, residency has been and likely will always remain my favorite time in medicine. I had a great group of co-residents and humane faculty who were most interested in teaching first and foremost.

I worked like a dog, but it seemed like it had purpose and I was doing something that mattered, with people I enjoyed. Sure, was I happy to give up the 80 hour weeks when I finished. Nonetheless, I would have traded a lot of money from my first job to keep the sense of camaraderie and joy in medicine which I knew in residency.

In contrast to medical school, marrying my wife in residency seems not redeeming, but complementary. The memory of getting married in my R2 year blends with the frenetic sense of energy, growth, and progress of my residency years. Altogether, it was a good time to be young, in love, and doing something which felt like it mattered.

Attending

Obviously, working as an attending has been the most financially valuable part of my time in medicine, however it has also had the most ups and downs.  I was seriously looking for ways to quite medicine entirely 6 months into my first job. 

I was making more money than I ever dreamed possible and I was miserable. Honestly, the work of seeing patient’s wasn’t bad, but it wasn’t good enough to make up for the toxic culture, uninspired and vapid leadership, and burnt-out, greedy partners.

Having our first daughter and having to say good-bye in less than a month was a whirlwind of emotions.  I would not trade anything the experience of knowing and loving her for anything.  It was nonetheless a trying time.  

My current job is entirely satisfactory.  I have times where I get a good deal of satisfaction out of what I do, times when I am entirely fed up with it, and most of the time it just seems like a decent enough way to make a more than decent living. 

The joy of having our second daughter grows exponentially with every day.  It has been a relief to experience fatherhood with the joy and hope we are told to expect.  Life keeps moving. 

Life is Rich

I read a lot of physician blogs at times, and enjoy most of them.  Many physicians correlate their discovery of financial literacy with improvement in their overall happiness and life.  

I think this improvement actually comes more from simply moving to a more disciplined approach to life.  Finance simply provides an easily accessible framework on a topic that matters. Money matters, it can be the source of great stress and anxiety.   However, it will never bring happiness.  

Looking through the last ten years through the lens of my net worth is actually really depressing.  If life were about net worth, I probably should not have become a doctor.  The jury might still be out on that decision anyway.  Life is so much richer than numbers. 

I have developed a much richer appreciation for the human condition and experience in medicine than I ever would have in almost any other profession.

This richness cannot be quantified nor repossessed.  It does not earn me interest, yet pays me great dividends.  The discipline to examine our finances opens the window to examining ourselves and our lives, if we follow the breadcrumbs. 

Discipline is one of the great keys to a life well-lived.  Financial literacy, not as a competitive sport of amassing net worth, but as a training ground for personal discipline, is a useful tool for honing the skills which actually lead to a rich life. 

If the trail is only a means to peak-bagging, we are already lost.  To gain the most important benefits from financial literacy and independence we must remember they are not the goals, but merely training grounds for the personal skills which can help us live a life worth reveling in. 

 

P.S. I have really enjoyed looking for images of classic artwork to use as my featured images, as they are all public domain, I do not need to reference them, but I think think I am going to start adding information about each featured image at the bottom of each post with a link to information on the painting for those interested. 
Featured Image: Chasm of the Colorado by Thomas Moran 1873-1874