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.
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.
“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.