Across the Great Divide…Part 1

The Urban-Rural Divide, A Culture Gulf.

“You see, this is why they are wrong…” began our guide Ibrahim. My wife had just asked him to explain the difference between Shi’ites and Sunnis. He was Sunni, as are the vast majority of Moroccans.

We prepared ourselves for a very unbiased and nuanced theological discussion…

No place in the world has made me feel so “other” than Morocco. Sure, in Taipei I was an obvious Westerner, a novelty. In Moscow, I was suspicious as an American, but could blend in. In Istanbul, I was barely worth noticing.

In all these other places, I was different – a rare breed perhaps – but still recognized as part of the same species. Only in Morocco have I felt as though I was something else entirely. I came from another world, another plane.

In the mountains of High Atlas, the desert Palmaries of the Sahara, and the markets of Marrakech, my wife and I were more other than I can explain.

Increasingly, I see this dynamic playing out between Urban and Rural America. As someone who now spends two thirds of his time in one world, and one third in another, I want to talk more about it.

This will be the first post on the Urban-Rural Divide I have navigated since I was 18 and currently straddle in my professional life.

A Foot in Two Worlds

I never thought of myself as a two-culture kid, a common phrase for first generation children of immigrants. I am a white male, who grew up in an overwhelming white place. In theory, I fit in growing up.

At least some of my family have been in the US for a couple of hundred years. Some are more recent, but we don’t have any living memory of immigration from abroad. So, I can’t even claim Polish-American, Irish-American, or Italian-American as a second culture.

My father was born in the poverty of the post-Dust Bowl Northern Plains. He didn’t have running water until his family fled to California when he was nine. My mother grew up an Urban girl in the Bay Area of Northern California. Both graduated from UC Berkeley.

Somehow, I was born and raised in the middle of grass, beef, and sky country. A full days drive from a Major League Sports Team.

Where all the women are strong, all the men are goodlooking, and all the children are above average. – Garrison Keillor

I did what a lot of us curious ones did, I left. I began wandering an archipelago of institutions of higher learning. Initially, I enrolled at a highly selective liberal arts college, on scholarship.

For the first time in my life, the majority of people with which I socialized voted like my family. Difference was not an inherently suspect trait.

It was a revelation. After an entire childhood of feeling different because my family wasn’t from “here,” I finally fit in. Then, as I got to know more and more people, it became clear that I was still different.

You cannot spend your formative years in a place like the rural Northern Plains and “fit in” with the children of hyper-educated, suburban Tiger Mom’s.

A common refrain became, “You’re the first person I’ve ever met from that state.” There it was, I was again a novelty, to be wondered at.

“Well, there aren’t very many of us.” Became my standard laconic reply. I fell back on my tried and true survival technique, talk less about myself and more about events, ideas, politics, etc. People like that love to share their opinion on things they think “matter.”

The Trouble with Normal is….It Only Gets Worse – Bruce Cockburn

By the time I reached medical school, my very existence confused people. I had learned Latin in High School. I had lived in Russia and spoke Russian. I could follow a basic conversation in Spanish. I read, I mean really read. Not just because I had to.

Yet, I couldn’t shake all my ruralness. Sushi was still suspect in my book. Professional sports still seemed an alien and foreign thing to me. Traffic left me jittery.

During medical school, I often left for the mountains and spent several days alone, a tonic to counteract the volumes of people I dealt with on a daily basis.

People like me weren’t suppose to come from places like mine. My being in medical school challenged their assumptions about places and people they didn’t think mattered or were worth knowing.

I was aberration, a statistical outlier, noted and then discarded so as not to skew the data.

What Rural People Know

Shortly after I graduated medical school, my medical school started to count people of “Rural Origin” in their diversity statistics. It was a shallow ploy to make their overwhelming white, suburban, upper middle class cohort look more diverse.

Nonetheless, the logic was reasonably sound. Those of us who grow up in Rural, or even Frontier counties face significant health and educational disparities. The geography of suicide is decidedly rural.

In nearly all the indicators which the Left uses to identify historically disadvantaged or marginalized groups, Rural Americans meet the definition. Yet, we don’t make those lists.

And we think we know why. We have all heard what Urban America thinks of us. No one wears “rural origin” visibly. Because when we leave, we learn to blend in. There is no definite marker of being culturally “rural.”

So, we hear what Urban America has to say about us, our families, our communities – in classrooms, conference rooms, at happy hours. That doesn’t mean all of Urban America disdains Rural America.

Nonetheless, it is the strongest narrative Rural America has about how Urban America feels about Rural America.

What is She, from Kansas or Something?

Medical School was where I truly came to know this disdain, it slipped out accidentally, but often. Usually without malice, but with an odiferous smugness.

Once, when discussing a formula for estimating height in a medical school workshop, the professor asked the class if it didn’t apply to anyone. My friend, Steve, a first generation Chinese-American, raised his hand.

The professor, who knew nothing of Steve’s personal background, said, “Well, it doesn’t apply as well to immigrants or children of immigrants.” She assumed, based on his Asian appearance, he was an immigrant.

Later, over beers, he vented. It had clearly touched a wound.

“How the hell does she get off just assuming I’m an immigrant?” He fumed. “She’s faculty for god’s sake. You’d think she’s from…Kansas!”

It never dawned on him he had just made the same transgression he was fuming about. Kansans – coastal code for Rural Americans – apparently weren’t deserving of the same level of consideration he demanded for himself.

Mutant Towns

Another evening, I was sitting having beers with a classmate and her significant other. Both had transplanted from some Coastal megalopolis and we were discussing travel around the state.

In discussing regions of the state, her significant other stopped and said, “Oh, I don’t go there, those are mutant towns.”

“Mutant Towns?” I asked.

“You know, there are some towns in this state that are just full of people who kind of look like mutants. Fat, unkempt, ugly.” I don’t go to those places. He laughed.

I stared in silence and disbelief.

In other words, poor rural people. He thought he was sincerely funny. He also thought he was worldly and cultured. He thought he knew things.

This is what Rural America feels.

Sure there are nice, decent people everywhere, but we don’t remember those people. We remember the people who made us feel like nothing.

Can I get a Witness?

Urban America paid no mind while Rural America stewed in its hurts, limited opportunity, declining population, closing schools, and disparate health outcomes. Rural America doesn’t matter after all, it isn’t wealthy, mass culture is not produced there, fortune 500 companies don’t put their headquarters there.

“Why don’t they just move somewhat nice?”

But, Rural America votes. ‘Merica is religion on the High Plains and many other redoubts of Rural America. And the Religion of ‘Merica demands voting. And, Rural America is the only human community of in this country who has their Affirmative Action enshrined in the constitution – the Electoral College.

Rural America was tired of being ignored and forgotten. So, when a huckster who shits on a golden toilet showed up and made them feel heard, they showed up in return. That is how important it is to people to feel heard, to feel counted.

People want their suffering heard, and will sacrifice a great many other of their values to feel heard.

I hope these posts will help you get to know Fly-Over Country a little better.

You don’t have to like Rural America. I certainly know its flaws better than most. Nonetheless, it is cold and smug to deny its hurts and foolhardy to ignore the power it has to make itself heard.

A Shift as Death’s Attendant

“When was the last dose of epinephrine?” I ask the Tara, the recorder.

Her blood is everywhere. My gloved fingers are tacky with it.  I see it dripping off the edge of the bed, smeared across the floor, oozing from the open fracture of her right leg.

Her foot, connected to her leg only by skin and tendon, was still in a shoe. This struck me as an obscenity.

I watch blood pulse back forth in the tube draining her chest with the same rhythm as the chest compressions.

Tara’s reply makes its way through the commotion, “3 minutes ago.”

I turn to the team.  “Get ready to give another dose of epinephrine. Pete, take over chest compressions at the rhythm check.”

“Still in asystole.”

“Resume compressions, give the epinephrine.”  My voice has so little emotion. It seems to simply echo the recordings of the ACLS trainings I just completed the week before. Good timing, I think to myself.

On the Banks of the Styx

This is the second time in 48 hours I have stood at the foot of the bed, directing our modern dance with death. 

36 hours ago, it was all for show. We surmised he was dead well before his family found him. But EMS started CPR in the field, so we continued it. We invited the family in, to see us try and bring him back to life. We showed them all we could do.

We added artificial adrenaline to his veins. Then, when the lab-made adrenaline did nothing, we gave him our own – in the form of chest compressions, bagged breaths, and sweat-beaded brows. We danced with him, this newly dead man. We danced for his family.

We danced so they would know the drama and pain of the moment when we had done all we could.

He gave his body to those he left behind. He allowed us his body as salve to the grief of those who would miss him.

Dance of Death, replica of 15th century fresco; National Gallery of Slovenia

He sacrificed his body to lighten the burden of guilt of those he left. He didn’t make that choice, we and his family made it for him. I don’t know if he would have wanted it, but I found the gesture noble.

Now, 36 hours later, I am back in the same position. But this woman, she came in alive. Now, she was dead.

Only by standing at the threshold do you see how thin the veil really is.

Despite the intubation, the fluid, the pressors, the chest tube, her heart had stopped.

A code can actually have a lot of down time, especially once chest compressions have been going on for 20+ minutes.  I take a moment to let my mind slide out of the algorithm.

I look at the woman on the bed.  She is elderly.  I can hear the crunching of her multiple rib fractures with each compression.  Dying in a car crash after you have lived so long.  Such a violent death, so unexpected at that age.

“Doc, I have the family on the phone, can you talk to them?”

“Yes.” I grab the phone.  “This is Dr. HighPlains.  How are you related to Gladys?”

“I am her son, what is going on?”

“What have they told you so far?”

“Only that she’s been in a bad car accident.”

“Yes, she has. When she came in she was having difficulty breathing and had severe fractures in her legsand ribs. We had to put a tube into her lung to drain blood that was keeping her from breathing and put her on a ventilator. “

He sighed audibly in the phone.

“We started giving her blood as she was bleeding internally. Despite all of this, her heart has stopped and we are now doing CPR to try and restart her heart….I am so sorry.”

“We are currently doing everything we can do. However, in my experience, given her injuries, it is unlikely we’ll be able to get her heart restarted.”


“Do you know what would your mother have wanted us to so in this situation?”

He regained his voice. “Well, I am her Power of Attorney. How long have you been doing CPR?”

“About 25 minutes.”

With a tired, tremble in his voice, “I need to get my head around this, Would you keep trying for 10 minutes, and then, if nothing changes, you can stop.”

So, the music continued. And again, we danced. And Gladys too, sacrificed her body for those who will grieve her. We all tried not to focus on the grating of the ends of her ribs past each other.

It is such violent dance, these days.

Time of Death, 18:00

12 minutes later, I made a phone call.

“Sir, this is Dr. HighPlains again. Unfortunately, we were unable to get your mother’s heart restarted…”

“Thank you for everything you’ve done…”

We share a few more words, and I hang up the phone.

The Strange Calm

The routine of operationalized death begins. I sit back and watch. I slowly peel off my trauma gown. The ball is over, no point keeping up the dress code.

I watch the nurses. They cover the body first. It is a body now, no longer a person, at least medico-legally. Staff has already notified the coroner. The transfer of care is in process. I no longer have a patient.

The nurses start gathering the detritus up and throwing it away. I help feebly. We draw the curtain in the trauma bay. It is customary to the give the dead their privacy.

But, whose sensitivities are we really protecting?

Breath, Light Awareness

I sit down at the computer. Documentation is impatient. I pause before I start typing. I sit and feel. I notice my breath, and my pulse.

Luxuries, I suppose.

I can feel the heaviness of death. I do not feel guilt, I do not feel shame. I did everything I could. Could we have used dopamine instead of levophed, sure. Could we have tried externally pacing when her heart rate started to drop, sure.

Nonetheless, I do not second guess. Death sits next to me in heavy silence. I do not shy away, nor do I linger in fascination. I allow my body and breath to relax in acceptance. All our paths end here.


“Patient arrived by EMS transport in extremis….”

Rugged Individualism Dies a Slow Death on the High Plains

If the High Plains had an official philosophy, it would be Rugged Individualism. The Rugged Individualist bends nature to his will under his own might and survives despite all odds on his own ingenuity and hard work. He is the mythic paragon of High Plains citizenry.

Of course, the myth holds up poorly when we take a closer look. The High Plains are very lightly populated. As such, individuals are even more dependent on community and society at large than in many cities.

Sometimes those bonds are strikingly personal. I walk into gas stations on the High Plains regularly. Without fail, a collection jar for some young person injured in a farming accident or suffering from some unexpected disease greets me when I enter.

More commonly though, those dependencies are complex networks of support. They are often not apparent on the surface.

Indeed, the entire economy of the High Plains is largely based in government support (save for grassfed ranching). Subsidies for corn, wheat, and cotton support the agricultural economy. The states and federal government pay for the education sectors. Medicare and Medicaid pays for the care of the ill and elderly, who make up a disproportionately larger share of rural populations.

Medicare and Medicaid are the lifeblood of the few hospitals who manage to eek out an existence on the High Plains. The numbers of the privately insured are too low to fatten their bottom lines. Indeed, a state’s decision not to expand medicaid has been linked to increased rural hospital closures.

Nonetheless, the Myth Lives On…

Despite the evidence supporting the dependency that rural areas have on the government and community institutions, the myth of the Rugged Individualist lives on.

Some of this is understandable. Many people on the High Plains have grown accustomed to handling challenges on their own. In the day to day of their lives, their lived experience is one of having to be very independent and resourceful.

Moreover, people place a huge value on “straight talk” on the High Plains. The residents of the High Plains are quick to dismiss any delving into complexities and grey areas as a form of obfuscation. As such, discussions on how economically dependent the High Plains are on the federal government are easily shut down.

But Why the Rugged Individualist?

The Rugged Individualist is part of the Defining Myth of the High Plains. Be they sodbusters or cowboys, those myths give a sense of place and identity to the High Plains.

Myths are powerful things. To destroy a Defining Myth is to philosophically destroy a person. He/She will resist it all costs.

Communities and individuals cling tighter and tighter to such Myths when they sense risks to their survival. The popularity of Brexit among much of declining working class Britain may be an attempt to reassert the Defining Myths of Britishness.

Similarly, the High Plains are on a century’s long economic and demographic decline. Small towns throughout the High Plains are teetering on the edge of viability. Every ten years we see how they are slowly hemorrhaging population. As such, their Myths have increased in importance overtime.

People and communities need to take pride in something. If they cannot take pride in their economic vitality, robust institutions, and entrepreneurial populace, people will seek solace in their Defining Myths. In this case, it is the Myth of Rugged Individualism.

This even seeps into the culture of healthcare in the region.

Treating the Chronically Ill Rugged Individualist

Contending with the myths of Rugged Individualism is one of the more exasperating parts of my job.

I see many people with multiple chronic diseases requiring huge amounts of medical intervention. Despite this, they continue to live 20 minutes from town on a farm/ranch or even just an acreage.

They have little to no family support. This is usually because the kids all left for the city and jobs. Sometimes, it is just clearly because the individual is such a goddamn pain in the ass.

Acutely, they are often suffering from COPD/CHF exacerbation, lumbar fractures, chronic wound infections, chronic debilitation from limited activity, or any other number of chronic complaints. To any reasonable discerning observer, the root cause is chronic deterioration of their health without social support.

Nonetheless, they cling to their need to live “independently.” Somehow, routine hospital stays, home health, huge expenditures of time and assistance on the part of family do not constitute “dependence.”

The Rugged Individualist often confuses stubbornness for strength.

An Encounter With a Chronically Ill Rugged Individualist

I am sitting in the clinic office finishing a note and the phone rings. A nurse from the hospital calls and asks if I can take a look a patient. The patient is here for some outpatient wound care.

The nurse goes on, “We had her in swing bed last week for rehab. She has been home for less than a week. I am worried that she might have cellulitis under her pannus.”

I walk into the room. The patient is laying diagonally across the hospital bed, feet dangling off the edge. The position is awkward and unnatural. I introduce myself.

“I am the On-Call doctor, do mind if I look at your wound?”

She barely acknowledges my presence “Go ahead.”

The nurse and I retract her pannus. Underneath is the characteristic beet red color with cheesy accents of a massive yeast infection in the folds of skin.

“Ma’am, you have a yeast infection. Are you able to keep the area dry and clean at home?”

“No, I can’t reach it and no one’s ’round to help.”

Afterwards, I learn the two home health agencies which service the county refuse to work with her.

“Yeast lives in warm, moist environments, like in between your skin here. All the medicine in the world won’t keep this from happening if you can’t keep it dry and clean.” I begin to explain.

“But I can’t reach it and I ain’t got no help.”

I continue. “So, you can’t take care of it yourself at home and you have no help. The only other option is living in a facility where there is help. Like a nursing home.”

She bristles as expected, “I ain’t going into no damn nursing home.”

“Well, then this is going to keep happening.”

She nods her head in reluctant acknowledgement and says nothing more.

An Institution Funded through Enabling

A good number of the acute inpatient admissions I do are effectively the result of chronic ailments getting so far out of control so as to justify admitting someone to the hospital. Basically, the hospitals stay afloat through enabling the untenable living situations of the chronically-ill.

This is largely achieved through federal tax dollars. Those hospitals prevent people from dying alone in their homes or being dispositioned to a nursing home in a larger town after a hospitalization.

I recently related a story about intubating a woman with end-stage COPD. As far as I know, this was her 3rd-4th time in a year. She had only been home 2-3 weeks after a long hospital and rehab stay. In the nursing home, she had done well and improved with simple, attentive care.

She spent 10 days intubated in the ICU, at which point they placed a tracheostomy tube sent her to a facility which specialized in long term ventilated patients. It only took a few weeks at home without attentive care for this to happen.

After years of hospital admissions, intubations, and nearly dying multiple times, she is now ventilator dependent. This will likely be for the rest of her life. I don’t know if her staying in the nursing home would have kept her off a ventilator, but I do know that attempting to live “independently” hastened the course.

I have watched her story play out over and over again. In residency we referred to it as “tuning ’em up.” We’d admit someone, diurese them, and send them back to the same dysfunctional environment which allowed them to get so out of balance in the first place.

The hospital bills Medicare, we all collect a paycheck, and we do it all over again.

The Costs of Healthcare Individualism

Americans believe in the rights and importance of the individual above all else. Similarly, we place patient autonomy atop the ethical totem pole in US healthcare, even if it leads to harm.

The incentives in our medical system have created a structure which ignores the interconnectedness of the patient to their broader world. We spend little on the social determinants of health even though they are far more predictive of health outcomes than clinical medicine.

The importance we place on the individual ignores the reality of human existence. Connection and dependency define humanity. Humans are inherently social animals. We need each other and our surroundings affect us immeasurably.

In attempting to treat the chronically-ill as rugged individuals, we deny their connectedness. Ignoring those bonds, especially with the chronically ill, continues to lead to enormous inefficiencies and harm within our healthcare system.

Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?


A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!


Your Medical Director”

I sit back and sigh, good to back working again….

How the Corporatists Stole Quality

As I was finishing residency, we talked increasingly about “quality metrics.” In primary care, these included diabetic control, hypertension control, depression control etc.

These are all worthwhile goals. We should be trying to control and manage these chronic diseases as improving their treatment will prevent a large number of expensive and debilitating complications down the road.

Now that I am out in the real world, the importance of quality metrics varies wildly from system to system. Additionally, as a locums, I don’t hear much about it. Moreover, I am in the ED more often now and those metrics don’t apply.

Not surprisingly, cash-strapped rural hospitals are often a little behind the zeitgeist. So, their definition of quality is different than what I was used to in residency.

Clinicians Don’t Decide

What I have learned more about is the culture of metrics. Clinicians rarely determine metrics or their system for collection. Administrators is optimize metric collection for themselves, not the people who are actually trying to achieve them.

Administrators manage the system, so it is natural they would try to manage that system to make their jobs easier. What that has translated to is doctors being data entry clerks.

I could maybe even stomach this if it meant administrators actually improved the system. Yet, that seems rare.

I can be a team player.

Instead, what I usually see is administrators trying to game the system to make the metrics look good. Rarely will they roll up their sleeves and get their hands dirty trying to make the system work for the people who depend on it.

Moreover, there is still a pervading fear of liability in administrative circles. So, administrators translate the idea of quality, of improved care, to mean low-liability care.

Low-liability care is not quality care.

Sometimes they overlap, but the goal is completely different. We can expose patient’s to loads of unnecessary tests, procedures, and risks and still have low liability-care. Rise of c-section rates, anyone?

Yet, we all know that is not quality care. The corporatist administrative class doesn’t care. The concepts of black-eyes and feathers in their caps are what motivates the culture of the administrative class , not patient outcomes.

Moreover, systems can charge for many of these interventions. It is a win-win for an administrator – charge more money and decrease liability at the same time. Why do it any other way?

The Institute of Medicine’s famous To Err is Human report pointedly articulated how systemic flaws are often the cause of poor patient care almost 20 years ago. Nonetheless, we cannot hold the stewards of these systems personally responsible for failing to manage systems appropriately.

Layers of obfuscation and bureaucratic interactions prevent us from holding people accountable. Only nursing home administrators even have licenses that can be revoked.

I want to emphasize this point – even though the evidence is clear that systemic processes are at least as responsible for poor patient as clinicians’ actions – only clinicians have a licensing process.

Would administrators care more about actually providing good patient care if they could lose their career through licensure revocation? It might at least lead them to feel more responsibility for the systems they manage.

How did we get to this point?

I think physicians have been trying to keep their heads down, see patients, and get out as soon as possible. The rVU gerbil wheel has tricked many of us into abrogating our duty to try and make things better.

Additionally, as physicians, we treat one patient at a time. Our training to think of problems as individual in nature can sometimes constrain our problem solving.

What if physicians received training in organizational theory and leadership as a standard? Would it be better? I don’t know. But, I know we can’t fix what is wrong with American medicine one patient at a time.

Systemic problems rarely have individual solutions.

“The only thing necessary for the triumph of evil is for good men to do nothing.”― Edmund Burke (disputed attribution)

Uh Oh, I Want to Fix Things Again…

feeling the burn, again.

Over the last 2 months, I have been feeling the dread slip back into my work.  I spend the day before heading out of town thinking about the all the crap waiting for me.  This used to be normal, but I haven’t felt this way since I left my first job.

I was starting to worry.  I needed to take a look around and figure out what had changed.

problem 1 – working too damn much

I decided to take some time off in January and February – about 6 weeks.  This is  really easy to do as a locums, you just don’t accept any work for that time.  On the other hand, I won’t get paid if I don’t work.  So, I have been working more than usual to bank some money

In September, I was worried about having enough income to make it through those six weeks (I am still trying to aggressively pay down on my student loans). So, I signed up for any and all work that came a long for Nov-Dec.  For instance, I was on call for 264 hours in November.

problem 2 – location monotony

One hospital gets its schedule of need out about 1-2 months before other locations.  In my anxiety about having enough work, I signed up for a lot of work at this location – 192 hours in November.

Every location has its problems and dysfunctions.  This location’s downsides are: it is near an interstate and serves a more transient, mental health burdened population(more drugs, alcohol, suicide attempts, etc.).  It is also near a prison – so that is always fun.

Summary:  an emotionally draining patient population.

Moreover, because of the its demographics, the hospital gets less funding from the local community and yet the ED and hospital are busier than many of the places I work (and doesn’t pay that much more).   For instance, they don’t have auto-injector epinephrine – too expensive.

Despite these downsides, I didn’t used to mind working there that much.  What changed?  Why am I getting frustrated and crispy again?

in the nomadic world – freedom is all

Nomadic societies adopted their ways of life because the resources in one location were too finite and ephemeral to support a permanent population.

In places with limited resources but permanent populations – i.e. the desert, societies drastically alter the landscape to create more reliable sources of water and food – i.e. irrigation works and aqueducts.

The same is true in my work life.  In order to subsist, I must either be a transient nomad or alter an organization to increase its efficiency and ameliorate its affects on my life.

The continued ossification of medical bureaucracy leaves me little hope for the latter.  So, I live light on the land and move frequently.

For instance, when I work at a hospital once a month or so,  I leave, hand off the remaining clinical work, and move on with my life.  That becomes harder when you are back at the same location repeatedly.

Seeing you on the schedule in 2 days, nurses won’t address a concern as soon as possible.  Instead, they hold onto it, letting it fester, until you have returned and drop it in your lap as soon as you walk in the door.

While understandable, it is frustrating.  Especially because the questions are usually the same ones over and over.  Standing orders, protocols, etc can solve a lot of this busy work.  However, I don’t have the power to enact any such thing at the hospitals where I work.  I don’t fix things, I just see patients.

This arrangement works fine as long as the boundaries are respected.  However, human beings don’t like boundaries.  2 year olds and 92 year olds try and test them all the same.  We just don’t like them.  Moreover, we love feeling like we are getting special treatment.

here’s the rub, i like fixing things

I like finding creative solutions to complex problems.  This is actually why I got into family medicine.  When done creatively and intentionally, the longitudinal relationship in family medicine is exceedingly powerful at preventing disease and improving people’s lives.

The human psyche is exceedingly complex and most illnesses in our society are rooted in behavior.  Finding creative solutions to disease processes rooted in behavior is really challenging, interesting, and satisfying work.  Unfortunately, our system does not value this work.

Moreover, making systems and organizations run well is also primarily a psychological task.   You have to understand the values and motivations of groups and individuals, thereby harnessing them to accomplish the tasks at hand.

Again, as the MD in the room, no one wants to let you do this work because in the short term, they can use you to generate more income.  This is doubly true as a locums.

Normally that doesn’t bother me much because I don’t have to deal with inefficiencies and dysfunctions of a given system on a regular basis. Yet, in my anxiety to make sure I had some financial wiggle room to get through the time off, I started playing with fire again.

getting singed

So, I am a little singed right now.  It shouldn’t surprise me given my workload.  Nonetheless, I have had the benefit of learning another lesson about locums work – better not to wear out your welcome.

But here is the beauty – I don’t have to quit, find a new job, or start attending hours of likely useless meetings to try and make things better.  I just change my schedule, move around a bit.

I employ the millennia-old nomadic solution – follow the rain to somewhere else.

Sisyphys (1548–49) by Titian, Prado Museum, Madrid, Spain

The downside is I don’t get to employ my desire to make things better and the system does not benefit from those skills (assuming I have any).  Yet, my personal experience is systems do not want to improve, only perpetuate, themselves.

So, I ask, Why be Sisyphus when greener pastures are just over the horizon?


The Ups and Downs of the 1099 Life.

Living la vida locum (tenens)

If you haven’t read much of my blog yet, in 2017 my wife and I had a daughter whom we took home on hospice after she was born unable to breathe or eat without mechanical assistance.  My partners and the health system that employed me were not particularly supportive of me carving out time to process and heal.

To create more space to heal, I ended up moving to my current gig as an itinerant critical access doctor.    I fill in when small, rural hospitals are short for 12-120 hours of continuous call coverage, depending on average volumes of the facilities.

Technically, I am a short-term locum tenens doctor or maybe more like a full-time moonlighter.  It also means that I am now 1099 independent contractor.

Either way, I have experienced some ups and downs with this lifestyle over the last 6 months.  I wanted to explore some of these, with a bent towards the financial.

positives of 1099 locums work
  1. I have complete veto power over my schedule. I can’t create work where work doesn’t exist.  However, if I don’t want to work somewhere or at a given time, I just don’t.  Back in June, I realized that if I wanted make faster progress on my loans, I would to work a bit more.  I didn’t have to find a moonlighting gig or start a side hustle, I just signed up for more shifts.
  2. The hourly wage is generally higher for the workload.  I was making more money in my previous job, but I was working my ass off in the process.  Per patient seen, I get paid much better now.
  3. I only take care of patients. No inbox coverage, no prior authorizations, no utilization reviews, no meetings, just pure patient care.
  4. Variety of work environments.  If I get tired of working somewhere or need a break from a given site’s particular brand of dysfunction, I just don’t schedule any work there for a month or two. Think of it as a burnout release valve.
  5. I work fewer calendar days.  I really only work 10-12 days/month.  Conversely, they are 24 hour days.
  6. I am now a business.  I get to deduct all sorts of things from my taxes.  Because my wife and I won’t make >$315,000, that includes the 199a 20% of qualified business income deduction.  So, w00t.
negatives of 1099 locums work
  1. My income is not guaranteed.  So far, I am still having to turn down work.  Rural America has more work than there are people to do it.  However, the possibility exists that it will just suddenly dry up.
  2. I get no benefits.  I carry my own disability insurance, life insurance, and have to fund my own SEP-IRA.  No 401k match for me.  Luckily, my wife likes having a regular job so health insurance comes through her job. But that is another big question mark.
  3. Limited opportunities for collegiality, unable to participate in system improvement. I have to just deal with whatever system is in place where I go.  The only bad feedback I have received was when I dared to have an opinion on a facility’s processes.
  4. I can’t build a team/workflow.  Because I am just a place-holder, opportunities to integrate and develop a team are limited.
  5. I work nights, travel, and am on call for long periods of time in a row.  It can be lonely and my wife doesn’t love it, but being around me is way more pleasant now, so I think it is a wash for her.  Also, no vacation time.
  6. I am now a business.  I have to keep  record all my expenses and track my income more closely.  My taxes got a lot more complicated and I suddenly care about tax policy in a way that I didn’t have to before.
the upshot: working as a 1099 isn’t that different from production-based reimbursement

In my first job out of residency, my contract would have eventually paid me 100% on production.  This an “eat what you kill” model for reimbursement.  Certainly not all compensation models are 100% production, but it is hardly rare.

Now that I have been an independent contractor and been a production-based employee, I don’t my financial stressors to be that different.

Before, I was basically a doctor paid on commission. The organization ONLY paid me to provide patient care. I had to track my RVUs closely, which are way more complicated to track than how many hours I work.

On the other hand, when I was employee, I constantly heard about the financial health of the organization and the organization expected me to give a shit.

The way the organization designed the system, the only power I had to help them financially was to see more patients.  I didn’t have the power to hire or fire staff, invest in training programs for staff, recruit new staff, or even choose to spend a half-day on system improvement.

Now, as a 1099, I pay a little more attention to my finances and workloads, but all of it directly affects me and I have complete control over it.

Hospitals only pay me to provide patient care and my responsibilities end there.  No one tries to sneak more duties onto my plate without carving out time or adding compensation.  Finally, an honest relationship between a physician and a healthcare institution.

honesty is a good policy

In the end, this is my favorite thing about locum tenens work.  The relationship between the physician and the institution is as honest as it gets. Seeing patients is the only way physicians produce income.  So, in an accountant’s mindset, that is the only time worth compensating us for.  It is immaterial that we could be adding value to the system in a myriad of ways.

Locum tenens work is the only situation I have found (at least for a family doc) where I get to work so honestly. I show up from X hour to X hour and receive Y in compensation, I take care of whatever patient care needs arise during that time as best as I am able and everyone leaves happy afterwards.

Honesty and transparency are worth a great deal in Medicine.  They are becoming harder and harder to come by (have you ever read a healthcare bill?).  If this is the only way to find a little of both and still practice medicine, life could be worse.

The Peripatetic Patient

“I reached some plains so vast, that I did not find their limit anywhere I went, although I traveled over them for more than 300 leagues . . . with no more land marks than if we had been swallowed up by the sea . . . . there was not a stone, nor bit of rising ground, nor a tree, nor a shrub, nor anything to go by.” – Francisco Vázquez de Coronado, letter to the king of Spain, October 20, 1541

lost on the llano

On the High Plains of the Panhandle of Texas lies the Llano Estacado, the Staked Plains.  These are the plains Coronado described.  Navigating their featurelessness proved so difficult he instructed his men to drive stakes into the ground, from which they took their bearings.

It seems many wander into the High Plains and never think to pound stakes into the ground.  Under the blue sky, they wander through their lives, unable to orient themselves, running from one crisis to another, finding only the slightest bits of respite in between.  Often those wanderings lead them to my ED.

vagabonds and ramblers

The ED is our society’s safety net of last resort.  Entry is guaranteed to all, the law requires hospitals to provide an examination and stabilization.  As such, many crises with social roots land the Emergency Department.

As a traveling doctor, I see many of these peripatetic souls.  Unfortunately, the happy wanderers and jaunty pilgrims don’t end up in my High Plains ED.

I have cared for the meth-addled, the anxiety ridden business drunk, the chronically ill truck driver who just couldn’t quite make it to the end of his run.  The elderly RVer with COPD or CHF who never seems to remember oxygen is sparser at higher altitude is a frequent visitor (they are called the High Plains for a reason).

The challenges of caring for the itinerant are many.  Treatments are often not portable. The lack of family members, who are a mainstay of support during illness, puts more burdens on the medical and nursing team.  Often the best you can do is get them patched up so they can get back to somewhere with better support.

high plains drifter

All of the above characters have parts of their stories that are touching or sad.

For instance, I once did a trauma evaluation on very stoned young man who had been driving a car that a train demolished in a collision.  I evaluated, observed, and released him unharmed, though he did annihilate several microwaveable burritos in the process.

Apparently, he stole that car two hours away and drove until he passed out, high-centering the car on the rails. Luckily he wasn’t actually in the car at the time of the collision, though his inebriation prevented him from telling us this when he arrived in the ED.

What did he do when after his discharge into a town where he knew no one and had no transportation?  He stole another car, lead the police on a high speed chase, and earned himself three hots and a cot for an unspecified amount of time.

Occasionally, something hits you like a train.

marooned on the high lonesome

On recent shift, a local foster family brought in a child for suicidal ideation and threats of self-harm.  The child was newly in foster care, less than 10 years old.  Already, it is a pretty sad story.

When the child arrived, we talked.

Me:  How are feeling, how is your mood?

Child:  Sometimes good, sometimes bad.

Me: Is it getting better or worse?

Child:  Worse

Me: Do you want to die sometimes?

Child: Yes.

He was in a new school in a new town with a family he didn’t know.  It was stressful, he was angry.  He hadn’t made any friends in his new school.

I asked where he was originally from – a state over 1000 miles away.  He had no blood relatives nearby.   I didn’t understand how he ended up in this hamlet.

Son of farmer in dust bowl. Cimarron County, OK. April, 1936. Arthur Rothstein, FSA.

As the story unfolded, he was traveling with his mother, a long haul trucker.  She stopped at a truck stop and law enforcement apprehended her for some previous violation, placing her in custody.  He went into the system.  After her release, she fled the state.  Here he stays, marooned on the Llano – no landmarks, no stakes, no family.


For now, he will continue to live with a foster family he doesn’t know, his mother having abandoned him to the wind and sky.

Me, Anemically: That must be really hard

Child: Yeah.

That, and a referral to mental health, is all I have to offer this poor kid.  It is better than nothing, yet so insufficient. This small child has rendered all my advanced diagnostic and medical technology impotent.

Like a tumbleweed on the Llano, it all seems powerless in the face of the incessant wind and limitless sky.


It’s the High Lonesome for a Reason

The plain gives man new and novel sensations of elation, of vastness, of romance, of awe, and often nauseating loneliness. – Walter Prescott Webb, The Great Plains (1931)

By Leaflet – Own work, CC BY-SA 3.0, Source: Wikimedia Commons 

Yet, America remains attached to the idea of Yeoman farmer and the rural bucolic existence.  It lays deeply burrowed in our collective mythology.  Many people who live in small town America are very proud of this association. Indeed, I have been to some places that seem to live this ideal every day.  They are very rare.

rural america is no spring chicken

Firstly, Rural America is much older than America as a whole (interestingly, the places where this is not true are largely in areas where refugees and immigrants are moving in to work in industrial agriculture – but we won’t touch that lightning rod for now).  Some of this age difference is due to youth moving to cities and larger towns for jobs.

However, I also increasingly hear narratives about people on fixed incomes – the disabled, the elderly, the rare retired military, government, or railroad worker who actually receives a pension moving to the small towns because of affordability.

This is especially noticeable in places not too far from larger towns/cities on the borders of the High Plains.  So, young people are leaving and older people moving in – a demographic double whammy.

what kind of person retires to high plains?

It takes a special kind of soul to thrive on the High Plains.  You have to love the sky and the wind and the sun.  You also have to be pretty self-reliant.  Self-Reliance is the central tenet of High Plains life, help is usually not close and may be unreachable.

Unfortunately, no amount of grit or curmudgeonliness will keep you healthy and independent forever, though it does seem to help.  I have seen dozens of people who retired to a rural area and bought a small acreage in their fifties or early sixties when they were still quite healthy.

This seems to last a good 5-10 years.  Property is a lot of work.  Roads may be plowed by the county after a snowstorm, but your driveway won’t be. A half-mile snowed-in driveway is a glacier to a wheelchair.  Moreover, 48-72 hours may pass before the county gets the road clear.

chronically ill in the middle of nowhere

One of my first patients in my real practice was Kathleen (obviously not her real name), an older woman who was supposedly in for a diabetes check up and establish care.  We sat down to go over her A1C and her medications.  A quick chart review revealed that she was undergoing treatment for Stage III-IV ovarian cancer, at 79.

Ovarian cancer that is this far along is not a curable disease.  It is what the patient will die from (if the treatment doesn’t kill them first).  Kathleen had already gone through surgery, chemotherapy, and radiation.  She was struggling to keep her medicines straight.

Her oncologist had told her this cancer was incurable.  Despite this, she still suffered through treatments thinking that a cure was possible.  We had hours of conversation about goals of care, she still wanted treatment.  It took me a while to understand this, seeing how much she was suffering.

caring for the seriously ill requires community

She lived on 2 acres on a gravel road, miles out of town.  They could be snowed in for days at a time.  She was too weak to cook for herself, she was losing weight.  Then I met her husband, he had significant dementia.

SHE was the caregiver in the relationship.   She felt she couldn’t leave her husband and his dementia made it impossible to reason with him. Children were in other states and not helpful.  Elder protective services were involved – but to no avail.

She was in and out of the hospital and the ED.  When you have no one to give you a ride and you are not doing well, the only option is the ambulance.  An ambulance can only take you to ED.   Discussions about nursing homes, hospice, assisted living went nowhere for over a year.

In the end, she had a chronic pneumothorax with an indwelling chest tube with a valve. She was constantly in pain and short of breath.  Finally, one of my partners transferred her to a hospice house an hour away, almost against her will.  She was simply too weak to fight.

This is an extreme example, but it is easy to imagine a bunch of hardheaded, tough people who are now on oxygen due to smoking, or with arthritis and limited mobility, or early dementia as yet unnoticed (no one has visited grandma in 6 months).

My experience doctoring over the last 2 years around rural America has left me feeling that the social isolation of rural America is literally killing people.

social isolation is a growing epidemic

The New York Times has written 2 articles on it within the last 2 years.  Additionally, an increasing amount of psychological and health publications are delving into the risks of social isolation, and it is more acute in rural areas.  These risks even include increased mortality.  This risk can be up to a 50% increase.

As a traveling doctor, I often feel powerless in the face of these realities.  I see people in the ED who are just destined to float back and forth between the hospital, nursing home, home (see hardheadedness above) and back until death or a permanent stay in the nursing home.  And I often just feel myself helping keep the assembly-line moving, unable to help renew the sinewy bonds of community.

Loneliness, thy other name, thy one true synonym, is prairie. – William A. Quayle, The Prairie and the Sea (1905)

On quiet evenings, when I walk around the edges of the little High Plains hamlets where I work, I stare up at that fantastic sky and think about my own isolation.  Watching the windmills turning wind to electricity on the ridgetops, I find the space to feel my loneliness.

By USFWS Mountain- Uploaded by Magnus Manske, Public Domain,

The loneliest kind of loneliness is the that felt when surrounded by a sea of humanity.  The High Plains welcome those feelings of isolation.  The sky seems to open up and embrace the lonely. Some of my loneliness stems from the grief of losing my daughter, I know.  However, I also feel the professional isolation.

physicians are not immune

As I have said before, there are times where I am the only doctor in an area the size of Rhode Island.  I am almost never physically adjacent to others of my profession.

How does one stay connected to the community of healers without a home base? How do you discuss tough cases when you are the only one in the doctor’s lounge?

Increasingly, researchers are identifying feelings of isolation as playing a role in physician well-being and burnout.  I know that the isolation I felt in my acute grief and how my partners reacted was worse that than anything I feel now.  It is one thing to be lonely by physical distance, another when social and professional exclusion and competition isolate you.

I think that the rise of the physician blogging community is a reaction to these feelings of isolation that we have in our work space.  Physicians are supposed to be social people, to connect with people.  We need our community to thrive.

Self-reliance and rugged individualism appear to be contributing to significant suffering and premature death in rural America.  Am I too at risk?  I don’t know, but I am trying to do something about it, and hopefully it helps.


An Introduction to Critical Access Hospital Doctoring Part 2

Doctoring on the High Lonesome

Hopefully, you read Part 1 of this series, or at least skimmed it (rural health policy isn’t for everyone) for some background. In this post, I will dig into why critical access doctoring is different.

rural family medicine vs critical access medicine

What is the difference between “critical access medicine” and “rural family medicine?”  Traditionally, rural family medicine practice was the “does it all” local doctor.  The doctor who saw patients in his/her own practice, admitted them to the hospital, took ED call, delivered babies, etc.

I currently don’t have a practice and am not a reliable presence in the communities in which I work.  I have no longitudinal relationship with patients. As such, I don’t really feel like I am doing “rural family medicine” in my current arrangement.

The bulk of what I do now is low acuity emergency medicine. Larger EDs label this  kind of care “Fastrack.”  However, I also have the occasional heart attack, stroke, sepsis, and trauma thrown in for sphincter training.  In certain locations, I see the occasional primary care patient or urgent care patient in clinic.  I also take care of low acuity acute inpatients.  On top of all that, there is the bag of worms known as “swing bed” in Critical Access Hospitals (CAH).

The biggest difference between critical access doctoring and being an urgent care doctor, hospitalist, primary care doctor, or emergency room doctor is that I am often juggling all of these responsibilities at once.  This demands a kind of mental flexibility and strategic thinking different from what I have experienced in more specialized settings.  Moreover, you are almost always doing something at the limits of your comfort zone.  You can call for advice (but rarely backup).  At times, I am the only doctor in an area the size of Rhode Island.

swing bed programs

Swing bed programs are designed to allow CAHs to “swing” some of their unused beds into post-acute care skilled nursing facility (SNF) beds.  CAHs most often use these for post-stroke, acute illness, or surgical rehabilitation services.  These services include: physical therapy, occupational therapy, speech therapy.  Occasionally, patients who require long term treatments such as IV antibiotics are swing bed patients.

The purpose of these programs is to allow CAHs another revenue stream to help them maintain their critical access mission.  The reimbursement for this is again “cost based.”  No hospital will be able to make a profit with swing bed services. However, they can get a lot of the costs covered that a hospital incurs from having nurses, techs, doctors on call or on the payroll just to have a basic level of service.

why can’t people just stay in the hospital?

Normally, swing bed patients are fairly easy to care for.  The acute care hospital (ACH) addressed their acute issues and it should be fairly simple from that point on.  In fact, the doctor only has to see them every 7 days, because they are not supposed to need acute care.  However, it is not rare for the transferring acute care hospital to present the situation in the rosiest light possible.

These patients are often chronically ill and debilitated and on government insurance such as Medicaid and Medicare.  These plans pay based on DRGs (diagnosis related groups). Meaning, for a given diagnosis, CMS pays an amount based on the average cost of providing care for the diagnosis.

So, once the ACH has dealt with their acute diagnoses, these patients are costing them money.  Especially if they are short of staffed-beds and having to turn away other acute care patients. They want them gone.

swing bed can be a solution

In the past, these patients might just be sent home or out onto the street by some of the more profit-hungry hospital systems.  If they came back, no worry, CMS paid them for the second hospitalization as well. Now, hospitals are getting penalized for 30-day readmissions.

Due to these new punishments, acute care hospitals want to get patients out of their hospital, but to somewhere from which they are unlikely to bounce-back –  SNFs(skilled nursing facilities), LTACs (long term acute care), LTCFs (nursing homes, assisted living, etc).  Basically, swing bed programs allow CAHs to function both as an acute care hospital and as a SNF.

This financial pressure on acute care hospitals means that sometimes the transferring hospital buffs the chart to make the patient seem less sick than they are.  It definitely happens where a patient arrived at the CAH, spent 1-2 nights, and quickly return to the ACH because of their illness acuity.

trials and tribulations of a swing bed patient

Specifically, I can think of a patient who had back surgery, was in the surgical hospital for 3 nights, then sent home.  She presented to our ED with worsening pain and inability to care for herself at home.  Due to her first hospitalization, she qualified for swing bed.  I admitted her to swing bed as there was no obvious acute diagnosis at the time.

Her pain worsened, she developed a fever, which in the end turned out to be secondary to a wound infection.  She returned to the acute care hospital for a washout and antibiotic treatment.  She was sent back to our facility for IV antibiotics and physical therapy.  3 days later, her wound was gushing with fluid again.  Back she went to the acute care hospital for another washout and treatment, after which the acute care hospital transferred her to an LTAC.

critical access doctoring

I spent a disproportionate amount of time on swing bed care because it is a type of medical care that really only exists in CAHs.  It is definitely NOT what I spent the majority of my time doing, but it is something that I had never encountered before working in a CAH.  It took me a while to wrap my head around it.  I have even hospitals that utilize swing beds often poorly understand it.  I hope that the discussion was useful for anyone who is trying to figure it out.

Finally, I hope this paints a basic picture of critical access medicine.  At its foundation, it is a commitment to meeting patients where they are, in a literal and geographic sense.  The challenge is that there is almost no routine and you are frequently reinventing the wheel.  This necessitates lower volumes as you have to think things over more carefully and can’t rely on muscle memory and reflex.  If you can handle those constraints, the benefits are more time with patients and more variety than almost any other practice environment.