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.

 

 

Wherever I Go, I am a Stranger

Spring is the best time on High Plains, especially on the Northern High Plains. The snow has melted. If the springs rains came, then the grass has greened and the winter wheat is growing in the fields. Verdancy is everywhere.

The birds have returned and their sounds can be deafening. The mourning doves and prairie meadowlarks fill the evening with their calls.

The wind brings the scent of sweet clover and moisture. Later, in July, it will feel like a dusty blast furnace. But now everything is pleasantly fresh and new. It is a good time to get out of the City. The sense of possibility and abundance surround you as you walk down dirt streets.

Towns on the plains are of two camps, clod hopper towns or shit kicker towns. This roughly divides them between towns that rely on farming and those that rely on ranching, respectively.

Farming requires more machinery, more labor, and is more lucrative. As such, these towns have a more robust tax base and generally more funds for services. They tend to have greener lawns and more orderly, well-kept homes.

I am on shift in one such town today. School has ended for the year, children run feral throughout the town, down lanes of arts and crafts homes and mid-century ranches. It reminds me of my childhood.

Upon going out into the world, I found out that even in the 1980’s and 1990’s, I was living a childhood out of a different time. Now, these children are having an experience downright foreign in comparison to their urban and suburban counterparts.

In this little pocket of America, the end of school year does not simply mean a transition from one overly-scheduled, hectic routine to a different overly-scheduled, hectic routine.

It means the freedom to roam, make mistakes, get hurt, and learn and grow. Freedoms now so rarely afforded children in our society.

I sit in the well-manicured park next to the baseball diamond and let myself dream of a simple life in a little world like this. Where my daughter could roam the streets in relative safety.

Forever the Rolling Stone

Freedom so often means that one isn’t needed anywhere. Here you are an individual, you have a background of your own, you would be missed. But off there in the cities there are thousands of rolling stones like me. We are all alike; we have no ties, we know nobody, we own nothing. When one of us dies, they scarcely know where to bury him… We have no house, no place, no people of our own. We live in the streets, in the parks, in the theatres. We sit in restaurants and concert halls and look about at the hundreds of our own kind and shudder.

Willa Cather, O Pioneers.

It is a silly little fantasy. I am a stranger here. I always will be. Even if we moved in and I set up shop as the town doctor, I would always be an outsider. I would be a little suspect, I wouldn’t really “understand” the town. That is the way it is.

As long as I am temporary, the staff and patients treat me well. They treat me like a guest. They are very kind and obliging. On the other hand, I know cultures which place the most importance on hospitality towards guests are also often the most closed.

As long you are a guest, you have no rights in community decisions. You are otherized and compartmentalized into a nonthreatening entity, ever so politely.

So, I roam, continually a guest, an outsider, an observer. Nonetheless, the dream of simple little corner of Americana is a seductive one…

To Dream a Little Dream

When I discuss these little flights of fantasy with my wife, she sighs and rolls her eyes. She knows why a simple, pleasant, little life for us is only a dream. We are not simple, pleasant, little people – and I am likely the worse of the two.

I don’t know if we dream of bigger things, but we do not fit into molds well. We are not terribly pliable people. We have not melded back into the city well, either. The self-indulgence, easy conveniences, greed, commercialized spirituality, and glorification of self have rubbed us raw.

I often wish I could be satisfied with a simpler version of what life was about. I wish I could still believe working in healthcare is about helping people.

But some things cannot be unseen, some hurts cannot be unfelt.

Simplicity is Complicated, Too

The funny thing is, my life actually is much simpler now that I travel for work. I roll in, do my work, and I roll out. Back at home, I live a life with plenty of unstructured time spent with my wife and daughter.

Work is far less draining. I don’t go to meetings to be harangued about productivity, my life is not held hostage to a call schedule. Yet, I am perpetually a stranger at work, and in the City.

It turns out, after a certain age, most of the people in our lives we meet through work. And most people don’t have 10-20 days a month free to spend as they like – they are at work.

It is an odd paradox, my life is honestly much simpler than it has been in years. Yet, that simplicity has not necessarily made it richer.

Without the demands of Medicine following me day and night, I have had to let myself be a human again. To let myself do nothing, without guilt, which has been the hardest part, by far.

After 9 years of being fashioned into a bow and strung tight, always ready to react to some new crisis, it is hard to unstring oneself. Sometimes, I force myself to remember I was a whole person before Medicine, and will continue to be so if I were to leave it.

The Stranger, only Human

So, this is the trade-off. I am perpetually the stranger, but much more human. I am not defined my role and relationship to my career and coworkers. Now, two thirds of the time I am simply me, not Doctor HighPlains, but just a guy with a family.

I also remember grief and disillusionment have led me here. They have forever changed my relationship to the world. Initially, it is all destruction and chaos. That is the painful part.

The world expected the pain after we lost our first daughter, it expected me to hurt. But then, as the pain transmuted from a gaping, burning wound to an ember of love and sadness, the next part came.

The awkwardness of building of a new self and a new world. This struggle is harder for people to see and relate to. It is a constant tension. I make progress and lose it all within seconds.

And really, even though we are 18 months removed from the loss of our daughter, only now has the pall of crisis started to lift from our lives. We lost our daughter, quickly moved states, set up new lives in new jobs. Then, we had survive the stress and anticipation of another pregnancy.

We had the normal stress of a newborn baby, mixed with the guilt of feeling the pain of losing our first fade. Only now, has our breathing seemed to slow to a normal pace.

Without crisis and loss and disillusionment, who am I? The Stranger, forever it seems now, the Stranger. I have become, it seems sometimes, a stranger to everyone including myself.

So, I accept this task. The awkward, slow task of getting to know this new me in this new world. I am bad at it, but I am doing it.

Across the Great Divide….Part 3

It is Memorial Day on the High Plains. The small, well tended town cemetery is full of flowers. People mill among the headstones. I often walk by this cemetery while I am on call and this is the first time I have seen anyone else.

On the other side of town, the town pool is being prepared for summer and children play baseball in the town park. American flags line main street. It looks like Normal Rockwell threw up all over this little town.

These are all small little rituals that maintain an identity of Americanness for people in small towns across America. There is no Walmart parking lot to negotiate, no traffic to fight. Simply the rituals family, country, and community. It is seductive, in a way.

Twentieth century White America needed all these rituals to form a cohesive identity. Many of the adults were children of European immigrants. On the High Plains alone Irish, German, Germans from Russia, Czech, Polish, Italian, Scandinavian, and Latino immigrants mixed in communities.

So, people got together in these rituals of Americanness in public. Even if in their own homes they cooked their old foods, read their old prayers, and told their own stories.

But, in public, it was all about being American. It was a communal effort to support the idea of being one people, bound together by location and a national ideology. Even if they did not share a historical culture, language, religion, or history, they could share a hot dog, a beer, and a baseball diamond.

America is a Fragile Idea

People tripped over themselves trying to be publicly American. Assimilation was all the rage. My father’s mother spoke German. After WW1 and WW2, his father discouraged her from teaching the children any German because of anti-German sentiment.

In the Southern High Plains, school teachers and classmates mocked and punished Latino children for speaking Spanish. I won’t even delve into the brutality and cultural genocide of the Indian Boarding Schools.

People paid the price of this cultural loss to assimilate and be “American.” Only the oldest resident’s of the High Plains have memories of their European immigrant ancestors speaking the Old Language and practicing their Old Ways.

The modern generations only know that their parents and grandparents did assimilate. They don’t realize it took decades or 1 or 2 generations for their ancestors to assimilate into “Americanness.” Nor, do they acknowledge the change their assimilation brought to American culture as a whole.

Immigration did not bypass Fly-Over County, then or now. The first Arab-American Senator in this country was Lebanese Maronite Christian from a small farm southern South Dakota – James Abourezk.

Fort Morgan, Colorado made news a few years ago. Somali immigrants working in industrial agriculture sued under religious freedom grounds for breaks at work to pray the requisite number of times per day.

What I hear and see when people on the High Plains talk about new immigrants is a feeling that the rules have changed. Their ancestors bartered one culture for another. Now, in the Cities and even in their own communities, they feel new immigrants are not forced to make those same concessions. I don’t know if this is true, but it is what they feel.

I doubt any of this is conscious. Much of it comes out as simple nativist, scapegoating for the pain of being in a world that is changing rapidly and leaving them behind. Nonetheless, I wonder if deep down, there is a jealousy. A sense of “Why did my parents and grandparents have to forget their culture and these new people don’t?”

Rituals of Americanness

Of course, new immigrants are assimilating, but it doesn’t happen overnight. Whereas their presence can change the fabric of a community or neighborhood in what feels like overnight. And, as they assimilate, they change the fabric of America.

Americanness is an identity based around ideas. These ideas have ebbed and flowed over time. Their relative significance has changed as well. Periods of time when these ideas were under debate have always been the times of great discord in American society.

The 1910s and 1920s saw race riots and a swell in anti-immigrant fervor. The debate over slavery that lead to the Civil War was a time of arguing over what it means to be American and who got to participate in the idea of America.

When your national identity is based on ideas, it is so very fragile. You cannot rely on history immemorial to bind you together. Every 3-4 generations we as a country must decide that we still want to be a nation together.

Group rituals are what bind a people together. In many cultures, the communities commitment to a given ritual is necessary to keep the world moving. The planting and harvest rituals are essential to the world continuing to function as it should.

Similarly, in a Russian Orthodox Easter service, Christ ritually dies and is resurrected every year. The community re-enacts it, together, to bind them in a sense of history, purpose, and collective emotion.

The Rituals of Rural White America: the baseball games, the laying of flowers on headstones on Memorial Day, the fireworks and backyard barbecues of the Fourth of July – they are held dear because in their completion, the idea of a certain kind of America is reborn, reformed, and confirmed.

The fragile existence of an American identity is solidified, if only for another year. When White Rural America perceives the mockery and dismissal of these traditions, they feel their identity, their nation is literally under attack. Because, at least ritually, it is.

Stories are what bind us together. From the vantage point of Rural America, the polyglot, postmodernist, multicultural milieu of Urban America is not a force of creative disruption. It is simply disruptive, even destructive.

I live in the City, and even there, I don’t hear anyone offering a new American story, I only hear them railing against the old story. Which is understandable, the old story was exclusionary.

Many in Urban America cannot see themselves in the old story. White, male, Christian Americans jealously guarded membership in the old story and its benefits.

You cannot simply be against something, you must be for something as well. If a large portion of the country, especially one with significant electoral power, cannot see themselves in that story, they will fight it with all their might.

I like the idea of a big, messy, diverse country striving together to make itself and the world better, safer, healthier. So, I am asking Urban America to remember to offer a New Story in return for subsuming the Old Story.

Rural America has its faults, but it is still part of the multiculturalism of this country that you purport to love and admire. So, tell them a story that includes them, don’t just shit on their story.

Across the Great Divide…Part 2

The High Plains are a place where people get by. No one is “hustling.” Instant gratification does not exist. Distance demands a certain level of patience. In the City I live in, Amazon offers Same-Day delivery. Of course, Amazon delivers to the High Plains, but add 1-2 more days than you would expect in any city.

To live in the small towns that dot the old rail lines of the High Plains, you have be willing to accept a ethos of “good enough and making do.” Optimization is just not really an option most of the time.

For instance, I had an patient in the hospital today who appears to have subclinical hyperthyroidism, rather unrelated to his reason for admission. So, he needs a radioactive iodine uptake scan. A Nuclear Medicine service does not exist here.

It’s the weekend, and none of the staff know where the closest place to have this done is. Obviously it is not in town, but it might be as much 2-3 hours away. It will have to wait and be arranged as outpatient. He is asymptomatic, so we can make do till then.

It’ll have to be good enough. He understands and doesn’t demand transfer to another facility or some other extremely expensive and unnecessary intervention.

World’s Apart

Going back and forth from the High Plains to the City can lead to a rather schizophrenic existence. I can have any product or food I could ever desire in the City, often within minutes. Of course, the caveat is – you have to be able to afford it.

On the High Plains, you can have meat and potatoes, and you’ll probably have to wait.

On the other hand, if you want to be able to see the stars at night, know true silence, the City can’t help you.

Being a Millennial, all my friends from before medical school are scattered about all the cities you’d expect: Seattle, Nashville, Oakland, Boston, London, etc.

Their lives, in those cities thousands of miles away, have more in common with my City life, than the lives of the people I treat, who live less than a couple of hundred miles away from me. The residents of the global city-states measure distance in hours in an airplane, not in miles of streets, fields, and people passed.

Few of them know the human and physical geography right outside their back door. They don’t the seasons of planting, the rhythm of sun, rain, and wind that marks the lives of those who live in the Great Wide Open.

Even those not involved directly in agriculture on the High Plains know those rhythms. The timing of calf sales, wheat and corn harvest, hunting season, determine the rhythms of all other economy.

Even the jobs titles and work in the City seem inexplicable. They are analysts, project managers, a few might even call themselves “influencers.” There is no tangible output to their work. Their hands don’t feel the pulse of a heart, the hum of a machine, or dampness of the soil.

They speak words, makes click on computer screens, and paychecks arrive. No goods are made, exchanged, or transported.

In the City, the idea of economics waiting on the rhythms of the natural world is laughable at best, heretical at worst. Why would a product that does not have a direct basis in the natural world hinge on it at all? We should be able to have anything we desire, yesterday.

Dangerously Simple

The City thrives on complex, interconnected system all available from the touch of the button. Understanding and commanding the complex is highly regarding in the City. In contract, simplicity is considered a virtue in much of Rural America.

People pride themselves on a simple, direct approach to life. If a machine is broken, I fix it. If my neighbor needs help, I help them. In small, close nit communities, this generally works well. It is so ingrained that people often view complex explanations with immediate suspicion.

To many on the High Plains, complexity and obfuscation are the same. In the past, the simple solution to complex situations, such as healthcare, revolved around personal trust. If a problem is too complex, I bring it to someone with knowledge whom I trust – simple.

Trust is simple, you either do or you don’t. However, as the institutions who employ the educated experts concentrate more and more cities, local communities have fewer and fewer experts to trust within them.

The decisions made in cities and state governments feel far removed and unrelated to daily struggles of life on the High Plains. Even in my life, I often have to explain to my consultants on the phone the capabilities of facility I am working in, because many cannot imagine practicing medicine where I do.

So, people on the High Plains must choose between trusting unknown people, who sound like chronic obfuscators, or finding someone who offers a simple solution to complex problems. Not surprisingly, they often choose the latter.

It is cognitively easier to believe something untrue which does not challenge the story one knows about the world than it is reorganize the world.

The Story of our Worlds

In High School, I once debated some Christian idea with a more fundamentalist minded classmate. He cited some part of the Old Testament, I stated that a different part of the Bible said the opposite. He looked at me suspiciously, then at our teacher, who said simply, “It’s true.”

“Noooo!” He literally wailed it. He was desperate as the underlying, organizing tenet of his young life shook precariously from the roots.

America is changing, somethings good, somethings bad, but very, very rapidly. It is becoming more complex, more multicultural, and the change is only accelerating, especially in cities.

These rural communities feel as thought the social anchors which have held them together: church, military fraternal organizations, schools, hospitals, are under attack. Whether they are under attack or simply withering from neglect is up for debate but the result is the same.

The gulf is widening, and all I hear on the High Plains is long, wailing Nooooo…. They wail because ‘Merica is under attack. Not the United States of America, but the story of America that their parents recounted to them and that they have since recounted to their children.

And I truly believe it is. I don’t think it is a bad thing, but I do think it is.

A war of narrative is being waged over what it means to be American in the 21st Century. Rural America is losing the that battle in media, popular culture, and demographics. So, they fight harder on the front where they have an advantage, electoral politics.

I have talked before about the importance of Founding Myths, and Rural America’s binding narrative is losing.

This is an important thing to understand about Rural America, they feel under attack and fear they are losing the battle.

Maybe that is necessary, or at least inevitable, I don’t know. But like all cultures which have existed in one form and now do not, we may look back on the rituals of ‘Mericaness and pine over their passing.

A piece of fleeting human culture that is no longer.

In the meantime, Rural America continues to wail, gnash its teeth, and rend its garments in grief over an identity that seems to be disappearing.

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.”

Silence.

“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.

Click…Click….Click

“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?

Recognition

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!

Sincerely,

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?