RURAL MEDICINE INTEREST GROUP
“If It Wasn't For You, I Wouldn't Be Here Today” Robyn Hitchcock, MD FAAEM
A
68-year-old woman presented to the emergency department towards the end of my shift yesterday with UTI symptoms.
When I went into the room to talk with her she expressed joy and recognition after hearing my name. She talked for some time about the heart attack she had in the summer and how appreciative she was of my care. She said over and over, “If it wasn't for you, I wouldn't be here today.” I encouraged her to share her perception of what she remembered of her ER stay. The nurse had given me a heads up that the patient remembered me so I did dig into her chart and review her ED care from several months ago. She had an inferior STEMI, I thrombolysed her, and gave her aggressive fluid, nitrates, aspirin, etc—the usual—and the helicopter was flying that day so I got her down to the cath lab 70 miles away pretty quickly. Her memory of her ED stay was rather sketchy but she filled me in on her tertiary hospital stay, the repeated cath, and other procedures she had, and how well she's doing now including getting her 10,000 steps every day, shoveling snow, and right back to her active healthy life style. She pointed out that her husband had some cardiac issues and she feels like people dragged their feet and his care was not expedited like hers was. She was grateful and happy and we chatted for some time. This was a very much appreciated mental boost for me. Like most weeks these days, this was a crappy week. The boarders we constantly have in the emergency department have no end in sight. This week, my long term boarders included a 79-year-old woman with a new brain tumor, probably metastases from her stage 4 colon cancer. She had a large amount of edema, shift, and mass effect. She boarded in the emergency department for three days on a hypertonic saline drip and decadron and I eventually sent her home because she can see a neurosurgeon as an outpatient for a discussion about removal versus palliative care. Right now, she can get into the office sooner than she could find a bed at a tertiary care facility. We had an 82-year-old NSTEMI that we
At one point there were 27 patients registered in the department. One doctor. One PA. Four nurses. Not good…But the positives of small town medicine are very real.”
boarded for a week who we finally sent down for an “out and back” heart catheterization on day number seven of his boarding in the ED. We try to phone consult with the specialists who will talk with us, but unlike larger facilities, these patients have no hope of seeing or being evaluated by a consultant until they are transferred. The frustration of small town medicine when there are never any beds at any higher level of care facility, and you are boarding these patients for days and literally just can't provide them the care you need is causing extreme moral injury and it escalates every day. On Tuesday of this week we had nine boarders in my ten bed emergency department. At one point there were 27 patients registered in the department. One doctor. One PA. Four nurses. Not good. But the positives of small town medicine are very real. In a smaller place, you're much more likely to get follow up like the kind, grateful woman that I saw at the end of my shift yesterday. I was called to OB a couple of months ago for an expedited delivery because the family doctor with OB privileges couldn't make it in time to deliver the baby of the woman who came in ready to push. A month later I took care of her older son for an abdominal pain evaluation and got to follow up on the baby, and three weeks after that I took care of the baby himself when he came in with a cough and had RSV. He looked great and it was fun chatting with Mom and catching up. There are many downsides of practicing in a location with limited resources. But it's important to remember the positives too. We are much more able to create relationships over time with the patients in our community. Sometimes, when I'm having difficult “goals of care” discussion with a family, there's extra trust because I took care of one of their family members with a broken arm or an anxiety attack. Sometimes you go to the grocery store or the local diner and your cashier or server thanks you for taking care of them or their family member. Grateful patients in small towns will occasionally send treats or snacks to be shared out in the break room. I haven't gotten a goat or chicken yet to pay for my medical care but it's probably just a matter of time. Academic medicine frequently overlooks rural practice. Small town care poses unique challenges, but offers significant, heartwarming rewards.
COMMON SENSE MARCH/APRIL 2023
37