RURAL MEDICINE INTEREST GROUP
Rural Patients, Critical Needs Chris Tanner, MD FAAEM
I
’m on the phone and the cardiologist is shouting at me, “Why didn’t you call me before reversing their anticoagulation?!” This is the fourth hospital I’ve attempted to transfer them to. The patient is caught between bleeding out or having a heart valve clot off. There are no good options. I explain again that I’m calling from a critical access hospital. It is clear they have no understanding of what that means.
My patients and I are isolated. The ED where I work is next to a stable of horses. Seeing the sunrise after a night shift at our shop is incredible. Occasionally we ignite a flare and can call a helicopter. Now, for this patient, not even that will help. There are no facilities willing to accept them. Every year it gets worse. The department, as usual, is full of boarders. Some ask if they can get in a car and drive to their tertiary care center instead of waiting. Of course, this would be an EMTALA violation on my part if I recommended this. Every emergency The roads are icy and pitch physician should be able black next to the farms. I ask to speak with consultants them how they would feel if and other specialists they had to perform CPR on regardless of location or bed their family member on the availability. We will continue side of the road. They resign to fight for our patients and to staying. advocate for the care they Our critical access facility is not need. To do so otherwise is appropriate for them. We don’t to abandon them.” have the services they need. I call the transfer center to speak to a specialist. They repeatedly tell me they won’t speak with me unless they have an available bed. I open a textbook and search for guidance. I feel myself trying to practice cardiology. I wonder how the hospital credentialing committee would react. This is outside my scope of practice. I explain to the patient that their specialist’s group refuses to speak with me. Though they are on call, they are abandoning them. It is a clear violation of their oath and obligation. I have two NSTEMI patients boarding with no ability to get them a cath. One of them now shows the ST elevation I was anticipating. A wave of relief washes over me. Their worsening is the only way I can get them to definitive care today. We activate the cath lab. The other patient will have to wait. As the ambulance leaves, I check on my other high risk chest pain. A thin line of heparin is all that I can do to protect them. I sigh, knowing that as the system breaks it becomes more dangerous to live in a rural area. We are the only resource for our patients here. The journey to the city is a distant one. The complex patients the specialists discharge home come back to our community. I continually need to explain how limited our resources are over the phone.
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COMMON SENSE MAY/JUNE 2024
We have seen firsthand the dangers when consultants refuse to speak to us. We share in our patient’s frustration when systems refuse to even acknowledge them unless a potential bed opens. The role of EMTALA seems more important than ever. Some days it feels as if hospitals are abandoning our patients. We recognize that everywhere is understaffed and struggling. It is recognizing this danger that the rural medicine committee pushed for a position statement from AAEM. Every emergency physician should be able to speak with consultants and other specialists regardless of location or bed availability. We will continue to fight for our patients and advocate for the care they need. To do so otherwise is to abandon them. We must continue to remind our systems and specialists of EMTALA. The support of the state and national organizations is with us. We must gain the support of our directors and those at our local level. When the system breaks the finger of blame will point to us. If we do nothing, then it truly is our fault. We must never stop advocating. I scroll through the discharge summary of the latest ambulance arrival. Their post op complication has already involved multiple teams at a university hospital. I explain I won’t be able to easily get them back there. They yell, “I never should have come here!” I am silent as part of me wishes they hadn’t. “But what am I supposed to do if I can’t make the trip?” “You come here.” Editor’s Note: To read the AAEM Statement on Emergency Patient Access to Specialty Consultation in the Rural and Critical Access Emergency Department, please scan the QR code or visit aaem.org/statements/emergency-patient-access-to-specialty-consultation-in-the-rural-and-critical-access-emergency-department