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Career Source: The Future of Rural Emergency Medicine

Katz, Barbara

doi: 10.1097/01.EEM.0000410116.68043.c8
Career Source


The future of rural emergency medicine lies squarely in the hands of its practitioners. Though it will be aided by technology like the Nationwide Health Information Network and the Mobile ER, the doctors on the front lines will determine how exciting and effective this segment of emergency medicine will be. If the commitment to the practice of cutting-edge rural emergency medicine by physicians like Todd Crocco, MD; Jeff Coben, MD; Jonna Cubin, MD; Tripp Wingate, MD; and EMN's own Edwin Leap, MD, is any indication, the future is bright.

A detailed picture of the challenges facing emergency medicine in the rural United States emerged from Jeff Coben, MD, a professor of emergency medicine and the director of the Injury Control Research Center at West Virginia University. “This federally sponsored injury control research center is one of 11 supported by the CDC, and maintains a strong focus on the Appalachian region,” he said. “The reality of it is that most of the bad stuff in rural regions is the same as in urban areas, but they are more frequent and response is not as prompt.”

Rural patients have higher mortality from injuries and higher nonfatal injury rates than patients in urban areas, Dr. Cobin said. Car crashes, falls among the elderly, and poisonings are less likely to receive prompt care because of delays in contacting EMS, transport, and even the availability of rehabilitation. “Many of these results are due to environmental factors, topography, and remoteness of the geographic area, and of course, weather conditions, but there are other factors at play including a higher prevalence of substance abuse and non-seat belt use in rural America,” he said.

As more providers in rural settings are linked with their counterparts in urban and academic areas, that expertise will be available to their patients. The Nationwide Health Information Network now in development will allow remote practitioners to access complete patient records from anywhere in the country at any hour of the day. The network will also coordinate information between hospitals, EPs, laboratories, radiology, physician offices, and even pharmacies. Availability of information will speed up the patient care process in rural areas.

“As the population ages, new thinking must be applied to geriatric cases. If grandma falls and breaks her hip, there is an associated 50 percent mortality rate,” Dr. Coben said. “Most emergency physicians don't think of a hip fracture as a life-threatening case, but the golden hour rule can apply here when it happens to grandma in rural Appalachia.”

It's vital that this patient receive specialized orthopedic and follow-up care, he said, and sending these patients home after hospitalization is usually not the answer. The creation of rural hospital-based care centers to handle non-terminal patients can decrease unnecessary mortality, especially because convenient and affordable rehabilitation centers are few and far between in rural areas. “Instead of going from the ER to hospital to home, going from the ER to a special care center to home is the way to go,” Dr. Coben said.

Another exciting innovation is video-conferencing. Davis Memorial Hospital in Elkins, WV, announced in September that it will offer more advanced care to stroke patients by video-conferencing with neurologists from the West Virginia University Stroke Center. Dr. Coben and Todd Crocco, MD, the chair of the emergency department at WVU, said this is just the beginning of integrating rural care centers into the bigger picture. “Most rural hospitals are not part of the larger health care consortiums that currently exist,” Dr. Crocco said. “I predict that over time that could change. Perceptions change. What appears not to be profitable now will be appealing as the practice of rural medicine improves. These smaller entities will be bought up and regionalized in various parts of the country.”

Drs. Crocco and Coben said rural areas are becoming part of the primary health care market because the larger entities are fostering relationships and creating practice and information networks. “No one wants to turn away a cardiac patient,” Dr. Crocco said. “You can fly them in, and get them to the cath lab. The same goes for stroke and trauma patients. Once these larger institutions and healthcare networks start to realize that … a relationship with a rural hospital … can benefit [everyone] … over the long haul, this will translate to better patient care all the way round.”

Next month: Networking within rural emergency medicine, including the perspective of ACEP Rural Emergency Medicine Section Chair, Jonna Cubin, MD, and her practice in rural Wyoming.

Ms. Katz

Ms. Katz

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In Brief: Injunction against Florida Gun Law

A federal judge in Florida issued an injunction against a law prohibiting physicians from asking if a-patient owns a gun. The law, enacted earlier this year, banned physicians from making inquiries about firearms-ownership, recording the answers in a patient's chart, “unnecessarily harassing” gun owners, and turning away patients who refuse to answer gun questions.

District Court Judge Marcia Cooke wrote in her ruling that the law, which cited the second amendment, impedes on freedom of speech, the nation's first amendment. She stated that Florida physicians were-”self-censoring themselves” out of fear that they would be disciplined for supposedly violating the law.

The National Rifle Association quickly became big backers of the gun law, deeming doctor's questioning gun ownership an attempt to undermine the Second Amendment, a right to bear arms, but Judge Cooke wrote that the question does not-prevent the right to bear arms.

“Despite the State's insistence that the right to ‘keep arms' is the primary constitutional right at issue in this litigation, a plain reading of the statute reveals that this law in no way affects such rights,” she wrote. “A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient's right to continue to own, possess, or use firearms.”

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• Read about the Nationwide Health Information Network at

• Learn more about ACEP's rural emergency medicine section at

• Read all of Ms. Katz's past columns in the archive.

• Comments about this article? Write to EMN at

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