The tour bus stopped for the train crossing. The elderly visitors to the last frontier had taken their daily meds and were drifting off to sleep, exhausted after a day of touring Denali National Park. They were on the road back to Anchorage, 230 miles away, where they would spend the night and catch flights home to share stories of grizzlies, moose, and more eagles than they could count.
The semi driver was also exhausted. He had driven four hours on this open stretch of road. He didn't notice the train crossing sign, and it was too late by the time he saw the tour bus. There was no stopping the physics of his loaded truck and the stationary tour bus. Now, there were 52 elderly and anticoagulated trauma victims 150 miles from the closest hospital, with one helicopter available and no EMS crew within 100 miles.
But that is life in rural America. There is no stroke or sepsis team and no real trauma team. You are handed the scalpel by a surgeon who says she does not feel comfortable doing a cricothyrotomy or by an anesthesiologist who can't get an airway, saying these are the worst they have ever seen.
Sometimes when the shift is slow, you pick up Emergency Medicine News and read “Emergency Medicine Doesn't Need More Residencies” by Eric Blazar, MD. (2019;41:6; http://bit.ly/2ViAA1y), and think about large swaths of American emergency departments staffed by nurse practitioners and physician assistants because they can't recruit board-certified emergency physicians to the area.
Or you read the letter to the editor by Gary M. Gaddis, MD, PhD, where he states, “Working at a rural, low-volume ED is arguably harmful for one's long-term career development” and “They don't typically have the patient volume to support the needs of a specialist with our training and skills.” He goes on to add judgment to those living in rural areas by saying, “People who live in rural areas inherently make certain choices. One of them is not to have the latest in technology or the most highly trained physicians near them,” and “...our society does not have infinite resources to make clinical care environments equivalent in all areas of our vast nation.” (EMN. 2019;41:30; http://bit.ly/2MpTbHQ.)
And you get angry. Not only are these statements judgmental and inaccurate, they are also harmful and pervasive throughout emergency medicine and only serve to divide us and harm patients.
Yes, many rural hospitals are insanely under-resourced, but the one resource they need is good emergency care. Dr. Gaddis is right; we don't have infinite resources, but staffing rural emergency departments with skilled emergency physicians can better use the resources we have. It may make sense to travel to an urban area for a specialist appointment (I flew my child 1500 miles for a 15-minute ENT appointment in Seattle), but that is vastly different from saying you should not have quality emergency care.
The utter disregard and judgment directed at rural people who “make certain choices,” as Dr. Gaddis said, is unfounded and insensitive. It does not take into account the ethnic and historic factors that have led to many people living in rural areas. It does not change the fact that rural areas are where many of our resources like food and timber come from, not to mention the millions who travel to and through rural parts of our country every day.
To say rural residents don't deserve good emergency medicine is fundamentally against the core of our specialty. We are the light that is always on in the house of medicine. To say don't worry if that light is off in rural America goes against the very principle of who we are.
Before you give the transferring hospital grief, post on social media about that patient “dump,” or write a letter saying one in five Americans who live in rural communities doesn't deserve access to quality emergent care, come on over. Come yourself (or send your residents) to learn what it is like to run a trauma center all on your own, manage a home birth gone wrong, and get used to discharging subdural bleeds. We are a fun bunch with great stories. You can do some of the procedures your specialist does and teach us about the latest and greatest advances.
We could use a hand. After all, we are on the same team, you and I. We are emergency physicians, and we are better off together.
Dr. Zinkis a practicing emergency physician in Palmer, AK, and is the chief medical officer for the Alaska Department of Health and Social Services. She is actively working on system and policy changes as a way to care for her patients. Follow her on Twitter @annezinkmd.