Rural Medicine: The Road Not Taken

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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Joseph B. -

Thank you Vanessa for sharing this difficult and very personal case. We all have experienced these and sharing them is so helpful for others to learn from, and to remind us we are not alone.

Vanessa C. -

Thank you for reaching out and for listening. We are definitely not alone and it is by sharing these stories that we build our community. Thanks again.

Richard S. -

Vanessa, you were in tears telling the denouement of this story, along with all 30,000* EMRAP listeners...

*I just made up that number but you know what I mean

Vanessa C. -

I knew I should have bought shares in Kleenex. Thanks for listening and sending in your thoughts.

Adam A., M.D. -

What a moving story, Vanessa! One every EM doc can appreciate. You cannot make this stuff up! Thank you for sharing it with us and thank you for providing these patient with such compassionate care.

Vanessa C. -

Thanks so much for the kind words, and for listening.

Adam A., M.D. -

Vanessa, I was wondering if you considered giving the Magnesium IM instead of IV? Would that have been allowed by your transport team protocols to give it IM prior to transport?

Vanessa C. -

Considered it but this caused a lot of stress for the nurses (all two of them in the department that night) as it wasn't written in the protocol and they were concerned about doing something outside of the box in this situation. They felt that the rules should still apply regarding MD presence and I didn't get into arguing with them about this as we were clearly all uncomfortable with what was happening.

I never mentioned it in the piece but the RN staffing level was another issue that night. Once we clued into what was happening with the patient we had to have a nurse on her 1:1 but this meant there was only one nurse to do triage, care for the rest of the patients, and handle the lockdown situation. And then when the patient left in the ambulance it was one of our nurses who went with her and was gone for more than 4 hours. The RN who stayed behind had a pretty hellish shift, and the one who went in the ambulance had a terrifying time.

Just made me realize that more clinicians need to be involved with protocol development. It isn't exciting work but having someone who no longer does, or never did, clinical work making the decisions for your department can be detrimental.

Thanks for the question :)

Bryan D. -

20+ years ago when I was a resident, I did quite a bit of moonlighting on Indian Reservations. One hospital was very small, and for 24 hours, I was the only physician in house. One morning a young woman came in, active labor. We got set up to deliver the baby, and by exam, I couldn't tell what the presenting part was (no sono). The nearest OB/operating room was 45 min away by ambulance. The ED where I worked had a very low census, and there were 2 excellent nurses on that day, so I decided to get in the ambulance with the patient and make the ride with her to the hospital where the OB was waiting. We dropped her off, and went back to the ED. Just after I arrived, the OB called and said he had to do a c-section because the baby was breach and he couldn't deliver vaginally. Dodged a bullet.

Vanessa C. -

Wow... that must have been quite the ambiance ride. Did you get any trouble from having left the hospital? If I had left there would have been an ER and a ward without an MD around so I was too scared to leave. Those decisions are so hard and they don't teach that stuff in medical school!

Vanessa C. -

Meant ambulance ride, clearly. Ambiance ride sounds more relaxing though. :)

James C. -

Great story, totally teared up in the parking lot, and credit to Mel for stressing the importance of sharing these sort of things amongst all the learning each month

Vanessa C. -

Thanks for listening and for the kind words. And yes, thanks indeed to Mel for being so supportive of these stories and of rural docs in general. Knowing that the big city docs have an inkling of our reality out in the wilds makes professional relationships and patient care so much easier and much more successful!

Aaron I. -

Really appreciate you sharing these stories. As a recently graduated PA working in rural emergency medicine, hearing these stories is inspirational and gives me a little bit of reassurance that others have had some of the same feelings as me (although I still don't have any stories to compare to this one).
I'm looking forward to hearing more, especially after the teaser about who gets to practice where.

Vanessa C. -

Thanks so much for listening and for the work you do. Rural ER work can be stressful and hair raising at times but there is nothing to compare in terms of job satisfaction and seeing the difference that your work brings to your community. Well I am a bit biased perhaps having always worked rural or remote... in any case, welcome to the club :). And thanks for the support!

Fred L. -

Thank you for your very compelling and touching story. It is unfortunate that many physicians don’t understand the challenges faced by their colleagues practicing in a rural area. I’ve always thought that a rural medicine rotation should be required of all residency training. I once did volunteer work in the ER of a small Indian Health Service hospital that was an hour or more away by ambulance from the nearest receiving hospitals. The staffing was a doctor and a nurse, which meant the doctor had to make all the phone calls and fill out all the paperwork to arrange patient transfer while at the same time managing some very sick and severely injured patients. It was not uncommon to find after multiple phone calls that all the hospitals in the nearest city were “on divert” for patients who might require ICU care, and to then have to arrange transfer to the next nearest city two hours away. Fortunately OB transfer was usually easier. Once I had a patient with preeclampsia, much less sick than yours and fortunately with no dogs or police in the ER at the time. I was in the process of getting a magnesium drip started when one or our paramedics who happened to wander through the ER informed me they were not allowed to take magnesium drips in the ambulance. I asked if I gave it IM would that violate their protocols, and he said that was fine. So she got two grams of magnesium in each buttock while I called to arrange transfer. When I finally got hold of an accepting OB doctor and told him what I had done he just laughed and commented on my apparent advanced age. I had to admit he was right. Though I wasn’t old enough to have seen preeclampsia treated routinely with IM magnesium, I was old enough to have had the more mature and always helpful OB nurses tell me about it when I was doing my OB rotations

Vanessa C. -

Oh that sounds so familiar. The fielding of calls and doing masses of paperwork. We don't have clerical support for our admin stuff or our phone calls to specialists so waiting on hold and filling out forms while managing the seriously ill can be rather challenging. Yet another skill they don't teach in most training programs. I was lucky that my residency had two months of rural family medicine. Thanks for sharing your experience and for listening.

Vanessa C. -

So I arrived in Chisasibi (my usual place of practice in the far north of Canada) yesterday. Walked into the ER and saw one of my colleagues sitting there looking at a patient's labs. . Turns out this was a 27 year old female who presented for a "check-up". Turns out she was 36 weeks pregnant (G1P0)! No pre-natal care up until today. Drug and alcohol use and cigarettes through-out pregnancy (which was unknown until yesterday). BP 160/84. PCR 102. Elevated ALT. Puffy right hand that is getting worse. Stomach "cramps" on and off for a few days. 1cm dilated. Thankfully we had a doc who could go on the plane with her and we gave her Mag and labetolol and she had a C-section last night. Sometimes things fall into place. Phew.

Bill Hinckley, MD -

Dr. Cardy, what a terrible and yet wonderful case. Thanks so much for sharing it.

Regarding your statement: "I can't call an ambulance for transfer for this patient unless I have the name of an accepting doctor on record." I can't speak to the accuracy of this statement in Canada; I'll take your word that it's correct there. I can speak to the situation in the US: the vast, vast majority of ER docs believe that your aforementioned statement is true here as well, under EMTALA. Actually, however, under EMTALA you *can* in the US call a ground or air transport team the moment it becomes clear to you that you have a patient that will need to be transferred. There's no EMTALA violation unless that transport team actually leaves your ER with the patient before you've obtained acceptance. Many transport teams won't head your way if you don't yet have acceptance (perhaps also because they're laboring under the misconception that it would be illegal?), but some will. If you can find a transport team that will do this, for a case like Dr. Cardy's, having things happen in parallel as opposed to in series (transport team is heading toward your ER while you are contacting the accepting doctor / hospital) can get the patient to definitive care much, much faster.

Vanessa C. -

Thanks for listening and for writing in with the tip on transport. Our rules vary from jurisdiction to jurisdiction but I certainly suggest that everyone be familiar with the rules in their area. Time and lives could be saved!

Elisabeth G. -

Thanks for sharing your story. I'm intrigued by what Dr Herbert touched on at the end in terms of staffing for rural and remote locations. I've worked as a PA in rural and remote areas for 14 yrs often without access to any backup MD and, while I really like it and do a (generally) good job, am flummoxed that sometimes this is the best that rural folks get. The problem is that in really rural/remote areas you just cannot get enough daily variety and procedures to be at the top of your game. Regularly Rotating PAs from rural/remote areas through big ED's would be great as would be an exchange the other way-one of you EM:RAP hot shots come on up to my remote clinic and see what we are up against. As in long stints of boredom punctuated by terrifying experiences such as yours. I look forward to hearing more of your stories and insights into rural medicine, Dr Cardy!

Vanessa C. -

Oh I totally agree! This is a major concern and I am certainly troubled that health authorities don’t think to develop active ongoing accreditation and training programs for the front line workers in the Rural and Remote areas. Also getting the folks from the big centres to visit the Rural sites helps them understand our reality. Thanks for the work you do out there on your own, and thanks for listening!

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