Two cases highlight the challenges of practicing in rural, resource-limited settings, far from the academic centers where guidelines are drafted.
Today, you are the sole EP on duty in a semi-rural, critical access hospital ED. As a matter of fact, you are always the only EP on shift. You were trained in a solid tertiary care EM residency with a level I trauma center, stroke center, and 24/7 cardiac cath lab facilities. You know all the clinical guidelines (all of which have been developed in tertiary care centers by academic faculty physicians) and all the tertiary care tricks of our trade. But now you’re practicing in a critical access ED (annual census 17,000) and things are looking a bit different.
Your ED has very good resources for its environment: 2-3 ED RNs, 12 ED beds, a hospitalist, a small ICU. The regional hospital is 40 min away (in good weather) by ground EMS. You have standard laboratory tests, standard radiology and CT scan. You read all your own plain films after business hours. Teleradiology takes care of CT scans and ultrasounds. You have taken several courses in bedside US and feel confident with your FAST exam. Your only consultant in the hospital is the hospitalist. The cardiologist is in the regional hospital. A surgeon and orthopedist are on call to the ED but may be covering another hospital 45 minutes away.
Case 1. Acute stroke
A 65-year-old man develops sudden rt hemiparesis and dysarthria. EMS announces 10 minute ETA for a likely acute stroke. Your 12 beds are full and there are two other patients in the ED you haven’t seen yet: a 2 month old with fever and your neighbor, a 40-year-old woman with chest pain.
Critical Access ED: 2 years ago
You do a rapid NIHSS: score is 8. The patient meets standard criteria for IV tPA. He is a poor historian so you wait for his family to arrive to review his past history for exclusion criteria and to confirm time of onset of symptoms. You ask the lab to run his CBC superstat so you can make sure he is not thrombocytopenic. You have only given tPA once before so you review the exclusion criteria one more time to make sure you are correct in discussing tPA as an option. You discuss options with the patient and his family, including the possible effectiveness of, and risk of hemorrhage from tPA. The family agrees to tPA; your stomach churns. If he develops a bleed your hospital can only provide 2 units of FFP in 40 minutes on a good day, and no other products or resources to treat a CNS bleed. Today it will take 2 hours to get to the regional hospital with the neurosurgeon and stroke center. You’re on your own. You check the CT scan while waiting for teleradiology. You gulp. The clock is ticking. You give tPA. You continue neuro checks with the help of nursing, while you check on the other patients in the ED.
Critical Access ED: Today
Your ED group, the regional hospital system, and a group of neurologists have organized a regional stroke response system. If your local EMS system identifies a stroke with positive results on the Cincinnati Stroke Scale, the EMS team transports directly to the regional hospital, with lights and sirens. They notify the stroke center that they are inbound with a code CVA. For walk-in patients with stroke symptoms, the triage nurse notifies you immediately. After your assessment you initiate a “Code Stroke”—which immediately pages your hospital’s lab and CT techs. As the patient goes to CT, the stroke center neurologist on call is notified and the regional hospital’s transport team is activated and starts for your ED—by ground or air depending on weather. When the patient returns from CT, the neurologist observes the trained nursing staff on camera doing the NIHSS, and both of you agree on the NIHSS of 10.
You and the neurologist discuss the options of tPA among yourselves and with the patient. The neurologist gives the order for tPA. You still don’t have rapid access to agents to reverse a CNS bleed, but you now have a neurologist making the final decision to give the drug. You continue neuro checks until the patient leaves the ED. The entire stroke system has been activated with a single effective action - ‘Code Stroke’ - and without a single telephone call, without the time-consuming efforts to find an ‘accepting physician’ at the regional hospital and to arrange transport.
Tertiary Care ED 2 years ago, and today:
EMS notifies the tertiary care ED of a possible stroke. Code Stroke is activated. You perform a quick NIHSS, blood is drawn, and you whisk the patient to CT scan. The neurology team arrives stat in the ED, confirms the NIHSS, checks labs and history, and tPA is given. Neurology quickly admits the patient to the neuro ICU for frequent neuro checks. There are 3 other ED physicians on duty to care for the multiple trauma pt and seizing child who arrive within the same time frame and you can devote your sole attention to the stroke patient until care is turned over to neurology.
One of the challenges of rural emergency medicine is the infrequency with which you see acute CVAs meeting tPA criteria. It is impractical to rely on your memory of the inclusion and exclusion criteria, especially when there is so much at stake if you make a mistake. Many times the findings are equivocal and the available history is incomplete. You do not have access to MRI which could help tease out the stroke mimics. And in the back of your mind you are wishing this patient had presented to a hospital with more resources – where you believe they could receive more complete care. Yet you are held to the same standard in your tiny ED as they are in theirs. The time pressures are multiplied by the fact you cannot ignore the rest of your department. You are the only one there to take care of any other life threatening injuries or illnesses, and it always seems the really sick patients come in twos or threes. This, however, does not exempt you from “ the standard of care”.
You can develop the best possible scenario in a rural or community hospital, but it still lacks the manpower and resources of a tertiary care setting to identify the condition, treat and monitor it, and treat acute complications. It is very difficult, and in some cases impossible, to translate care that is somewhat routine in a tertiary hospital, to a more basic ED setting. At a tertiary care center, within minutes of announcing a code stroke, the neurologist personally completes the clinical evaluation, views the CT, and quickly moves the patient to a setting with intensive monitoring. The staff cares for stroke patients frequently, and staff are very familiar and experienced with the NIHSS stroke scale and the administration of tPA. In the rural setting, this may be the first time your ED nurse has ever given tPA for stroke.
Case 2. Ice Storm
Everybody is falling down today. You’ve already diagnosed, splinted, and admitted a bimalleolar fracture and reduced a shoulder dislocation. EMS brings in a 66-year-old morbidly obese woman with severe left leg pain after a fall on ice. Six months ago she had a left total knee replacement. Stat x-rays show a distal left femur fracture and a fracture-dislocation of the left ankle. You are doing your best to relieve pain with IV Dilaudid and Fentanyl, but narcotics aren’t very effective. Her BP is 120 systolic and you give fluids. Your FAST exam and the rest of your evaluation do not show any injuries other than the fractures, but your exam is limited by the inability to move the patient for a totally thorough exam. Luckily the patient’s orthopedist is in your OR today. She takes the patient to your hospital’s OR under spinal anesthesia to stabilize the fractures. However, the orthopedist tells you the patient will need transport to a Level 1 trauma center for definitive treatment. The patient returns to the ED after stabilization so you can arrange transport, and she is now hypotensive with BP 90 systolic. EMS refuses to transport a patient with MAP less than 65. You call anesthesia. They tell you this is common after spinal anesthesia and tell you to give ephedrine. “How do I do that?” you ask. “What is the dose?” They say give 5 mg IV, push every 10 minutes prn! Medical transport can’t do that, so just give 25 mg IM. You follow their instructions, are able to maintain the BP 120 systolic, and now the regional center accepts the patient in transfer.
As a trained emergency physician I have the skills to perform moderate sedation, and to reduce and splint the injuries described above. However, in my ED, this would have tied up two of my four nurses and myself for at least an hour during a crazy day when there were already eight patients in the waiting room and all 12 beds full. The key to this true-life episode? Having consultants who understood my time constraints, and who were willing to think outside the box to do what was best for the patient in our environment. At the end of the day the patient had gotten better care than I could have provided in the ED, and I had learned how to manage post spinal anesthesia hypotension!
Unfortunately in rural emergency medicine, the opportunities to collaborate and learn from consultants are rare. Our consults are done over the phone and the patients are taken away to other hospitals. We do not have the opportunity to bump into consultants later and get casual follow up. Without this, we do not know how often we were right or wrong. And, most unfortunately, do not have the opportunity to alter our clinical practice based on outcome.
I have a friend who says “emergency physicians are only as good as their backup”. In many ways I agree. I believe that is one of the reasons it is hard to recruit physicians to the rural setting. It can be unnerving to try to manage cases beyond the scope of care in your setting. It is difficult to maintain procedural skills over decades when you use them infrequently. It is very difficult to incorporate ultrasound into your practice when there is no one present to instruct you real time, to tell you if you are right or wrong, or how to improve the image in front of you. It is hard to keep up with cutting edge technology when it is not available for your use. And most of all, it is a lonely practice. There are days I crave the opportunity to interact with another emergency physician – to ask what do you think of this chest x-ray – or how would you handle this case?
On the positive side, I find the patient population in rural communities less inpatient and more appreciate of the care they receive. I enjoy taking care of the elderly farmer population that says yes ma’am to me when I am young enough to be their grandchild. I enjoy using my skills in an area where medical resources are limited. I chose ‘the other road’, and while it has its bumps, it is a fantastic one.
Dr. Kim Keith is a past president of the Virginia College of Emergency Physicians. She currently practices emergency medicine at Shenandoah Memorial Hospital.