Recently, while on a locums assignment in a very small, rural hospital, I cared for a gentleman with chest pain. His discomfort seemed classic for an MI, but his EKG did not. I treated him as normal, with aspirin and nitrates, and waited for his cardiac markers to come back from the lab. In the interim, his chest pain worsened. Sure enough, he developed an anterior MI. The tombstone of tombstones, you might say!
The facility where I was working did not have a cardiologist on staff, much less a cardiac cath lab. So, I went “old-school.” I gave him a thrombolytic. I know. It seems pretty Stone Age, doesn’t it? But it was the right thing to do. There was no interventional cardiologist in the area. In fact, the patient would ultimately be transferred by fixed-wing aircraft to the nearest cardiac care center.
While he had one brief episode of ventricular fibrillation (responsive to one shock), his event was otherwise unremarkable, and his EKG normalized before the flight crew arrived. He was pain free and grateful as he was loaded for his trip to the referral center.
Afterward, two things became evident. First of all, the charge nurse thanked me for making a decision quickly. Apparently, she had experience with other locums tenens physicians who were uncomfortable making such a call on their own. They inevitably wanted to show their patient’s EKG’s to cardiologists and have discussions. I looked and acted. Second of all, I realized yet again how much fun it is to be…important!
We live in an era of specialists, subspecialists, and sub-sub specialists. In large cities, the job of the emergency physician is to order the EKG as quickly as possible (hopefully before the patient arrives), and call the right interventional specialist in what seems like a nanosecond. In some places, we serve as facilitators, almost brokers. But in the small centers of America, where the advanced technology of medicine isn’t always immediately available, our job becomes absolutely critical.
I find that refreshing and exhilarating! Too many young emergency physicians have grown up in the long shadows of never-ending backup. But a few short miles out of the city, an airplane flight over a mountain or a drive along a jagged coast, and one may discover that he or she, as an emergency physician, is the truly the last, best hope for patients who populate the remote parts of America, doing hard work in hard industries. We are needed by farmers and timber workers, miners and fisherman, hunting guides and raft guides, truck drivers and oil-well workers, and all their precious loved ones.
I encourage physicians to reach out and work in the remote places. Take the chance, and take your skills out to the places where they are truly precious! If you are older, your experience will be priceless. And if you are younger, well, be bold and do your best. And learn to make decisions “all by your lonesome.”
You may find that working in those out-of-the-way places is just the thing you need to remember how very special, and very valuable, your skills and experience really are. And why worry? Help is only a fixed-wing flight away!
