Driving Country Roads to the ER

These days, I work most of my shifts about 45 minutes from my ‘house on the hill.’ At one of those jobs, the day shift starts at 06:30. Which means I’m rising from my bed at 04:30 in order to get on the road in time. I’ve started waking up at four, spontaneously, as if it were the most natural thing in the world.

I lay out my clothes the night before, so as not to awake my darling wife in her sleep. Sometimes I am able slip out without her knowledge. Others she wakes to kiss me goodbye. Then I go downstairs and put together some lunch, get the backpack and make my way out the door. I know that my wife and children are safe upstairs, as I lock the door behind me.

The door creeks a little, or did until my son Elijah oiled it. (One always wonders why a teenage boy oils a front door…) Occasionally I lock it as I realize I left my keys inside, and poor, tired Jan opens the door for me patiently. On the front porch, by the soft yellow of porch-light or the shock of flashlight, I step over dogs freshly awakened from sleep, who look at me with gentle annoyance. The sharp-eyed cats sleep in more secret places, so are seldom seen in the morning. Other dogs (we have five), sleep on the gravel drive in the summer and seem confused as to how to react when my Tundra rolls towards them, slowly, and I roll down the window. ‘Get up, you silly dog!’ Heads and tails down they amble away.


Up the long drive and down the road, I am suddenly all but alone on the two lane roads that lead me to Tiny Memorial Hospital. Despite the early hour, I am ‘awake, alert and oriented.’ The sky is dark, and in winter stars shine down when clouds don’t lay low against the earth. I scan the roadside for deer, their eyes reflecting the truck’s headlamps. Opossums sometimes shuffle across, along with squirrels and rabbits. (One day I saw a big, black bear on a hill by the road. He ran away as I stopped for a photo.)
I drive through forests, past sleeping houses and across a dark, still lake where sometimes, the light from a bass-boat shines across the emptiness where someone has fished all night…or started very early. Or a campfire on the shore still burns as their line rests untroubled in the water.


It is so early that I drive past gas-stations and convenience stores still dark and locked, the ‘closed’ sign reminding me to keep on moving. The air, even in summer, is cooler and in winter, positively cold. Winter is my favorite, I think, with the heat of the truck turned out, and the chill wind blowing past.

I think as I drive. And I pray. And I listen to the news, a recorded sermon, a pod-cast. Many mornings I turn on an oldies station from the North Carolina mountains; in the loneliness of the drive the music of Sinatra, Johnny Cash and others, make me feel I’ve gone back in time.

I cannot talk on the phone (hands free or otherwise). I pass through places where cell-signals are only a dream, and often even radio reception is poor. Remote areas, mountainous places, lonely and beautiful places defy cell signals and seem to say ‘look around! What else do you need!’ Even at 5 am, I agree.
Eventually I am near, and I find a fast-food joint for the obligatory chicken biscuit and tea, because, well, the South and all. And then I roll into the ER parking lot, lock things up and head to work.
Because this is no urban trauma center, the early morning is sometimes very slow and relaxed. A few patients may be waiting for turnover, but often none. I can sit and think, I can ask about the previous night. I can ease into work. My drive has already prepared me, but it’s nice to have a few minutes peace in the department before the chaos of the day begins. I text Jan. ‘Here safe, love you,’ and she answers. ‘Love you back, have a great day.’
There are those who don’t have to drive long distances. For most of my career it was about 15 minutes to work. And there are those who have long commutes through traffic, and through the waking body of a large city, people and cars just starting to fill its veins and arteries. Sometimes I am jealous. It can be lonely where I am.
But I think I’ll keep it for now. There is a solemnity, a serenity to my mountain and lake commute, with animals heading to bed and people not yet rising, with my own thoughts and prayers to myself.

And I suppose that if there were a better way to prepare for the madness, badness and sadness of the ER, I don’t know what it is.

Tell me about your little hospital!

I’m putting together a project on small hospitals.  While I’m particularly interested in critical access facilities in rural areas, other small facilities (urban and rural) are welcome.  I’ve always contended that big teaching centers get all the ‘love.’ There are television shows and books and movies about the enormous referral hospitals in big cities.  But not so much about the little hospital at the end of the road on the mountaintop, or on the windswept coast or in the desert Southwest.

And yet those places have dedicated staff who do great things, save lives, comfort the sick and do most of it on a pretty limited budget and in all kinds of weather.

So if you are interested in being part of this project (I’ll reveal more in time), tell me about your hospital.  Where it is, why it matters, its great successes and struggles.  If you have anyone I can contact there, please let me know that as well.

I want to hear your stories!

You can respond here or e-mail me at edwinleap@gmail.com.


Edwin Leap, MD




Rural doctors, you may be the last, best hope for someone.

Rural medicine really matters.  My post at the Barton Associates blog.


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. So 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 tombstones of tombstones, you might say!


Well, this wonderful facility 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, 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 ever 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 experienced some locums physicians who were uncomfortable simply making the 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 and 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 it seems), and call the right interventional specialist in something like a nano-second.  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 back-up. But a few short miles out of the city, an airplane flight over a mountain, 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!