(My column from last February.  The more things change the more they stay the same…)

Life in Emergistan

Having No Beds is Nothing New in Rural America

Leap, Edwin MD

doi: 10.1097/01.EEM.0000734572.71536.be

rural emergency medicine, COVID-19

I am writing this in December, and COVID, of course, is surging. The vaccine is just launching, and all of medicine is in a state of chaos. EDs and ICUs are full. Physicians, politicians, and the media have forgotten how to communicate without using the word COVID in every other sentence. Everyone, and I mean everyone, is just about done with the ‘rona.

But as more and more facilities report being at or near capacity, I realize that this idea of having no beds and no place to send anyone is nothing new in rural America where I practice.

It seems as if every year during flu and pneumonia season, we on the medical frontier of this great republic find ourselves with sick patients who need critical care beds or specialty care in a higher-level facility, and they have no room in the inn.

That presents a unique conundrum. It’s an easy sell to get a teaching center to take a critically ill child. Nobody declines major trauma, stroke, or STEMI. But others—complex metabolic issues, patients needing dialysis, respiratory failure (not COVID-flavored), seizures, severe psychosis, small subarachnoid hemorrhages, and assorted infections that do not meet the criteria at already-over-capacity referral centers.

So what happens? Well, this year (and every year), they simply stay in our rural emergency departments. They’re too complicated for the local hospitalist or too sick for the local intensive care unit (if we have one), or they have problems a surgeon can’t handle (if there’s a surgeon at all). They’re in labor, but there isn’t an obstetrician on call, and they can’t be transferred because of EMTALA (the active labor part of that acronym). The list of things that can’t be admitted or transferred is long.

The rural emergency department at that point becomes a critical care unit and disaster staging facility and trauma center and psychiatric hospital and detox center. No matter how desperate the situation, we are reminded by our hospitalists that it’s easier to transfer them from the ED and that they aren’t comfortable managing “that” without a consultant in specialty x, y, or z. Because we have none of the requisite specialists, we become de facto specialists, at least through what seems like the endless watches of the coffee-filled, cracker-crunching, transfer-line-ringing dark night of the physician soul.

A Dirty Secret

It gets worse. As if to make things even more miserable, there is the issue of ambulances. The dirty secret of rural EMS is something that locums and rural physicians know all too well but many urban physicians may not. Many small towns have limited EMS capacity, and that means patients don’t get transferred quickly. Sometimes it takes a long time even in the clear light of day, but it’s always a struggle at night. Those patients just wait until morning. The NSTEMI, actually accepted elsewhere at midnight, won’t leave the charming town of East Cackalacky until 9:30 or 10 a.m. Nor will the surgical complication going back to the place the surgery was done.

The town can’t spare the truck because other things might need the medics’ attention, and the medics are exhausted (and don’t make enough money to be interested in a six-hour round-trip drive in the snow). And this county EMS won’t take patients from that county. A private transport company is available, but they shut down at 11 p.m.

“Just call the helicopter” is the typical refrain. Even ground EMS falls victim to this mentality when the supervisor says they can wait till the next day if they don’t need to go by air. Because such a flight can financially devastate a family and because gravity, weather, and the gazillions of Erector Set pieces that make up a helicopter can result in a large hole in the ground followed by funerals, I try not to use air transport unless it is absolutely necessary. Convenient isn’t the same as necessary. Having the receiving physician say, with drama fit for television, “Just send the bird,” isn’t the same as necessary.

This allows me to follow my best judgment, but it still leaves human beings waiting in suboptimal conditions to go places where they will get much more thorough care than I can provide. And to circle back, it leaves them waiting for beds to open up in places that were full before COVID and will be when we leave COVID in the rearview mirror.

I’m not trying to minimize the pandemic. My heart goes out to those professionals and patients crushed under the burden of this nasty virus. But “the system” should remember that we have work to do. We were always, every year, on the razor’s edge of disaster. It’s just that this year we actually fell off the edge and into the nightmare.

Pandemic or not, complicated patients will always need a place to go when EPs at small facilities have done all they can. And they will need a way to get there quickly and safely, day or night.

We can do better. I just hope we will.

Dr. Leappractices emergency medicine in rural South Carolina, and is an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available athttps://amzn.to/2T60WET, and Working Knights, Cats Don’t Hike, and The Practice Test, all available atwww.booklocker.com, and of a blog, https://edwinleap.com/. Follow him on Twitter@edwinleap, and read his past columns athttp://bit.ly/EMN-Emergistan.

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