Years ago I had a conversation with a surgeon at our facility.  He was unhappy that a seriously injured trauma patient came to our facility after an MVC.  ‘These patients shouldn’t come here Ed, they should go to a trauma center!’

Fair enough; we aren’t a trauma center.  Not a Level I, not a Level II or III; not even a level 0.5!  But we are the only hospital in a large rural county, and the closest, largest facility for portions of a few other counties nearby.  The nearest hospital with neurosurgery and thoracic surgery is at least 30 minutes further away.

The problem is, torn blood vessels, crushed spleens,  collapsed lungs, swollen brains don’t look at the clock, and cars aren’t designed to wreck only near trauma centers, any  more than assailants shoot and stab people only within proximity of appropriate care.  (It rather defeats the purpose of attempted murder, you know. )

Recently, my partner had the same conversation with the same surgeon.  The patient had been shot twice and was hypotensive.  ‘These patients shouldn’t come here!’   We understand, the conditions may not be ideal and trauma is, to be quite honest, fraught with medical and legal peril.

Agreed; but where?  So much in medicine is like this: this care shouldn’t be this expensive, these patients shouldn’t return so soon, that patient can go home…there’s no objective reason to do anything, that drug isn’t approved, this patient shouldn’t have that complication.

Shouldn’t…we know.  But reality trumps the ideal with remarkable consistency.  T.S. Eliot said it:  ‘Between the idea and the reality falls the shadow.’  That line of poetry has followed me my entire adult life, and has been proven true time and again.

This patient had to come here, that patient’s care (in order to make a difference) will be costly, those patients don’t know they shouldn’t return so soon, that family says the patient is too sick to go home, this drug is the only one that will help, complications (despite our best efforts) just happen.

Sometimes we just have to face reality and deal with it; because in the world of reality, not the world of theory, is where human beings live and die.

Edwin

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