Why I love rural EM

[EMEDPA]

Rural EM PA podcast of potential interest:

Emergency NP & PA Workforce | Rural Emergency Medicine: A PA's Journey with Dr. Eric Holden (transistor.fm)

 

 

[Mayamom]

OMG I follow Dr Glaucoma on Twitter or whatever its called these days.   He is one funny guy.  Speaking at Pri Med East this year.

[sk732]

On 9/12/2023 at 11:57 PM, CAdamsPAC said:

 

Yeah, sounds awfully familiar...

So, my last rotation saw me medevac a dude I thought had some sort of GI malignancy with incessant vomiting x 1 year, night sweats and a 70lb weight loss over 6 months...tender, palpable liver tip, POCUS showing weird arsed stuff - thought was possibly appendicitis...so turns out the large cystic thing I saw in the R iliac region and the "liver tip" was a 17cm gallblader, the appendicitis "target" structure was one of the gallstones.  For you non-metric types, 17cm is about 7 inches...and not 7 guy inches .

Sunday/Monday, up to 0430 with two medevacs - meningoencephalitis with what turned out to be a dural sinus venous throumbus in an IVDU/HIV pt and a youngster who I thought at best had a skull Fx after coming off an ATV and landing on the the noodle cover (no helmet)...Peds ED doc wanted me to just give some analgesia and observe for a bit first .  I said "Umm, I'd be OK with that except that I just told you they landed on their head, were going an unknown speed, have severe HA AND have bloody show in their nose but no facial injuries..."  "You're right, send them down".  In their defence, it was midnight, however...  Turned out was a skull Fx with contrecoup ICH.  I hate being right...sometimes.

Happier case - had a dude I honestly thought wasn't going to make it after being smashed by a truck a few months back, actually hobbled out of the SICU and is back up on the rez - still packing the open abdo/pelvic wound (had an open iliac wing Fx - I actually packed it with hemostatic Combat Gauze initially and pelvic binder took care of the rest).  Breathing ok now - had bilat flails, with all the ribs on one side fractured posteriorly (landing site).

[SedRate]

On 9/12/2023 at 11:57 PM, CAdamsPAC said:

 

This is a good one. Although I haven't worked at a rural/critical access facility, I'm prn at a couple of regional trauma centers. One call I got was from a rural Indian health facility for a fracture-dislocation. The attending told me they didn't have X-ray capabilities after 5pm. Another facility had a high-speed MCC and a guy in hypovolemic shock from a spleen rupture. They had a capable surgeon but no blood available. To all you who keep those places running and people/limbs alive, thank you for all that you do! 

[CAdamsPAC]

4 hours ago, sk732 said:

Yeah, sounds awfully familiar...

So, my last rotation saw me medevac a dude I thought had some sort of GI malignancy with incessant vomiting x 1 year, night sweats and a 70lb weight loss over 6 months...tender, palpable liver tip, POCUS showing weird arsed stuff - thought was possibly appendicitis...so turns out the large cystic thing I saw in the R iliac region and the "liver tip" was a 17cm gallblader, the appendicitis "target" structure was one of the gallstones.  For you non-metric types, 17cm is about 7 inches...and not 7 guy inches .

Sunday/Monday, up to 0430 with two medevacs - meningoencephalitis with what turned out to be a dural sinus venous throumbus in an IVDU/HIV pt and a youngster who I thought at best had a skull Fx after coming off an ATV and landing on the the noodle cover (no helmet)...Peds ED doc wanted me to just give some analgesia and observe for a bit first .  I said "Umm, I'd be OK with that except that I just told you they landed on their head, were going an unknown speed, have severe HA AND have bloody show in their nose but no facial injuries..."  "You're right, send them down".  In their defence, it was midnight, however...  Turned out was a skull Fx with contrecoup ICH.  I hate being right...sometimes.

Happier case - had a dude I honestly thought wasn't going to make it after being smashed by a truck a few months back, actually hobbled out of the SICU and is back up on the rez - still packing the open abdo/pelvic wound (had an open iliac wing Fx - I actually packed it with hemostatic Combat Gauze initially and pelvic binder took care of the rest).  Breathing ok now - had bilat flails, with all the ribs on one side fractured posteriorly (landing site).

All good stuff!!

[sk732]

2 hours ago, CAdamsPAC said:

All good stuff!!

Rarely a dull moment up there - I have the "Weird Shit" magnet on my forehead....though the dude who works opposite me still has the record for most frigged up evening yet - 4 people trickled in all messed up after drinking meth bong water.  Patient that drank the most died within 45 minutes of presenting, other 3 ended up in ICU, 2 with protracted stays due to brain edema...that was a new to us thing, and I worked in Winnipeg for 2 years, which apparently has some of the best Meth in North America according to some polls.  They ran out of IV diazepam AND lorazepam.  I so far have the record for lowest recorded K in a living person there (non-recordable by i-Stat, 1.2 when arrived in ED 3 hours later after 60 mEq of po stuff so I'm assuming around 1.0 ish +/-) , tied for the lowest living pH in a DKA at 6.70 - and they almost carcked on us.  That one took over 12 hours to get out incidentally as all the ALS planes were tasked.

[ohiovolffemtp]

Pretty much anything that happens on "the res" means that that it was hours before it got any kind of medical care, whether trauma, drugs, EtOH, etc.  It often means long term substance abuse, especially EtOH, poorly controlled chronic conditions, esp. diabetes, and multigenerational households making transmission of infectious dz rampant.  Definitely a challenging population.

[CAdamsPAC]

8 hours ago, ohiovolffemtp said:

Pretty much anything that happens on "the res" means that that it was hours before it got any kind of medical care, whether trauma, drugs, EtOH, etc.  It often means long term substance abuse, especially EtOH, poorly controlled chronic conditions, esp. diabetes, and multigenerational households making transmission of infectious dz rampant.  Definitely a challenging population.

Same out in the remote Alaskan  villages.

[sk732]

9 hours ago, ohiovolffemtp said:

Pretty much anything that happens on "the res" means that that it was hours before it got any kind of medical care, whether trauma, drugs, EtOH, etc.  It often means long term substance abuse, especially EtOH, poorly controlled chronic conditions, esp. diabetes, and multigenerational households making transmission of infectious dz rampant.  Definitely a challenging population.

I was cross covering a different spot - where I usually work, most common drug of abuse is home brewed alcohol, followed by opioids and gabapentin, the other place I was in was big into huffing lacquer.  Place I'm likely moving to has a big meth problem...ironically the meth issue where I normally work was put to rest by the gang leadership there - they actually clamped down on it coming in.  The irony of all the homebrew is the place is supposed to be a dry town - all that means is if I get caught bringing any alcohol in, I get PNG'd/banished.  I drank enough in my youth in the military and have seen my fair share of issues from it from that and working in emergency medicine - I don't really need it.

Many people live in one house - they sleep in shifts, so not surprisingly, the town is often on vampire hours, except those that have normal 8-4/9-5 jobs.  I pretty much assume everyone has MRSA, we double cover everyone when we prescribe antibiotics and I'm pretty sure H.pylori is in the water supply here.  Birth control is a four letter word here, STI's are overly common, especially syphilis, would be unsurprised if half of the RUQ pain we see here is Fitz-Hugh-Curtis, we have a TB thing going on too.  Most trauma I see here are stabbings, axe and machete wounds, MVC's of various types.  No shootings (yet) surprisingly, given we're in Northern Canada, so there is at least one rifle and or shotgun in each household for hunting.  The houses are generally in shit order, most have no proper running water and have outhouses.  Water is either delivered or hand bombed from a standpipe somewhere.

Part of my job is to help manage chronic disease - in this community area of about 15k people on 4 reserves, we actually have our own hemodialysis unit, despite being 600 km from anywhere.  An average A1c when I get ahold of the patient is roughly 12-15% and ACR's in double digits. Many people aren't particularly interested in managing their disease, even with assistance, at least until they have body bits falling off or they end up on PD/HD...and even then maybe not.  Of course the food in the grocery store isn't the greatest, there are a couple fast food places and everyone heaps sugar into their tea or coffee...thankfully they've marked up the price of pop here to around $35-40/case, but still an issue.  We have a dietician attached to the dialysis unit we get to use/abuse, so she helps out - takes people to the store and shows them work arounds based on what's there.  For DM management, I'm pretty much starting to max out people on at least one med in each drug class, though we're having some good results with injectable semaglutide if we target the right person - since not everyone remembers to take daily stuff, forget trying to get them on the weekly.  Down side of the stuff is there is a high preponderance of gall bladder disease here, with resultant downstream pancreatitis issues and this also limits who we can give it to.  

As we don't have a hospital or a birthing unit, we often will send out pregnant women in last 4 weeks of gestation - this is leading to an issue of concealing pregnancies until the kidlet is on its way out...I kind of get it, getting sent out for a month at least away from home, especially if there are other kids in the mix and minimal safe family to look after everything else.  However, it's not safe to (a) have no prenatal care, especially in a higher risk population, and (b) this isn't the place to be delivering kids if things go wrong.  Unfortunately/fortunately, things haven't gone bad yet, so people think it's just fine to deliver here.

The Feds and the Province are constantly bickering about who's paying for what, so trying to get a hospital or at least a birthing unit here would be literally like pulling birds's teeth due to responsibility/accountability issues on both sides.  There'd then be the battle of which rez would the place go to, since there'd be a huge influx of money/jobs/prestige attached to that...and then there'd be be the "who's going to pay to maintain services", since health care is a provincial baileywick, however it's federal when it comes to Aboriginal, military and RCMP health.  Meanwhile, people and their families get caught in the middle. 

[CAdamsPAC]

4 hours ago, sk732 said:

I was cross covering a different spot - where I usually work, most common drug of abuse is home brewed alcohol, followed by opioids and gabapentin, the other place I was in was big into huffing lacquer.  Place I'm likely moving to has a big meth problem...ironically the meth issue where I normally work was put to rest by the gang leadership there - they actually clamped down on it coming in.  The irony of all the homebrew is the place is supposed to be a dry town - all that means is if I get caught bringing any alcohol in, I get PNG'd/banished.  I drank enough in my youth in the military and have seen my fair share of issues from it from that and working in emergency medicine - I don't really need it.

Many people live in one house - they sleep in shifts, so not surprisingly, the town is often on vampire hours, except those that have normal 8-4/9-5 jobs.  I pretty much assume everyone has MRSA, we double cover everyone when we prescribe antibiotics and I'm pretty sure H.pylori is in the water supply here.  Birth control is a four letter word here, STI's are overly common, especially syphilis, would be unsurprised if half of the RUQ pain we see here is Fitz-Hugh-Curtis, we have a TB thing going on too.  Most trauma I see here are stabbings, axe and machete wounds, MVC's of various types.  No shootings (yet) surprisingly, given we're in Northern Canada, so there is at least one rifle and or shotgun in each household for hunting.  The houses are generally in shit order, most have no proper running water and have outhouses.  Water is either delivered or hand bombed from a standpipe somewhere.

Part of my job is to help manage chronic disease - in this community area of about 15k people on 4 reserves, we actually have our own hemodialysis unit, despite being 600 km from anywhere.  An average A1c when I get ahold of the patient is roughly 12-15% and ACR's in double digits. Many people aren't particularly interested in managing their disease, even with assistance, at least until they have body bits falling off or they end up on PD/HD...and even then maybe not.  Of course the food in the grocery store isn't the greatest, there are a couple fast food places and everyone heaps sugar into their tea or coffee...thankfully they've marked up the price of pop here to around $35-40/case, but still an issue.  We have a dietician attached to the dialysis unit we get to use/abuse, so she helps out - takes people to the store and shows them work arounds based on what's there.  For DM management, I'm pretty much starting to max out people on at least one med in each drug class, though we're having some good results with injectable semaglutide if we target the right person - since not everyone remembers to take daily stuff, forget trying to get them on the weekly.  Down side of the stuff is there is a high preponderance of gall bladder disease here, with resultant downstream pancreatitis issues and this also limits who we can give it to.  

As we don't have a hospital or a birthing unit, we often will send out pregnant women in last 4 weeks of gestation - this is leading to an issue of concealing pregnancies until the kidlet is on its way out...I kind of get it, getting sent out for a month at least away from home, especially if there are other kids in the mix and minimal safe family to look after everything else.  However, it's not safe to (a) have no prenatal care, especially in a higher risk population, and (b) this isn't the place to be delivering kids if things go wrong.  Unfortunately/fortunately, things haven't gone bad yet, so people think it's just fine to deliver here.

The Feds and the Province are constantly bickering about who's paying for what, so trying to get a hospital or at least a birthing unit here would be literally like pulling birds's teeth due to responsibility/accountability issues on both sides.  There'd then be the battle of which rez would the place go to, since there'd be a huge influx of money/jobs/prestige attached to that...and then there'd be be the "who's going to pay to maintain services", since health care is a provincial baileywick, however it's federal when it comes to Aboriginal, military and RCMP health.  Meanwhile, people and their families get caught in the middle. 

Have you checked your map lately? If not , welcome to rural Alaska!!!!

Edited October 1, 2023 by CAdamsPAC

[sk732]

15 minutes ago, CAdamsPAC said:

Have you checked your map lately? If welcome to rural Alaska!!!!

Lol - farthest north I worked was Eureka, on Ellesmere Island - roughly 900km from the North Pole.  Closest hospital was in Thule at the USAF base there.  I've worked and or lived in all three Territories.  Northern Manitoba where I work is actually fairly south compared to Alaska...https://www.google.com/maps/place/Garden+Hill+First+Nation,+Garden+Hill,+MB/@53.8937676,-94.59836,12z/data=!4m6!3m5!1s0x528ec9a9a122efc5:0xea602bfcce33ffa4!8m2!3d53.8997927!4d-94.5749175!16zL20vMGI0NTN3?entry=ttu

Unfortunately, while I wouldn't mind working in Alaska, the cross border reciprocity for PA's only works South to North...

[CAdamsPAC]

3 hours ago, sk732 said:

Lol - farthest north I worked was Eureka, on Ellesmere Island - roughly 900km from the North Pole.  Closest hospital was in Thule at the USAF base there.  I've worked and or lived in all three Territories.  Northern Manitoba where I work is actually fairly south compared to Alaska...https://www.google.com/maps/place/Garden+Hill+First+Nation,+Garden+Hill,+MB/@53.8937676,-94.59836,12z/data=!4m6!3m5!1s0x528ec9a9a122efc5:0xea602bfcce33ffa4!8m2!3d53.8997927!4d-94.5749175!16zL20vMGI0NTN3?entry=ttu

Unfortunately, while I wouldn't mind working in Alaska, the cross border reciprocity for PA's only works South to North...

You seem to me an asset  to any community  lucky enough  to have  you, and our loss  in the US!!!

[sk732]

Thanks...ironically was accepted to PA school at D'Youville College in Buffalo many years ago - just couldn't come up with the money to get through first year (would have had to do the whole 4 year deal there at the time).  Oh well, the CAF lost me when they started treating me like a Pte as a Warrant Officer - they didn't believe me when I told them if they didn't get their act together, they'd be losing me.  They seemed completely surprised, lol (well, a few of my bosses weren't).

[CAdamsPAC]

4 hours ago, sk732 said:

Thanks...ironically was accepted to PA school at D'Youville College in Buffalo many years ago - just couldn't come up with the money to get through first year (would have had to do the whole 4 year deal there at the time).  Oh well, the CAF lost me when they started treating me like a Pte as a Warrant Officer - they didn't believe me when I told them if they didn't get their act together, they'd be losing me.  They seemed completely surprised, lol (well, a few of my bosses weren't).

I fully understand both of your points I was lucky enough to have my PA education fully paid by the VA after I walked away  from the US Army

 

[sk732]

So have come off a wacked out 2 week rotation in 2 different little places - one that will be my new home away from home starting in January...first afternoon in community and 2 women in premature labour, no pre-natal care...one delivered at home, and another was labouring in our "ED" when the kidlet that was already out came in.  26ish weeks, though looked less cooked than that, we resuscitated to no avail - managed to intubate with a 2.5mm ETT; second kidlet was a little farther along, but neither made it...the lady with the second delivery had a PPH and the one that delivered at home was retaining the placenta - while someone was fishing around, they thought they felt a head - U/S confirmed a twin .  A neonatal air transport team arrived not long after and thankfully had no choice but to stay due to a weather system.  OB/Gyn on call in Winnipeg asked us to give Mag Sulf and some ABx, but she started labouring again anyway and delivered around 0Dark OMFG in the morning.  Luckily there was me and 2 docs and an experienced NP in house...most surprised person there was me as the first 2 intubations I've done on a non dummy in over 7 years were 2 premies.  Ironically just finished NRP about 6 weeks ago.  The bright side, with the NNATT there, the second twin did and is still in NICU to best of my knowledge...however took forever to get the two moms out - the dispatch idiots cancelled the twin mother's plane as she'd delivered, but hadn't delivered the first placenta (the main reason we were sending her out) and the PPH mom was there for some time as well.  That whole week was a story of stacked up medevacs due to "safety" - wasn't weather that's for sure, since for most of the week it was pretty clear - I'm thinking that the sole HEMS provider just didn't feel like flying after a certain point - they make enough money there that it can't be because they can't afford NVG's for the pilots  - I personally believe it's a typical Canadian sole source contract issue where they're getting paid if they fly or don't, so they don't.

[CAdamsPAC]

7 hours ago, sk732 said:

So have come off a wacked out 2 week rotation in 2 different little places - one that will be my new home away from home starting in January...first afternoon in community and 2 women in premature labour, no pre-natal care...one delivered at home, and another was labouring in our "ED" when the kidlet that was already out came in.  26ish weeks, though looked less cooked than that, we resuscitated to no avail - managed to intubate with a 2.5mm ETT; second kidlet was a little farther along, but neither made it...the lady with the second delivery had a PPH and the one that delivered at home was retaining the placenta - while someone was fishing around, they thought they felt a head - U/S confirmed a twin .  A neonatal air transport team arrived not long after and thankfully had no choice but to stay due to a weather system.  OB/Gyn on call in Winnipeg asked us to give Mag Sulf and some ABx, but she started labouring again anyway and delivered around 0Dark OMFG in the morning.  Luckily there was me and 2 docs and an experienced NP in house...most surprised person there was me as the first 2 intubations I've done on a non dummy in over 7 years were 2 premies.  Ironically just finished NRP about 6 weeks ago.  The bright side, with the NNATT there, the second twin did and is still in NICU to best of my knowledge...however took forever to get the two moms out - the dispatch idiots cancelled the twin mother's plane as she'd delivered, but hadn't delivered the first placenta (the main reason we were sending her out) and the PPH mom was there for some time as well.  That whole week was a story of stacked up medevacs due to "safety" - wasn't weather that's for sure, since for most of the week it was pretty clear - I'm thinking that the sole HEMS provider just didn't feel like flying after a certain point - they make enough money there that it can't be because they can't afford NVG's for the pilots  - I personally believe it's a typical Canadian sole source contract issue where they're getting paid if they fly or don't, so they don't.

 

My professional nightmare for being out in the villages, complicated labor, and deliveries with fetal demise! I hectored gravid women to make their prenatal visits and to get onto the plane to spend the last month at the prenatal unit in Anchorage! Strong work my friend.

[sk732]

2 hours ago, CAdamsPAC said:

My professional nightmare for being out in the villages, complicated labor, and deliveries with fetal demise! I hectored gravid women to make their prenatal visits and to get onto the plane to spend the last month at the prenatal unit in Anchorage! Strong work my friend.

This is becoming a huge issue in the communities I work in - nobody wants to spend their last 4 weeks until confinement away from home and family, so they show up in active labour with no prenatal care - "My body/My choice" is being bantered around a lot...which get's tossed back at them when we can't/won't give them the epidural they want, etc, that we're not equipped for.  Thing that always freaks me out is that my first solo delivery in school was a shoulder dystocia and my last one was 5 weeks undercooked and showed up out of nowhere...and came flying out like a KY'd football...I'm on the phone if someone is remotely in labour when they show up - they get a PV right away and if they're less than 5cm we're on the horn for a plane.  I'm sure my luck is going to run out soon that way, but here's hoping 

[CAdamsPAC]

15 minutes ago, sk732 said:

This is becoming a huge issue in the communities I work in - nobody wants to spend their last 4 weeks until confinement away from home and family, so they show up in active labour with no prenatal care - "My body/My choice" is being bantered around a lot...which get's tossed back at them when we can't/won't give them the epidural they want, etc, that we're not equipped for.  Thing that always freaks me out is that my first solo delivery in school was a shoulder dystocia and my last one was 5 weeks undercooked and showed up out of nowhere...and came flying out like a KY'd football...I'm on the phone if someone is remotely in labour when they show up - they get a PV right away and if they're less than 5cm we're on the horn for a plane.  I'm sure my luck is going to run out soon that way, but here's hoping 

Selfishness,  ignorance,  sloth seem to come together  and create mayhem for providers; who mysterious  end up holding  the bag and blame for poor outcomes.

[EMEDPA]

we had a surprise right at shift change a while ago. 14 yr old, no prenatal care. Baby with cleft lip and palate and airway issues and mom with significant PPH. Nice that it was at shift change as we had 1 provider for each patient. Doc delivered the baby just before I arrived and managed it and I got mom bleeding like stink. Lifeflight for both. 

[CAdamsPAC]

I can say that emergent childbirth is the one area  of EM that makes uncomfortable . When it goes well it's  good when it goes badly it is bad. Babies and kids deserve the fullest care possible by parents  and providers. 

[ohiovolffemtp]

I've been fortunate and the only perinatal emergency I had in the ED was a largely stable mom who delivered in the car on the way in.  Both OK, OB/Gyn got there in time to deliver the placenta.

My most scared few moments in my firefighter/medic days was the delivery of a very premie in the back of the ambulance to a mom who's only prenatal care was a pregnancy test from her methadone clinic and was hep-C positive.  Kid came out blue with the amniotic sac intact.  Very fortunately in the 2-3 minutes that felt like forever I was able to get the sac opened, baby suctioned and resuscitated, and kid started to cry.  We hit the ED and it was like TV: ED doc, OB doc, and lots of RN's, etc met us under the apron, grabbed kid, and ran.  My EMT driver and I were left with mom who was stable.  We got her to the OB floor, heard that the OB was very pissed about what had just dropped into his lap, and headed back to the station where neither of us could get back to sleep.

I definitely would be totally fine with never having to manage something like this again.

[SedRate]

Wow, this is some intense stuff. 

[CAdamsPAC]

Yeah I  think  that would keep me up for a few hours!

[ohiovolffemtp]

Had a really rewarding expression of thanks the other day:

EMS brought in a prison inmate after a suspected opiate OD with positive response to narcan and signs of aspiration.  Pt had a huge aspiration pneumonia on CXR and required BiPAP to keep his sats up.  This was at a critical access hospital that can't keep a patient like that.  Between delays in finding a bed at a tertiary facility and finding a flight, patient was in my ED all night.

In the morning the prison warden came by to check on the patient and on the CO's with the patient.  He thanked me for taking care of the patient and gave me a challenge coin from the prison.  I've never had that before.  The warden clearly cared about the inmate and those who were providing his care.

[SedRate]

On 12/29/2023 at 10:18 PM, ohiovolffemtp said:

Had a really rewarding expression of thanks the other day:

EMS brought in a prison inmate after a suspected opiate OD with positive response to narcan and signs of aspiration.  Pt had a huge aspiration pneumonia on CXR and required BiPAP to keep his sats up.  This was at a critical access hospital that can't keep a patient like that.  Between delays in finding a bed at a tertiary facility and finding a flight, patient was in my ED all night.

In the morning the prison warden came by to check on the patient and on the CO's with the patient.  He thanked me for taking care of the patient and gave me a challenge coin from the prison.  I've never had that before.  The warden clearly cared about the inmate and those who were providing his care.

Wow, what an honor. Glad you received the recognition you deserve. Keep up the good work.