The ABCs (and T) of Rural EM

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rural-em-prevWhen you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing an airway . . . and a lot more difficult.

When you’re practicing in the middle of nowhere, planning out a timely patient transfer can be as critical as securing an airway . . . and a lot more difficult.



Case 1

It is the night shift in your rural ED. At 02:30 a call comes in from ED registration.


“Need help getting patient out of a car.” Nurses yell, “Dr Keith – we need you” in that tone of voice that sends your heart racing. “His friend says he has been stabbed.” The nurses wheel in a 20 year old man slumped in a wheel- chair – grey, not breathing, blood everywhere. You help get him up on stretcher and with positioning he takes a breath – AIRWAY Check. Thank goodness, airway is OK. There are breath sounds anteriorly both sides, BP 54 systolic, HR 160. There is a 4 cm stab wound to the left lower chest wall that spews blood all the way across the treatment bay when he coughs. You instruct the desk tech to call for medical transport to send the nearest available unit to come lights and sirens because it’s raining outside and the helicopters will not be able to fly. You call the trauma surgeon at the nearest referral center to arrange acceptance and transfer. You mobilize all your available resources – two ED nurses, the night supervisor who luckily has a supervisor in orientation (another set of hands), the hospital’s only lab tech and a respiratory therapist. You start two large bore IVs and give two liters saline and two units uncrossmatched blood.

Now the patient is talking to you, BP 100 systolic. Bedside ultrasound, fast exam neg, but no pleural sliding in left. You place a chest tube on left side 0300: The patient is on his way to the trauma center.

Lesson 1

Situational awareness is key in taking care of the critically ill in a rural setting. Many rural hospitals do not have the same back up coverage and resources from day to day. The hospital may on certain days have general surgery coverage from another facility, so response time of the surgeon makes calling for help in the ED impractical. You can get your patient out of your ED faster by doing everything yourself. EPs in my group start their shifts with a situation check that includes the following:


#1 Do we have inpatient beds (or are we going to have to transfer all admissions).

#2 Do we have local orthopedics and general surgery coverage.

#3 Which surgeon is on call, because some do not perform endoscopy.

Weather conditions may eliminate helicopter transportation as an option. Ground transport of a complicated intubated and ventilated patient may require mobilization of a respiratory therapist or an additional medic. All these things take time – so my ABCs with a critical patient are ABC and T’s. How am I going to transport and how fast can I make that happen. Remember that initiating medical transport right away can ultimately save a life if the patient needs a life saving intervention that you cannot provide. If you wait to do “T” after you have done all your interventions, you may be too late.

Case 2

23:00 EMS calls in with a 38-year-old female with sudden onset RUQ pain – probably a gallbladder attack. She is pale and in distress as they roll her in on the stretcher. You place your hand on her abdomen, find diffuse tenderness, and and ask two questions: when was her last period and what was she doing at onset. Answers: last menses irregular and pain began during intercourse.

You send off labs to include BHGC and order ultrasound (ultrasound tech is one hour away). Bedside FAST shows blood in the abdomen. You call for emergency transport. The ED tech asks, “What is the diagnosis for transfer?” You answer “ruptured ectopic.” You page the OBGYN service covering and explain to the patient and her husband that you believe she has a ruptured ectopic pregnancy not a gallbladder attack and needs urgent transport to a facility that can care for her. You have used all the tools at your disposal – NS 2L and 2 units blood going in.

You then begin the most time consuming but crucial part of this patient’s care – the transfer. The OBGYN covering your hospital does not have clinical privileges at your hospital. You explain that you suspect you have a ruptured ectopic, but no official ultrasound and no BHCG result yet. He refers you to the referral center. You repeat the story to the OBGYN at referral center, but they will not accept a potentially unstable patient. They instruct you to ask your general surgeon to come in and take the patient to the OR.

You now tell the story a third time – to the general surgeon (who is 40 minutes away). He declines and instructs you to transfer the patient. The lab calls. BHCG is positive – and now you are positive of your diagnosis. Meanwhile, the transport crew arrives – patient’s BP 106/60 and HR 105. You, in desperation, speak to the ED physician in the ED at the referral center who will accept the patient but wants you to speak to OBGYN again. OBGYN once again tells you not to transport a potentially unstable patient. You try to explain you do not have resources to stabilize, and send the patient anyway. Patient makes it safely to referral center and is quickly taken to OR with good outcome. You were right – it was a ruptured ectopic.

Lesson 2

As rural emergency physicians, we are forced to transfer unstable and potentially unstable patients – and patients with suspected but unconfirmed diagnoses. Sometimes we are right and a person’s life is saved by our quick action. And sometimes we transport patients that are not as sick as we suspected. In a rural ED, diagnostic modalities such as ultrasound are not available 24/7. If you are lucky you might have an ultrasound tech on call. MRI is not generally available more than one day each week. The majority of our CTs and Ultrasounds are read via teleradiography which delays results for up to one hour. Our really sick patients cannot wait for these results. We must convince consultants at other facilities to accept our patients based on our clinical suspicions.

And then there is the task of the transfer phone conversation – or conversations – since most transfers require more than one call. This task is ours alone and cannot be delegated to a nurse or tech. It takes precious time away from the bedside. It requires a skill that I was not taught in residency, but is as important as my ability to secure an airway. And when we are unsuccessful, or if time prohibits multiple calls, we rely on our ED colleagues in receiving hospitals to help. As rural physicians we understand that our colleagues in referral centers have to ultimately rely on their consultants as well – so to accept a patient not accepted by the specialist is problematic. But in the end we are the ultimate patient advocates, and fill that role as a band of brothers.

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