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Heroics in Rural Emergency Rooms

Discussion in 'Emergency Medicine' started by Dr.Scorpiowoman, Jun 18, 2019.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    Life and near-death of small hospitals

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    A while back I came to work in the emergency department of a small rural hospital and greeted my friend who had just finished his overnight shift. In that wee, six-bed emergency department in rural Appalachia, he had just seen a seriously sick patient; a patient he gladly handed over to me. She had taken an intentional, very dangerous, overdose. What she ingested was a whopping dose of bupropion. She intended to die, but was found by family and brought to the hospital.

    After enough time in emergency medicine, certain things make a physician nervous; certain conditions give seasoned emergency physicians the 'heebie-jeebies.' For me, one of those is the possibility of uncontrolled seizures with a side of arrhythmia.

    I remember watching the monitor, concerned about her tachycardia (fortunately sinus), concerned about her QRS duration and her QT interval. IV's initiated, fluids running, EKG obtained. She was awake but sleepy and became drowsier as I came up with a plan.

    It was plain that she had to leave. What this young woman needed was an intensive care unit in a large teaching center. We had neither ICU nor specialty care in our Critical Access Hospital. I spoke with her family and explained the situation. They understood.

    Not long after that, she had a seizure, and another. Bupropion has lots of side effects, but near the top of the list in overdose are seizure, hypertension, and arrhythmia.

    Her convulsions stopped with a little lorazepam. I intubated her because her level of consciousness was decreasing. (And because she would probably need more medication if her seizures persisted.) The intubation went well, the seizures stabilized and her tachycardia persisted. Then came what is probably the second most important aspect of rural emergency care; the transfer call. This was followed by the subsequent call to Poison Control, who suggested that she might benefit from lipid infusion, since bupropion is lipophilic.

    The transfer line put me in touch with the intensivist who said, 'send her on!' Music to my anxious ears. We contacted the regional helicopter service and help was on its way. Before we could get the lipid emulsion from the pharmacy, the helicopter crew arrived. She had no more seizures (at least while she was with me). She was thankfully whisked off to a higher level of care.

    We cleaned up, sat down, and I took a deep breath. And a few more. I had a cup of coffee and finally ate some breakfast. The rest of the day was uneventful; especially by comparison.

    But that's the thing about rural emergency care. It isn't just the medicine; a significant bupropion overdose would raise the hackles of any ER doc with a good education and enough experience to be afraid. However, the medical condition was compounded because I was the only physician in a hospital with limited resources and nursing staff, and we were far away from advanced care. Had this patient come to me on an icy, snowy day, things would have been a lot more frightening.

    First of all, no helicopter would have flown. Second of all, the hospital was in a very mountainous area. Transport times by ground take two hours in good weather; bad weather would probably double that (or more).

    I can speak from experience. Early in my career I had another patient with a terrible injury, a lot of snow and no way to transport him. He had been sledding in the National Forest and went under a truck, hitting his head on the trailer hitch at a high rate of speed. He had a significant intracranial hemorrhage with cerebral edema. He didn't have seizures, but he was intubated as well.

    As the evening became night, the snow kept falling and falling and the roads grew more treacherous. Nobody was going to fly in that mess. And ambulances could barely navigate our county, much less go 45 miles away. Our ED became a de-facto neurocritical care unit, as I called on every trick I had learned in my ICU and neurosurgery rotations during residency. (Those things obviously supplemented with phone calls to the actual neurosurgeons in the next town.)


    When morning came, along with snow-plows, my patient left for higher, better care. But he was a reminder that in so much of rural America, we work with what we have, and with the limitations imposed upon us by inconsiderate weather patterns and unchangeable geography.

    The rural ED physicians of America have far more harrowing tales than these. Tales of unimaginable injuries and strange pathologies, managed with skill and innovation. But they are yearly, weekly, daily events in those places that so many Americans only drive through or see as dots on the map.

    But dots on the map where heroic things happen all the time. Thanks to professionals courageous enough to step outside the boundaries of urban medical care.
     

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    Last edited: Jun 23, 2019

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