Into the Fire

It’s only been four days of work on my rural rotation in Burns, OR, and I’ve seen and done more in those days than I had in a month of my internal medicine rotation. The hospital in town serves the largest county in OR, about 10,000 square miles, with only about 7,500 people in that area. It is true frontier country, with high desert weather (sunny most of the time, but very cold at night), minimal foliage among the low lying sagebrush, with the call of the Steen mountains off in the distance. Most of the patients come from right in town, but often they drive from over an hour away, either in their private car, or in one of the three ambulances available at the hospital.

People here love their physicians, so much that it’s difficult for the doctors to even go to the grocery store without needing to talk to everyone, who of course, are their patients. There are three full time family medicine doctors, one part timer, several nurse practitioners, a physician assistant, and one rotating surgeon that comes from far away, and stays for a week or so at a time, waiting for any surgeries that may be needed. There isn’t enough surgery here to have a full time surgeon on staff, so they use a system called Locum Tenums, which is a temporary agency that provides different surgeons a week at a time. I’m living in a house right across the street from the hospital, sharing it with the surgeon on call. I was warned that it can be very lonely and isolating here, but so far, I have not found that to be the case, mostly because I spent most of the first week in the hospital and clinic taking care of patients.

The pace of work here is incredibly fast, and I’ve been thrown right into the firestorm of rural medicine. Usually the hospital census is only about 6 patients, with a total capacity around 24, including 2 ICU beds, and 2 labor suites. For some reason this week is incredibly busy, probably due to my karma, since on my internal medicine rotation I was blamed (jokingly) for bringing in patients since the team I was on always had 10 patients, while the other teams would only have 2 or 3, meaning the other physicians and students would leave daily by 2 or 3 pm. So with such luck here, we had 12 patients in hospital, and full days of outpatient clinic patients.

The first call day was just several days ago, and was an incredibly long 36 hours. Because we had 12 patients in the hospital, I stayed with the inpatient patients, rounding on them, examining them, and making decisions for what they needed for the day. My preceptor went over to the outpatient clinic, where he saw a new patient every 20 minutes. I would call him to double check the orders on the inpatient folks, and write up daily progress notes. It’s so different here than in the university setting, where the residents make all the decisions and the students sit by and watch. Here I am expected to make medical decisions, and am treated like a “baby” doctor. At one point during the long call night, my preceptor went home to be with his family for a little while, and there was a line of nurses in front of me, asking me questions about the patients. Bed #21 hasn’t urinated since this morning, would you like to put in Foley catheter? Bed #13 has an order written for a scopolamine patch every 3 hours, but I think it should be every 3 days? Bed #32 is tachycardic and dropping his pressures, what would you like to do? Inside I was panicking, thinking I have no idea….then I took a deep breath, and just used the knowledge that I have. Sure, let’s put in a Foley for patient in 21; I used my hand held to look up the frequency for scopolamine patch changes, and confirmed, yes it’s every 3 days; and I’ll go take a look at patient in room 32, whom we eventually moved to the ICU. I thought to myself, this is what the interns I have seen at the University experienced taking care of so many patients, with the nurses constantly paging them for answers to patient care questions.

In addition to dividing our time between the inpatient and outpatient folks while on call, we were also responsible for any patients that came into the ER. I understand that on any given day or night, there may only be one or 2 ER patients. But again, with my luck, I just brought them all in. First we were notified that there was a gunshot victim on the way. We rushed to the ER, trauma notes in hand, only to discover that the patient was not alive, and we needed to go to the site to pronounce the patient dead. What I saw on that trip is something that will forever be carved into my mind, and not something anyone should see in their lifetime. The patient lived in a mobile home park, and was very poor. We checked the notes in the system prior to leaving, and learned that the patient was in chronic pain, and in a recent visit to see his physician, had mentioned some suicidal thoughts. At the scene we confirmed our worst suspicions. He had taken his own life with a shotgun blast in his mouth.

How do you return to work after seeing something like that? We had no choice, as we returned to the hospital and clinic to pick up where we left off. Several hours later we learned there were three patients needing pickup by ambulance. One patient was a 96 year old woman in respiratory distress, another was a man with severe back pain, and the third was a woman with confusion, sweating, nausea, and vomiting (we were thinking possible heart attack). As the nurses scrambled to make the ER ready for three patients arrival at once, the paramedics hopped into their trucks to make the long drives out to retrieve the patients. Unfortunately, they couldn’t find the keys to the third ambulance, and so the anesthesiologist picked up one of the patients in his station wagon. Welcome to rural medicine; when there is a lack of resources, you just do whatever needs to be done.

The rest of the day went by in a blur as we took care of the three new patients in the ER, admitting two of them to the hospital. At this point my preceptor had been up for over 30 hours. Thankfully he had let me go home to lie down for a few hours, but I was still feeling the incredible fatigue of a 30 plus hour adrenaline rush, in addition to not having eaten in over 10 hours. We were so relieved when the night doctor came on at 6 pm. We caught him up on all of the patients in hospital, and then sat down to decompress from the day. Thankfully my preceptor asked me if I needed to talk about the suicide victim we had seen, and I took him up on it. We talked for some time about what things we had noticed in the mobile home, what little things that would always stick in our mind. The other doctors there also checked in with me during the day, asking me if I was OK after seeing such a gruesome event. I dragged my butt across the street, and talked with the young surgeon about my entire call shift, which was such a relief. As someone who had just recently finished her training, she understood the work load, the fatigue, and the emotional trauma associated with extreme medical patients. Then I went up to my bedroom, and called my best friend in the whole world, Ronando. I also called a classmate, and another friend, as I knew I needed to talk, so that I wouldn’t just store this trauma in my body. Then I laid my head down on the pillow and did not open my eyes for another 13 hours.

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