Newsletters

POSTED: March 15th, 2023
POSTED IN: 2023 Quarter 1, EM Pulse - The Official Newsletter of MOCEP,

Written by Jeremy Hunter, DO

Rural emergency medicine is a sleepy environment for the most part. You get away from the big city life avoiding the exciting adventures we dream of (mass casualties, GSW’s, stabbings, MVC’s). Why would I want to work in a rural environment as a physician board certified in emergency medicine?

It was a busy afternoon in a small town in a 6 bed emergency department.  The hospital does have general surgery on call, Ob/Gyn on call, so not too small of a place.  I had just finished taking care of some lower acuity patients and was sitting down to finish documenting and teaching my medical student with me about cases we had just seen. As we were sitting there we saw a car drive up to the window very quickly and slam on the brakes in front of the main doors to the ED.  We were wondering what the heck was going on, initially a little concerned for a reckless driver.  Someone came from around the driver side of the car carrying a limp toddler sized patient and running into the ED.  I suddenly realized this isn’t going to be a sleepy afternoon.

We got up from our desks and met them as they were running through the doors and took them into our larger “resuscitation” bay.  My view from the door walking in was a cyanotic, limp, approximately 2 years of age patient.  They placed the patient on the cot and I felt for pulses.  The patient was obviously bradycardic and then lost pulses within a few seconds of arrival.  The next was on autopilot.  Asking for a bag valve mask, IO, fluids, preparing for intubation, trying to find someone to get some history of what happened.  IO is in, bagging is somewhat effective, Epi is on the way.  Got my laryngoscope and tube ready.  We don’t have video assist backup, don’t have trans tracheal jet insufflation kit available if this doesn’t go well, it’s all going on in the back of my head. During intubation the patient’s epiglottis was somewhere between the size of my pinky and my thumb. I could not visualize the glottic opening. I slid the ET tube behind the epiglottis and kept it anterior and it went somewhere. Positive color change, patients color rapidly improved and we got ROSC. Nurses called for children’s hospital transport.

After ROSC, attention was turned to the parents in the room. Family is Amish, very kind and obviously distraught. They report that the patient had been sick with a cold and has been struggling to breathe for about 1.5 days. They stated that at home she was having to lean forward to breathe. When she collapsed prior to arrival, they sought help to bring them to the hospital. She has not had any vaccinations.  We started an IV, obtained blood, started ceftriaxone, and waited for the Children’s hospital to arrive. Patient was transferred to Children’s hospital somewhat uneventfully after this. Blood culture later grew (Haemophilus influenzae type b) Hib.   Patient had epiglottitis from Hib that led to respiratory arrest.

Rural emergency medicine isn’t for the faint of heart. Volumes are lower, but there typically are not the resources available to those of us working in larger facilities. When something has to be done to save a life, we are oftentimes the only resource available. The level of skill and education in the rural communities makes a difference in the outcomes for the community we are serving. I have worked in large academic settings, busy community settings, rural settings to critical access.  I have enjoyed my experiences at all my settings, but the times that I have been so grateful for my training, it has been most appreciated in the small rural settings. In the rural settings I have seen GSW’s, stabbings, airplane crashes, MVC’s, heavy equipment accidents, and of course farming accidents.  

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Dr. Hunter currently serves as the Medical director at Mosaic Life Care in St. Joseph, and practices at multiple rural and critical access hospitals. He also serves as a member of the MOCEP Rural EM committee.