Rural ER, Small Town, USA

By Daniel Greg Stevens, DO, Medical Director

I’ve been working in the rural ER now for a little over 7 years, and I have loved almost every minute of it. I grew up in a small town and I have always liked the rural atmosphere—people are so relaxed and easy going. Most of my hobbies take place outdoors, so naturally I wanted to move back to my rural hometown after medical school. I like that people say “yes ma’am” and “no sir,” and most people are able to get along with almost everyone; willing to lend a hand at a moment’s notice. The local people bring cakes and cookies to the staff on Christmas, and I know I will never go hungry on Thanksgiving because of the donations of local churches. Most small towns in Mississippi are like this, so I thought I would write down a few things to think about when it comes to rural Emergency Rooms, which are scattered not only around Mississippi, but most southern states.

Many of the Level IV Critical Access Hospitals scattered across the south are tiny. They have around 25 beds on one floor and 3-4 beds in the ER. There are no “trauma teams,” no surgeons and no specialists at most of these locations. They might have one nurse and one doctor, and can pull one nurse from the floor if things get serious in the ER. Three people working  two codes at the same time can really have their hands full. Sometimes, if one of the staff is fairly fresh in their training, he or she will get a “baptism by fire,” which makes the event even more hectic. Everyone, including the physician, can get a wonderful workout doing chest compressions, and the local EMTs will usually stay and help if (1) they were the ones who brought the patient to the hospital in the first place, and (2) they don’t have another call to go on. Many facilities usually have one or two more staff members that can assist, but at night the bare minimum is what we have to work with.

Speaking of which, what happens after midnight at rural ERs? The x-ray and admissions staffs go home. When night-time imaging services are needed, an x-ray tech is called in from home, a process which can take up to 30 minutes. Ultrasound may not be available at all. The nursing staff are also the admissions personnel after midnight. Lab personnel usually remain, but not all labs are available.

Rural ER providers must possess a special ability to work with low volume staff and the local patient population. Not all physicians are comfortable with this. I have met doctors that feel right at home in huge Level I Trauma Centers, but will freely admit that they are uncomfortable working in a rural ER. They will go on to tell me that they feel safer having other physicians, specialists and nurse practitioners around that can help during frenzied situations. They also enjoy having all the tools of a larger hospital at their disposal; tools such as MRI, Cath labs, Obstetrics, Surgery and others that are not available at critical access hospitals.

This is why small town ER doctors are essential to rural medicine. We have to be able to “make do” with the tools at our disposal to give each patient the care he or she needs. We have to make tough decisions and be able to work with limited staff and resources. Most importantly, we have to incorporate ourselves into the local community and smile or cry with patients’ families. There truly is an art to working and living as an ER provider in Small Town, USA.