After leaving the FIX conference, I couldn’t help but feel inspired, energized and quite frankly, a bit intimidated (despite an empowered talk on imposter syndrome).
Hearing women share their leadership stories, entrepreneurial endeavors and academic achievements, I was left in awe of this accomplished group of providers.
But as I often feel after big conferences, the voice I didn’t hear loud enough was that of the providers in the trenches . . . the stories from our community EM providers.
Having trained in an ivory tower of medicine beneath the skyscrapers of a major metropolis, I was conditioned to believe there is nothing harder than the rigors of academic EM. Success resided in the grant application, the grand rounds lecture, the journal submission. These academic EDs are stroke and cardiac institutes of excellence, level one trauma centers, social nets for large urban communities. Graduates of these programs have encountered both “bread and butter” EM as well as the complications of a transplant and LVAD patient. When I finished residency, I felt that I had trained in the best environment possible and couldn’t perceive of a setting as challenging and rewarding as where I’d been.
But now that I’ve spent some time in the trenches of community EM, I realize how naive I was as a young graduate.
What tests your pace more than a full waiting room in a demanding university ED? Being single coverage in a busy community one . . . on an overnight 12-hour shift. No resident, no mid-level, no scribe. Perhaps there is a lac or two waiting to be seen, a Colles that needs reduction/splinting and a run of the mill abdominal pain . . . that you’ll get to . . . right after you see the higher triaged chest pain and syncope. And you know full well that when you finish up the evaluation on those first few patients, no one will have scooped up those lower triaged, time-intensive procedures or met the two ambulances that arrived in the meantime, because IT’S. JUST. YOU.
It’s not that you don’t have some help, some consult services, you do . . . but mostly by phone. That friendly surgeon may be thirty minutes away when that dialysis fistula won’t stop bleeding (and it’s bleeding fast). A STEMI isn’t whisked upstairs in five minutes because the nearest cath lab is a thirty-minute life flight away (if the weather is good enough to fly) and that level 1 trauma center . . . well that’s you in a critical access hospital. TPA is your call on your assessment alone; not the stroke team, not the neurointerventionalist. There is no turf of procedures; no med student to shakily sew that lac, no Ortho or EM resident to reduce/splint that Colles, no surgical or EM senior to place that chest tube. And that’s the bread and butter EM.
What’s much harder in community medicine are the things that don’t roll in the door every day but will arrive in your career now and then just to take your breath away, to push your skills and challenge your clinical judgement.
A pediatric epiglottitis at 4 am, audible stridor. You promptly start antibiotics and steroids, but ultimately this child requires the PICU which will necessitate transfer an hour away. There is no ENT or anesthesia provider to back up your intubation. Stridor improves, he is protecting his airway at the moment, but is he stable for transfer without a tube? Tough call and no shared responsibility on this one. It is all you.
A traumatic eye injury arrives with the rare but dreaded retrobulbar hematoma. You’ve never even observed a lateral canthotomy; there is no ophthalmologist to guide you. It’s time to scan that Roberts and Hedges and get it done.
Angioedema with airway compromise, no ENT or anesthesia back up on the night shift. You’ve tried direct laryngoscopy, glidescope and bougie without success. Now, that cricothyrotomy kit that’s been beckoning from the sidelines gets opened, when you finally, shakenly and gratefully pass a 5.5 ET with a size 4 miller.
And then there are those cases that sting for years and nearly break you — the pediatric arrests. When you are alone in that ED, no colleagues to co-manage, no PICU to assist, no chaplain or social worker at night to help mitigate the pain when all of your efforts fail and voice cracking, you tell that mother, their child is gone.
And somewhere in those years since residency you became a mother too, and it hurts that much worse because you now know what it means to be a mom and love that deeply.
These are the challenges in community and rural EMs. But there are also amazing rewards. You have exceptional skills, because you do every line, intubation, lumbar puncture, cardioversion and reduction that walks through that door. I have seen EM community docs deftly float pacers, perform cardiocenteses, place suprapubic catheters, all without the back up of a specialist. You have mastered the multitask, the solo coverage, rushing to the floor for a code or delivery while still caring for those in your own department. You have survived those twelve-hour days that became fifteen because that critical care patient arrived twenty minutes before your relief did. You have incredible experience, because you work a full clinical schedule. You do not have a buy down or shift reduction to teach residents, conduct research, chair committees or prepare podcasts.
Your niche is clinical emergency medicine and your domain isn’t the lab or lecture hall, it is the frontline of the ED. You provide exceptional care in resource limited settings to those that matter most — your patients, your community.
You are leadership in your field. You are excellence in emergency medicine.