The other day while on call I received a message from the transfer center that a doctor wanted to discuss a sick child he felt needed to be transported to a higher level of care. I answered the call and talked with the physician who was worried about this little girl.

A 2 year old had presented to his hospital with vomiting and loose stools, low grade fever and over the course of 24 hours she worsened with abdominal distension, tachycardia and agitation, on her way to shock.

An abdominal film demonstrated dilated loops of small bowel and a nasogastric tube decompressed her stomach.

Antibiotics were started for sepsis and she was fluid resuscitated. Despite the interventions, he felt he no longer had the resources to care for this child.

What is rural medicine?

Rural physicians represent 9% of the practicing doctors in the United States despite rural locales being home to nearly 20% of Americans. These physicians work in an environment with limited resources and in my experience have incredibly wide skill sets, deep medical knowledge, expert medical decision making allowing patients to avoid advanced imaging, and sharp acuity at deciding between the gravely sick to be transferred and those who will recover locally.

While there is a tremendous need for rural physicians, few medical students and residents pursue this career path.

There has been much written about a rural medicine pathway as a very rewarding career offering the opportunity to work in areas of true need, decreased physician burnout, an immersive patient experience where a physician may find themselves buying milk next to their patient at the local grocer (this also happens to be true in Las Vegas), and a greatly expanded skill set.

Why heroes?

I write that these doctors are heroes and should justify, as many would consider the super sub specialist who conquers new peaks in medicine and surgery on a weekly basis in urban megacenters around the world heroes.

These are the physicians and surgeons who are celebrated on our news channels, in our published peer reviewed articles and other media.

As a specialist, specialist defined as a career pathway requiring additional fellowship training, I work in different environments but in most I have unlimited resources including PICU and NICU intensivists, ECMO, pediatric anesthesiologist, an experienced nursing staff, a blood bank and many super subspecialists that are available to consult.

What if I didn’t have all of these things?

If I didn’t have those resources I wouldn’t be able to care for the babies and children I care for every day. I would not be able to confidently tell parents that my system is capable of caring for their soon-to-be son with a prenatal diagnosis of congenital diaphragmatic hernia. I would not be able to operate on the extremely premature neonate with necrotizing enterocolitis.

I would not be able to provide the multidisciplinary care required for severe traumatic injury. I would be able to care for and operate on the sick child but many things would be beyond my abilities and my system’s abilities.

Back to our patient

When this 2 year old was transferred I was present to evaluate her in our pediatric intensive care unit. She was lethargic and her abdomen had involuntary guarding in the right lower quadrant and right flank.

An ultrasound demonstrated free fluid in that area and concern for perforated appendicitis.

In the operating room I was able to remove the perforated appendix, clear her peritoneal cavity of purulent debris and achieve source control of her sepsis.

After the operation I called the referring physician and thanked him for sending the child, sharing with him the diagnosis. Within a day her complexion brightened, her abdomen softened and I found her in the pediatric floor playroom busy with unlimited stimulation.

Rural physicians don’t have all of the resources and tools I have at a tertiary center but they provide outstanding care despite these shortcomings, in fact I don’t believe they see the lack of resources as shortcomings at all, just a matter of fact.

The decisions these physicians must make are based not only on their expertise but on their knowledge of their healthcare system and what it can and can not care for with sick patients.

These decisions are the difference between life and death.

Take the patient with a history of angina and a physician without a Cath lab or access to cardiac specialists.

When do they send the patient for further testing or perhaps emergent bypass surgery?

If we define heroes as people who have courage, outstanding achievement and noble qualities the rural physician is a hero.

Questions

If you’re a resident or medical student have you considered rural medicine?

Why?

Why not?