Primary differences between rural/urban ER

[Groy]

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I'm a first-year med student curious about Emergency Medicine.

Worked in an ER for a year prior to medical school and liked it a good bit. The variety of cases, the variety in patient demographic and acuity, the hours, the camaraderie, working with a medical team, etc. It was all pretty nice.

The ER I worked in prior to med school was only 18 beds at a level-II trauma center in a small town. I am scheduled to shadow at my school's affiliated ER next week (a huge level-I trauma center, biggest in the region), and am curious about the primary differences I will most-likely experience.

I can imagine that the patient volume and traffic will be much larger, obviously. But other than that, what will be the main differences? The average types of cases? The complexity? The demographics?

Anyone with experiences at both types of centers have any insights on the similarities and differences between the two?

Thanks!

 

[Angry Birds]

18 beds isn't even that small. I've seen rural ER's with 4 beds.

I've worked rural ER and I love it. It can be a cush job, although it can be hard to find such a job that pays well, at least in some regions.

 

[pepes1lv1a]

I'm a 4th year in the middle of applying to EM residency. I came in with almost exactly the same experience/attitude as you seem to have--fell in love starting with my EMT-B class and job as an ER tech (small suburban level 2), and pretty much stayed that way all through med school.

It was really cool to see the types of traumas they would get at the level 1 program where my home rotation is (also did 2 aways at level 1 traumas), but after a while the gunshot wounds/creative suicide attempts/grisly MVCs start to feel like a semi-depressing (but still occasionally exciting) part of the routine. There was lots of gallows humor at most of the places I've worked/rotated at--whether or not it's trauma, you gotta find a way to cope with the emotional intensity somehow. At the end of the day, the majority of the residents' and attendings' time is still spent dealing with "bread and butter" (god, I hate that phrase, I just don't know how else to say it) EM stuff that might be surprisingly familiar to you in terms of quality/rhythm (you'll just end up understanding it a lot better)

If your experience is shaping up to be anything like mine, you won't even realize how immensely helpful your work experience in the ED was until you start your 3rd year rotations. I had friends who would get totally lost if someone wasn't telling them exactly where everything was all of the time and what they should be doing minute-to-minute. The sort of self-directed problem solving you do as a tech comes in handy on just about every rotation, not just in the ED--and certainly not just in a level II ED. It's not really so different. Good luck

 

[deleted109597]

My med school had a 2 bed ED in Mountain City. I don't think they come smaller than that.

 

[BoardingDoc]

My med school had a 2 bed ED in Mountain City. I don't think they come smaller than that.

Waiting for someone to bring up their 1 bed ED....

 

[CajunMedic]

Waiting for someone to bring up their 1 bed ED....

(slowly raises hand) We had one in Fayette, Mississippi until they built the new hospital a couple of years ago.


I worked in rural Southwest Mississippi as a Paramedic before med school, 4 of the 6 counties I worked in, the ED's were from 1 bed, up to 7 beds. The other 2 had 10-18 bed ED's. I did my 3rd year in a Level 3, 18 bed center. Most of the trauma bypassed us unless they were profoundly unstable, or a prisoner, everything else went up the road a couple of hours to the academic level 1 due to the design of the state trauma system. We saw a huge indigent population with a lot of Diabetes, HTN, Renal failure, CHF, COPD, and quite a few sickle cell patients. There would be the occasional heroin OD or shooting

I just finished up a 4th year audition at an 85,000 visit a year, Level 2, urban ED. Same indigent population but more spanish-speaking. Here, I saw a lot more Methamphetamine usage, not as many chronic condition exacerbations, and a lot more trauma, especially construction injuries. The gun and knife club was a daily event.

Ultimately, it will depend on where you are, what the prevalent diseases are, and how traumas are handled. We have little to no specialty care, maybe an orthopedic surgeon on a good day, GI is gone more than they are in, no chance of urology, definitely no neurosurg. A lot gets shipped across the state for those things. You will definitely learn the art of the transfer and have to be able to care for some of these patients until a ground unit or helicopter can get them out.

 

[BAM!]

(slowly raises hand) We had one in Fayette, Mississippi until they built the new hospital a couple of years ago.


I worked in rural Southwest Mississippi as a Paramedic before med school, 4 of the 6 counties I worked in, the ED's were from 1 bed, up to 7 beds. The other 2 had 10-18 bed ED's. I did my 3rd year in a Level 3, 18 bed center. Most of the trauma bypassed us unless they were profoundly unstable, or a prisoner, everything else went up the road a couple of hours to the academic level 1 due to the design of the state trauma system. We saw a huge indigent population with a lot of Diabetes, HTN, Renal failure, CHF, COPD, and quite a few sickle cell patients. There would be the occasional heroin OD or shooting

I just finished up a 4th year audition at an 85,000 visit a year, Level 2, urban ED. Same indigent population but more spanish-speaking. Here, I saw a lot more Methamphetamine usage, not as many chronic condition exacerbations, and a lot more trauma, especially construction injuries. The gun and knife club was a daily event.

Ultimately, it will depend on where you are, what the prevalent diseases are, and how traumas are handled. We have little to no specialty care, maybe an orthopedic surgeon on a good day, GI is gone more than they are in, no chance of urology, definitely no neurosurg. A lot gets shipped across the state for those things. You will definitely learn the art of the transfer and have to be able to care for some of these patients until a ground unit or helicopter can get them out.

are you sure that was an ED. Aren't there basic requirements like a CT scanner, etc? I can't imagine a 1 bed ED with all the necessary equipment/resources to satisfy EMTALA.

 

[deleted109597]

are you sure that was an ED. Aren't there basic requirements like a CT scanner, etc? I can't imagine a 1 bed ED with all the necessary equipment/resources to satisfy EMTALA.

EMTALA doesn't require a CT. It doesn't even require a doctor (note the PA/NP staffed EDs). And in some places, it doesn't even require somebody to be in house. It's a weird set of rules.

 

[gro2001]

Waiting for someone to bring up their 1 bed ED....

Well, I worked at an ER where we didn't even have a bed. Just a chair.

 

[smokn]

 

[Groy]

Now whenever someone tells me about their past hardships, I will immediately and loudly interject, "LUXURY!"

 

[Tenk]

The biggest differences will be: volume and disposition. In GENERAL, rural will have lower volume and patients per hour than urban and in GENERAL, it can be much harder to get disposition on a patient who requires subspecialty care in a rural setting (lots of phone calls and transfers). For smaller differences: you will probably see more violent trauma in urban (guns and knife) and more accidental (think farm and shop injuries) in a rural setting. Most of the rest is relatively similar other than I get treated a lot better by patients in the rural settings.

 

[Vandalia]

A few random thoughts:

1) There is rural, Rural and then there is RURAL. We cover one "rural", critical access hospital that is about 20 minutes away from ambulance from our "big" hospital. That environment is different from being at a place that is a couple of hours away from anywhere else, and I am sure we have people here who have worked in facilities that were 10+ hours away from civilization. The key issue is the obvious one - for most of the day you are the only physician in the building, and at least for the last two examples, you are it. There is no safety net.

2) For many reasons, people envision only EM board-certified physicians in the big hospitals and other specialties and mid-levels in the small places. However, in terms of actual need, it is the other way around. Just about anyone can practice medicine if you have a ton of resources to rely on. My 13 year old used to joke that he could do my job "Headache? Sure. Stat CT, a bevy of labs, emergency neurology consult, outpatient MRI, psychiatry, and neurosurgery." But when the only option is you, that is when the EM training is really needed.

3) In practical terms, one of the biggest differences is in what a shift can end up being. In larger places, with bigger populations, things tend toward the central mean. Sure, there are busier and lighter days/nights, but all-in-all not that much deviation. In the smaller places, it can be all or nothing. Recently, in the "rural" place, I had a shift with one patient in 8 hours and that was a pretty cut-and-dry renal stone. On other shifts, it has been completely swamped. Starting a shift at the "big" hospital, I pretty much know what it will be like based on the time and day. At the "rural" place, I don't have a clue. It is interesting to note that this is a small measure of why more of the senior people like night-shifts at the rural place. There is a non-zero chance that there will be a couple of hours free to work on paperwork or whatever else. One colleague claims to be writing the "great American novel" and again knows there is a slight chance of some time to write. (Note that both places are a package deal, with "big" effectively subsidizing "rural".) At the "big" place, the chance of more than 30+ minutes free at night, approaches zero. But at the same time at the "big" place, the situations that are so busy you can't go to the restroom are also pretty rare.

 

[Redrox]

Couple days a month I work a 4 bed ER, 1.5 hours from the nearest real hospital, 24 hour shifts, been doin it a couple years for variety and here's somma my thoughts on rural ER, should be plenty of urban descriptions elsewhere on the message board.

It can suuuuuuck, but also sometimes it's dope.

Official average is 0.8 patients an hour but it's extremely streaky. Maybe one shift will be 7 people all day and I sleep a ton and burn through Netflix. Other days it's nonstop work with no break from 7am to 4am. Others might not be that many people total but all 12 for the day checked in just after dinner and my two nurses are in full on panic mode.

Expect suuper low back up or support staff, extremely poor follow up. Only hospitalist in town is on call 30 days a month so he's super powerful, no to be effed with. Super cautious too, which makes sense I guess because we have no surgeons or OB or any critical care beds if patients turn more ill. No one stays for admission unless it's a slam dunk easy admit is healthy enough they shoulda gone home in the first place. Expect a lot of questions if you wanna admit someone, expect a lot of skeptasism from big city docs about whether or not someone's sick enough for a transport.

All PCPs are actually nurse practioners so expect an even higher level of 'holy crap what a dumb reason to send someone to the ER" situations.

Expect suuuper long delays sometimes. If the helicopter isn't flying, EMS might take up to 3 hours to arrive to pick up your patient for transport. Had a stemi recently take 4 hours to get to cath lab. I've needed to run my own little ICU on days with rain and even longer delays.

Expect suuuuper poor follow up. No stress test or EGD in town and no one wants to drive into the big bad city. We also gets tons of cancer patients (new and established diagnosis both) who come in with questions and complications and it can be a mess.

On the pro's, it's a completely different patient population and the variety can be nice. Small town people look out for their own and everybody knows everybody. Got just curtains between our four beds and patients flow from room to room chatting with their neighbors while waiting for test results. Netflix days are cool too, so's getting paid for sleeping, usually I get 4-6 hours at least. Pay for 24 hours is almost the same as 2 9 hour shifts in the city.

 

[TheComebacKid]

I'm doing residency in one of the "level 1 trauma centers in major city/ivory tower/quaternary care/every single subspecialty available with a click of a button" places. I thought this would be the ideal place for me to work/train. We have a huge knife and gun club, lots of interesting pathology, extremely SICK patients. But we also get a ton of transfers from outside rural hospitals. I mean A TON. This is a huge downside in my opinion. To give you an example: A few days ago we had someone who was flown in by helicopter from a rural hospital after a farming accident. They were stabilized at the outside hospital, got intubated, had a femoral cordis in place, bilateral chest tubes already placed. When the patient came to me, he was fairly well resuscitated all things considered, and I got a pile of disks and outside hospital records to sort through. I made a bunch of phone calls, called the appropriate consultants, got the patient admitted to the SICU and the rest was history.

I've realized as I've gone through training, I want to be on the other side of the equation. I really think that's where emergency medicine as a specialty shines, in a location where in the middle of the night, a bad trauma or sick patient comes in, and you are the only one there to stabilize the patient and package them up to be shipped out somewhere else. Sure, there's a lot of crapping your pants when you work in a rural ER and have to manage those patients, but that's what we signed up for.

While working in an urban level 1 trauma center is cool and I get to see a lot of interesting pathology, dispositions are rather straight forward because your consultants do a lot of heavy lifting (that being said they are by and large pretty unpleasant to deal with since they are usually an overworked second year surgery resident). It's a phone call and the patient has a bed. Consultants live in house, and they are always a phone call away. Why reduce this fracture when I can call ortho to do it and I can see this other patient in the waiting room? To some this may be seen as a benefit. But for those who really want to get their hands dirty, not-so-much.

I haven't really looked into the reimbursement and salaries, for that I defer to those who already posted above and are in practice. I would think that rural ED's have a harder time attracting potential employees and are force to offer more competitive salaries, but hey, that's just what they taught me about capitalism in my high school economics class. Who knows if it's really true.

 

[dchristismi]

are you sure that was an ED. Aren't there basic requirements like a CT scanner, etc? I can't imagine a 1 bed ED with all the necessary equipment/resources to satisfy EMTALA.

You know *technically* that would be an Emergency Room...
har har.

 

[DrFrankenstein]

Urban I got an envelope stuffed with cash, rural I was paid in pies and chickens.

 

[wholeheartedly]

I know this is an old thread that was bumped. But I gotta chime in that my current shop was a 1 bed emergency "room" until July 1st when we moved into new facility with a 9 bed ED. Which turned out to be really fortunate because just over a week later the town got hit by a tornado and we got 28 patients, including 9 criticals in about 45 min. It took a crazy long time to transfer people out because all of our flight resources and bigger hospitals were in the direction the storm was going.