"Rural" EM

[AquaFortis]

So, as a med student in the pre-clinical years thinking about what I want to do, I've perused many of the threads here in the EM section. A common theme that seems to crop up is the tough working environment for ED docs with non-stop shifts, etc. eventually leading older docs to want to get out. I'm assuming here, but I would think that for most of the forum (not just EM) there is a large city bias, as that's where most people train and many people live/want to live. Well, what about "rural" or small-town EM? It seems like that would help alleviate some of the issues of shifts where you just get hammered with tough cases, lots of trauma, etc. By rural/small-town I'm thinking towns of 10-75k with EDs that see probably less than 15-20k visits a year. Would this not be a better working environment (depending on the specific location obviously?). Is this what folks mean when they suggest moving to lower acuity/lower volume ED's later on in their career?

Feel free to educate me, as obviously I don't have much experience with this besides growing up in a small town. It seems like cost of living would be lower, you would still make good money, be valuable to the ED if they don't have mostly EM trained docs, and would still be able to enjoy the benefits of rural life (I'm as depressed thinking about missing spring hunting season as I am sitting in my neuroscience lectures ). Thanks!

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[deleted6669]

...moving to lower acuity/lower volume ED's later on in their career?

just a side note- lower volume doesn't necessarily mean lower acuity. I work part time at a rural/critical access e.d. that sees around 15,000 pts/yr. it's a desirable/coastal retirement community with a large elderly population. we have fairly high acuity there and an icu admit rate higher than anywhere else I work( and I also work at level 1 and 2 trauma ctrs). I can work an entire week there and not see many pts under the age of 70.
that being said I think lower volume is more "relaxed" and gives you the time to deliver excellent care to every pt. seeing 10-15 pts in a 10 hr shift is a much nicer experience than seeing 30.
there are times when we have multiple critical pts in the dept at once but we do have the ability to stabilize and fly traumas, stemi's, etc
I would work full time in this environment if I could convince the family to move out of "the big city".

 

[Farmer2DO]

I'm with you on the rural environment. I work in a medium sized city, but commute to the sticks.

Here's my thoughts, and they are purely observational. When you get into the small, rural EDs, there aren't many EM trained physicians. I have worked with quite a few non-EM docs that literally scare the hell out of me. Also, out there, you are often truly alone. The surgical resident, or trauma team, or ortho resident, or cath lab aren't a phone call away. You may have a STEMI but be an hour by ground from the cath lab, in good weather, if your only commercial ambulance isn't already on a transfer. I routinely see 2-3 hour times to get the patient to definitive care. For a surgical belly from trauma, or a leaking AAA, or hypotensive STEMI that failed thrombolytics, or intubated kid, that can REALLY increase the pucker factor. You also may be backup for the whole hospital, when the admitting doesn't want to come in at 2 am, and depending on how it works, be second guessed the next morning for everything you do. I've seen the patient in septic shock and in DKA admitted to the ICU, intubated, with a 22g for a line, with a MAP in the 30s, no pressors, who has been KVO on fluids for 24 hours with NO urine output, and the admitting physicians "don't believe in" PEEP or sedation. Just tie 'em down. I've had to transfer these patients. And the ED doc on downstairs isn't interested in over-riding them with reasonable orders.

Also, someone else posted on here about moonlighting in an ED where he was EM trained but worked with primarily non-EM trained physicians in the ED, and would receive crap for doing appropriate workups and admissions.....I'll try to find the thread and link it.....

I love the rural area, esp if you are within an hour or 2 of a decent sized city. Just go in with your eyes open.....

 

[deleted6669]

agree with the pucker factor. we are 2 hrs by ground from the nearest cath lab and 30 min by air(if they are willing to fly-weather is frequently uncooperative). we have had situations with multiple critical trauma pts and utilized the services of both area helicopters + ground units at the same time. it's a sleepy little town but a few times/yr all hell breaks loose.

 

[Birdstrike]

I don't work in a rural location. I work in what would be described as a fairly desirable location. From what I've seen, the better and higher paying jobs are not in the most desirable locations. I've had several partners leave where I work and go to awesome jobs in less desirable locations. It makes sense: they have to pay more and work harder to attract people and keep people happy, in a less desirable location. They don't have to work hard to keep people happy in a desirable location because if you get disgruntled and leave they just open the door and another body falls right in to your slot, because people are lined up waiting to take your job.

"Job by the bay, half the pay"

 

[deleted6669]

agree with above- I make 30% more/hr to work rural to see fewer pts.
also a much more mellow environment because the rural job is the only show in town. at my other jobs they are constantly harping about "customers" because there are many other local er's and they want folks to keep coming back to theirs so the customer is always right, even when they clearly are not..

 

[AquaFortis]

Thanks for all the replies! Definitely some interesting perspectives. I was a little surprised about the backup thing. I just assumed that the PCP or whoever did the admission (hospitalist, PCP on call for the group, etc) would handle issues in the ICU. Do rural ED docs do in house codes over night too?

I like the idea of eventually settling into lower volume (but who knows, I like everything at this point in my training). emedpa, I like your point about having more time to give with patients as well. It's nice to hear a generalization that "less desirable" areas (more desirable for me, so I guess it's in the eye of the beholder) are many times nicer and pay well.

I noticed just in a brief Google search for EM jobs in my area (SE state medical school with a number of surrounding regions that are substantially rural) that some places over the choice between 12 hour shifts and 24 hour shifts. What's with the 24 hour shifts?

 

[deleted6669]

if the typical volume is 20 pts/24 hrs then a 24 hr shift is very doable. they generally have a call room for you with bed/tv/fridge/shower so when there are no pts you can be off the floor to sleep, etc
some of my shifts are 16's at such a place.
my dream job is at a place where full time= eight 24 hrs shifts/mo.

 

[Dwindlin]

The system I worked in as a medic prior to school was nice. I would love to end up back there after school/residency.

Medium sized city, ~40-45k. Medium sized hospital serving fairly wide area. 25 bed ED, 20 bed ICU, ~200 in patient. 24hr Cath lab, but no trauma services. Nearest tertiary care center is an hour by ground ~20-30min by air weather permitting.

ED is mainly double coverage seeing roughly 30-40k/year. ED is responsible for codes after "business" hours as there are no in-house docs after ~5-6pm and all day on the weekends.

 

[deleted6669]

At my rural gig they have an in house hospitalist/intensivist during the day and available by phone at night. some community docs also manage their own admissions.

 

[MLT2MT2DO]

At my rural gig they have an in house hospitalist/intensivist during the day and available by phone at night. some community docs also manage their own admissions.

Just curious, is it manned by EPs or FPs?

 

[deleted6669]

Just curious, is it manned by EPs or FPs?

a mix of both. docs do 12 hr shifts without overlap and a pa is there as double coverage during the day for 8 hrs.
of my 4 jobs this is my favorite. docs are always happy to have the help and willing to let me do anything I feel comfortable with and walk me through more challenging stuff that I may be less familiar with. on slower days the docs go take a nap and I run the dept and wake them up as needed.

 

[deleted109597]

Thanks for all the replies! Definitely some interesting perspectives. I was a little surprised about the backup thing. I just assumed that the PCP or whoever did the admission (hospitalist, PCP on call for the group, etc) would handle issues in the ICU. Do rural ED docs do in house codes over night

Yep. All codes all night.

I noticed just in a brief Google search for EM jobs in my area (SE state medical school with a number of surrounding regions that are substantially rural) that some places over the choice between 12 hour shifts and 24 hour shifts. What's with the 24 hour shifts?

As emedpa mentioned, these are low volume shops.

 

[Birdstrike]

We do all the codes at night where I'm at and I'm at a level II trauma center and we are busy as h--l. It's more than annoying when you're trying to run a busy ED at 4am, single coverage and you have to run up stairs and code the patient of some doc that has a blatant history of refusing to respond to ED consults and floor nurse calls and the administration refuses to do anything about it because that surgeon "brings lots of business" into the hospital. Tag that under "stuff they don't teach you in residency".

"Call the code team!"....wait "I am the code team!"

 

[NSAIDAllergy]

Don't look so much at ED volume. Rather, look at the doc to patient ratio. An 80K ED with 60 physicians in their employ is impressive. However, a 30K ED with 8 docs is also impressive. Remember, tertiary referral hospitals get said referrals from somewhere. Many times it's the "little" community shop often rural. Pathology doesn't maintain an address.

Granted, you're not going to find a rural knife & gun club. But that stuff isn't too complicated to manage anyway.

"Call the code team!"....wait "I am the code team!"

much truth here

 

[deuist]

My large shop (90,000 visits) still runs all codes on the first floor---same floor as the ED. That includes the radiology suite. Luckily, we have 4-6 attendings in house at all time and only one has to respond.