5 Dark Sides Of America You Only See As A Small Town Doctor
Hey, remember Doc Hollywood? No? Nobody? Okay, well, imagine all the drama of your favorite ER show, but with a skeleton cast of occasionally unqualified people in a town so remote that they only have one Starbucks. Or god help us all, no Starbucks at all. That's the reality of rural medicine. We talked to Sean Conroy, a physician assistant working in "middle-of-nowhere Kansas," about what it's like to be a real-life Doc Hollywood. After we finished explaining to him what that was, he told us ...
Your Town May Not Have A "Real" Doctor At All
First of all, there is no physician for our physician assistant to assist. It's Sean or bust: "Mid-levels [healthcare professionals who are not MDs] are a godsend to the rural areas in regards to providing healthcare to people who would either have to drive a long distance to see a doctor or would be unable to do so at all."
There are many offices where the waiting room is mere yards away from where the cows shit.
Forget about whether there's a doctor in the house; there may not be a doctor in the whole damn town. "My first job in a rural area, I was hired to join another PA in a town with no doctor," Sean continues. "Legally, we have to be able to contact our supervising physician in 30 minutes. We were in damn near Colorado, [while] our supervising physician was in Kansas City, in damn near Missouri."
424 miles in a half hour? Surprise: Not every country doc has a G6.
This is technically legal, because calling someone still counts as contact, but in our experience, the words "technically legal" don't inspire much confidence. Luckily, Sean is so good at his job that no one would ever know.
"Us two PAs kept the emergency department [ED] and family practice clinic running this way for three months before we could con a doctor into moving to the boondocks and working with us," Sean says. "Even then, he did not stay long, as greener pastures called him away. The original problem was that doctors all started specializing -- pediatrics, ob/gyn, orthopedics. If you specialize, you need to be in a town with enough people [that] you can get away with just seeing the kids or the women or the joint problems. In the rural areas, they can't afford to pay all these specialists, so they don't exist out here."
The ER becomes the children's room becomes the colonoscopy lab becomes the enema table becomes the ...
Even GPs are scarce, because a bigger city equals more money equals crippling student loans paid off faster. "Instead, you get Sean to take care of the snotty baby, and Sean does your pap smear, and Sean does your joint injections and fracture care."
Hopefully not all at the same time. Unless he's a hell of a juggler ...
You Might Get CPR From The Janitor
If you live out on the far side of Chucklefuck, Michigan, you're lucky to have a medical professional at all. "EKGs [electrocardiograms] are real easy to learn to administer, and so everywhere I have gone, various people have been the EKG people," Sean says. "Many bigger hospitals have a respiratory therapist who is always in house to do it. If a small hospital in rural Kansas even has an RT, there is probably only one, and they have to sleep sometime, so good luck the rest of the time. That is when I get an EKG from a nurse, a CNA, David the IT dude, and the lab. Even though it has nothing to do with laboratory work, it is a machine, and they have been trained."
"Just one long, flat line? I didn't study for that one ... Eh, it's probably nothing."
It's a little like your grandma hearing you're good with computers, so she suckers you into running all her antivirus scans. Only with way, way more pressure: "My favorite worker who wore many hats was at my second rural job. Our IT guy was a 19-year-old computer technology major who was taking classes at the university 30 miles north of town. He was also an EMT and ran EMS in our county, bringing me fallen grandmas, heart attacks, car wrecks, etc. via ambulance. When he was working IT and a code was called, as an EMT, he would run down to the ED and help with running the codes, starting IVs, doing chest compressions, bagging the patient, getting EKGs."
"Have you tried turning her off and on again?"
"Hats fly all over during codes, too," Sean continues. "Usually, if there is one code going on, no problem. There are enough nurses and CNAs, providers, lab, etc. to do all the necessary roles in running the code. Two at once? Now you are spread thin, and the next thing you know, you have laundry in the back of the room taking notes, calling in extra nurses, the dietary ladies are talking to the family to keep them calm, and the maintenance guys who know CPR are switching out tired chest compressors."
Take it easy! The janitors have a vested interest in keeping you alive. They're the ones who have to clean up the mess if you kick the bucket. Plus, it's probably their bucket.
In A Small Town, Everybody Knows Your Medical Business
Enjoy medical confidentiality? Not if you live in a town that only dreams of a stoplight. "If you see your neighbor head off into radiology, and the only rad tech who does ultrasound is the one taking her back, it doesn't take but half an hour [before] rumors of a new pregnancy are sweeping across town, despite everyone doing their part for privacy," Sean says.
Snitches talk about the sonogram news they heard while in the waiting room for their stitches.
If you're thinking "So what?" then you're forgetting how connected a small town can be. Maybe that woman's ex-mother-in-law happens to be the receptionist. Maybe she's going to tell her son. Maybe you've inadvertently kicked off enough drama for a season finale when you called that patient's name.
Sean says, "When I started my first rural position, there was an EMT who ran EMS for us whose son was diverting his grandmother's Oxycontin, which she had been prescribed for her terminal illness. Apparently, everyone in town but this little addict's parents knew, but as medical providers in the clinic and hospital, since the guy was over 18, we could not say anything to his parents."
Secrets don't stay that way forever, though. "I had never gotten a true drug screen on him, and was curious, so I got one off his urine," Sean says. "Sure enough, he was positive for pot, benzos, and narcotics. The results came in, and the nurse did not see the EMT hovering too close when she announced to me, 'Looks like he has added marijuana to his repertoire.' Well, the cat was out of the bag -- he was ripping his kid a new one before I could bring the labs up in my computer."
Lesson One: Don't steal from your grandma. Lesson Two: Always piss where the cows shit if you don't want to get caught.
Drug Addiction Is A Huge Problem, Even In Remote Areas
There is a huge pharmaceutical drug abuse problem in rural America, and Sean can tell you exactly why. "Typically, you need a major roadway to bring in heroin, cocaine, and the 'hard drugs.' In Kansas, where I live is right off I-70, but prior to this, I was a good 75+ miles from the interstate, and there, you just don't see the bad stuff."
Surprise: Not every country junkie has a G6.
Usually, this is where meth comes in, steals all the copper, and takes a shit on your pillow. But that again relies on having a good meth cook in your town. "Meth is bad out here, but mostly the super nasty trucker shake-and-bake stuff," Sean says. "We don't have Walter White making our meth. Instead, we have moms diverting their kids' Ritalin for a good upper. In lieu of heroin, we have 'hillbilly heroin' -- crushed Oxycontin that you snort or inject." Rural doctors have to be on high alert for drug-seeking patients, but on "the plus side, the purity is phenomenal, since it is all FDA-level pure. The bad news is you die just as fast from an overdose."
Oh, yeah, serious overdoses on prescription drugs are not uncommon. "I specifically recall a patient who was brought in to the emergency department at my tiny hospital in a town of less than 1,000 residents by a concerned passerby," Sean says. "I did not know her from Adam because I was new to town, but I know an OD when I see one. I assessed her, she was somnolent, but I could rouse her up to mumble answers to me, so I told the nurses to push some romazicon [a drug for treating drowsiness caused by sedatives] and narcan [for reversing the effects of opioids] to reverse the likely culprits. I no sooner got out to the nurses' station to try to open her medical chart when there was a 'code blue' called in the ED. I rushed back into the room, the nurses were bagging her, but she had a pulse, just wasn't breathing. Well, that was a relief. I asked if they had given the narcan yet, as it reverses oxy, among other things, one of which was the likely substance she had over-consumed. 'No, we gave the romazicon first.' I requested we hurry up and give the narcan, please with sugar on top."
Since the alternative was "six feet of dirt on top."
"The nurse had not even finished giving the IV of narcan when my patient rose off the table like Frankenstein's monster, holding her head. 'Owowow, this headache is killing me!' You see, narcan instantly binds all the opioid receptors, kicking the oxy out of them. It is kind of an immediate withdrawal, which sucks, but beats dying."
Here's the especially crazy part: The patient immediately started begging for more of the drug which had just temporarily killed her. "I politely informed her she had already had enough pain meds for today, and thanks to the narcan, it wouldn't work too well anyway. Less than an hour later, she was wandering down the street in her pajama pants and a hospital gown, looking for her next fix."
We're not saying "aspirin is a gateway drug" or anything, but don't think for a second that because a drug is legal, it's somehow less dangerous.
Rural Areas Have Unique Medical Emergencies
Sean's clinic deals with insecticide and herbicide poisoning so often that they "always have the reversal agents on hand, even if they do expire frequently and we throw them away a lot. The cost is worth it. One of the major points I remember in learning medicine in Nebraska was organophosphate poisoning and SLUDGE -- salivation, lacrimation, urination, defecation, GI disturbance, emesis."
Or in layman's terms: "Don't drink this."
We only understand two and a half of those words, so we'll take Sean's word for it when he says, "if you get into the right kind of insecticide/herbicide, you come into a very small ED falling apart." He meant that literally. Farmers can deal with some hardcore medical emergencies. See this?
That's a grain auger, and you do not want to get the wrong part of you in the wrong part of it. "[An] auger can chew a limb into spaghetti in no time," Sean says. They're built to last forever, "meaning some of it was made before safety was something people cared about."
See, a lot of old rural farmers don't wanna spend the money to replace perfectly good machinery just because the CPSC says so, and Sean gets to witness the aftermath. "Some very old tractors have no cabs, no roll bars, so you are pretty mangled when you hit the ED. [In grain elevators], the fine grain dust floating in the air only needs one spark to ignite. In rural areas, that grain elevator might be the tallest structure in town. If it blows up, the debris will make it a good distance, leading to collateral damage a ways away."
"If you can't handle me at my exploding-death worst, you don't deserve me at my cereal-making best."
While David from IT is frantically malware-scanning explosion victims in the lobby, Sean is chasing a tough-guy farmer through the parking lot, trying to get him to seek treatment. "If the farmer is not fully incapacitated, you might have difficulty getting them in for treatment," he says. "I had one come in one morning after he hit a rock in his tractor while crossing into a field to spray fertilizer. He had a bloodied rag on his head, explaining he had hit his head on the roof of the cabin. The bleeding had stopped rather well, but there was a flap of skin that did not want to stay down, exposing part of his skull. Come to find out, he finished spraying the field before he came in, so the flap had shrunk a bit. Furthermore, he refused to go to the for-real ED 19 miles away. I had suture material available, but he said the local anesthesia would take too long, and he had to get back to farming. I eventually talked him into letting me glue the flap down, [and give him] a bandage and some antibiotics to prevent a nasty infection."
You try being a rural doctor when every other patient thinks they can "walk off" a gaping head wound. No seriously, please try. They could use the help.
Sean literally wrote the book on rural medicine, and you can buy it here. You can also find him on Facebook and Twitter. If you don't follow Manna on Twitter, she can't be held responsible for what happens.
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