Middle of Nowhere

(I know, I know, this commentary doesn't have a lot to do with the episode per se, but I started writing and discovered that I didn't have much to say about the medicine. Soooo.. I've decided to focus on one problem associated with rural medicine. Anyone wishing to complain about this is invited to do so.)

I remember reading, shortly after this episode aired, comments in alt.tv.er about how silly and impossible it is that the nearest hospital from a settlement is 70 miles away. And I remember scoffing loudly at that, but maybe that's because my experience is slightly different than those of American readers. (If the post was referring specifically to Mississippi, then I apologize.) Part of the joys (?) of living in Canada is that we're a big country. Very big. 300, maybe 400 miles away here. We're not the only place that has this problem -- Australia springs prominently to mind for some reason. (Hi, Chris!)

Imagine this: you're in southern Alberta. You're a good 150 miles from the nearest hospital. You've just had a patient who got sucked into a combine, and while he's kinda stable, Jethro the paramedic doesn't feel like driving the guy into Calgary with the siren going -- it's going to be three hours, and Jethro is kinda deaf as it is. What do you do? Easy: you pick up the phone, call the Shock Trauma Air Rescue Link Center, and say, "I need a helicopter." A bunch of guys in dorky blue flight suits then get into their big red helicopter at the Calgary International Airport, fly over to Foothills Hospital, yank some unsuspecting doctor out from his or her carefully controlled environment, stuff them into a flight suit and hand them a helmet, and throw them in the helicopter. Lifting off from the classic example of where not to put a helipad, they fly south to your piss-ant town and land in a parking lot or a field somewhere, knocking over everything that isn't tied down and scaring the snot out of the townsfolk, who haven't got a clue what's going on. They steal your patient, you thank them profusely, and they rise into the sky, returning from whence they came, like modern-day angels. (You know, sent from above and all that junk.) The helicopter goes north, lands at the world's worst helipad once more, and the patient gets processed in Foothills' ultra-modern emergency department.

I'm waxing dramatic (and exaggerating considerably), but air transport is the only solution for acute, unstable patients who are a long way from a hospital. Whether you fly them out by helicopter or by fixed wing aircraft depends on the specific situation, but the reasons the same. "Helicopters," one textbook notes, "are fast ambulances, curising at 125 to 175 mph, depending on the aircraft. The usual flight range for a helicopter is 150 to 200 miles. They do not have to stop at traffic lights and are not limited by the quality of roads available." I don't mean disrespect to Dr. Daniel Hankis, and the publishers and editor of Emergency Medicine: A Comprehensive Study Guide, but.. DUH. Of course they're fast ambulances. Of course they don't have to stop at traffic lights. What is this, glaringly obvious day or something?

[pause]

Okay, I'm better now. Long transport times throw monkeywrenches in the emergency medical system. The basic issue is that trauma patients need to be transported to an appropriate facility as quicky and as efficiently as possible, and in most rural situations, that means using aircraft. Many people have tried to establish rules about when air transport should be used, and I think the best guidelines come from the National Association of EMS Physicians:

When transport time is greater than 15 minutes by ambulance.
When transport time is greater by ground than by air.
When patient extrication time is greater than 20 minutes. (MVA pts.)
When utilization of local ground ambulance leaves community without coverage.
I freely admit that several of these are regularly ignored by many services in many communities, and one of them (the one about ground transport time being more than 15 minutes) I flat-out don't agree with. I'm unconvinced that the use of air ambulances within an urban setting is particularly useful, but I don't dispute its importance within rural medicine.

Why did I just spend all that time talking about air evacuation? Two reasons. First, because this is my commentary, I can talk about whatever the hell I want, and I like airevac work. I like flying, period, and if you throw in some medicine, I'm about as happy as I get. (Pathetic, I know.) Second, because I was thinking about Benton's four year-old patient, ejected from a tractor. 70 miles in the back of an ambulance while bagging someone is not my idea of fun, and not just because of the resuscitation part. (I dunno if you've ever been in an ambulance in a non-patient role, but lemme tell ya, it's very easy to get sick while riding back there.) I don't know anything about Mississippi's EMS system, but 70 miles to go with an unstable pediatric patient is a pretty good candidate for transportation by flight.

So, on rural medicine. I'm actually surprised Benton did so well. Some people, like the gang on "ER," need hospitals to justify their existence; in Benton's case, he needs a big hospital to justify his existence. It would be pointless, for instance, for a cardiothoracic surgeon to open a practice in Norman Wells (I bet you don't know where it is either) -- not because one would never be needed in Norman Wells, but because the demand is so low and infrequent that it isn't worthwhile. The local medical infrastructure won't support it, either, and while it would be great to put trauma surgeons all over the place, it just isn't cost-effective. The best rural practitioners are, quite obviously, general practitioners -- good at lots of stuff, excellent at none. :) All kidding aside, given a bit of specific training in advanced life support techniques and patient stabilization, and they're ready to be community docs.

A part of me -- the part that doesn't require a hospital to justify its existence -- finds the idea of living in a small community and being the town healer to be very appealing. I suspect it's the part of me that contains my six-mile-wide romantic streak. The other part of me, the part that does require a hospital, reminds me that I'd hate it after six months, if not sooner. :)