Rural ER problems

[medicgirl05]

My local ER, is a small ER with very limited capabilities. The doctors that work there are NOT ER doctors, most of them are just primary care doctors who are moonlighting and haven't been in an emergency environment in 30 years or so. There are some that are VERY good doctors as well.

Now I can respect the doctors that know they are in over their heads, they reach out to us and let us give input when they are unsure of something. We "help" with all codes, and if they are busy we help triage. 

My issue is, there are doctors that are too prideful to ask for help. 

For instance, one night we had 2 codes working at the same time. We had been busy all day, when the ER settled down they had only one patient. The patient was on a ventilator after we had RSI'd her. She was relatively stable. We decided to go back to the office so we could get a little sleep while waiting for the ER to arrange a transfer.

When we came I walked into the patient's room to see how the patient was doing. I found this person still intubated, rails down, eyes wide open, thrashing around on the bed. This person had disabilities which would cause the inability to understand things on a normal day. I tried to calm her and hollered for more sedation. The ER dr refused. I persisted, and he asked my partner(a basic) how much fentanyl he should give. I was not opposed to the fentanyl, but it is cruel to keep a patient awake and intubated. A nurse gave the fentanyl which did nothing. The patient had tears running down her cheeks, I was trying to comfort the person the best I could. This went on for about 15 minutes. At one point the patients guardian was in the room and the dr walked in. I lost my cool. I told him to either extubate or sedate. There was NO reason not to sedate. My supervisor arrived and told me to take a walk, which was needed. Eventually the paperwork for the transfer came in and I prepared sedation as they loaded the patient in the ambulance. The patient was sedated, causing an almost immediate improvement to her vitals. She made a full recovery.

This same doctor needed me to explain the pharmacology behind sodium bicarbonate as well as the dose after I suggested it while working the code, he ordered midazolam about 2 minutes after he ordered and a nurse administered Versed. He had no idea they were the same thing.

My issue is this, I am not at all claiming that I am smarter than any dr. I do however think I have more knowledge and experience in emergency situations than a few of the moonlighters.

Is this something that is a problem at all small hospitals? How do you handle it?

 

 

[Off Label]

This type of things isn't limited to the ER in Critical Access/rural hospitals. There is a reason why these are referred to as "underserved" areas. Low reimbursement for physician services at these hospitals as compared to more "desirable" areas means that board certified specialists and sub-specialists cannot afford to live and work in these areas even if they did consider the quality of life acceptable for them and/or their families. That means what you sometimes end up with are folks that can't work in those more desirable areas because of some problematic element in their work history or younger less experienced physicians coming out of their training that are there as part as a "pay back" for financial grants for their training. They can leave after the agreed upon time frame.

It is kind of scary sometimes, but in my experience with rural access hospitals, the administrators are desperate to keep the doors open (as they should be) and if having a physician on duty is a requirement for receiving the critical access federal dollars, being able to fog a mirror may be the only other requirement for working at some places.

 

Good luck.