RURAL EMERGENCY MEDICINE

What’s in it for you?

 

With more and more EM training being conducted in large, city departments, the idea of moving to a smaller, rural department might be a bit daunting. But experiencing life without tertiary specialties down the corridor can be quite refreshing.... here’s why!


This information is prepared primarily for potential candidates for our Clinical Fellow posts, but we hope it will assist anyone wondering about making a leap to try life in a small-town ED. You definitely haven’t experienced all there is to offer in EM until you’ve tried it!

If you currently work in a city, you might never have thought about the challenges of working 100 miles away from tertiary services..... but consider the following:


Time with your boss


Small department = close working with consultant colleagues = time for reflection and chatting and starting to gain an appreciation of management issues, organically and for real..... not just in an artificial package to get you through the FRCEM.


Interesting caseload


Rural department = trauma cases of the like you just won’t see in the city.... “Man versus bull” with severe chest injuries..... 100-foot falls from rock climbers.... drowners (a few every year).... even the occasional pig attack or farmer who’s garotted himself driving into a wire fence whilst rounding up sheep on a quad bike. Which, last time we looked, wasn’t a common presentation in Liverpool, London or Leeds!


Our Clinical Fellows (most of which are predominantly city-trained) have been astonished by the amount and variety of high-acuity patients we see - and specifically said we should mention it on these FAQs! And in case you are wondering about major trauma, you’ll get your fix here.... we are too far from our regional RTC for many severely-injured patients to bypass us, so it nearly all has to come to Bangor just as it always has. Only a few daytime, nice-weather cases get bypassed straight to the MTC.

Interesting stuff doesn’t get pinched by the super-specialists down the road...


Rural department = using your medical skills in a way that you may have forgotten how to do.


We only recently stopped routinely thrombolysing MIs when our regional PPCI centre finally went 24/7!


Ditto strokes.... in our ED, we need to see and assess them, and set in motion the wheels for thrombolysis, which some urban hospitals don’t do any more in areas where stroke patients bypass DGHs for the stroke unit.


We have found a number of our Clinical Fellows have hardly any experience of managing acute myocardial infarction, as they have never had the opportunity to do so. We can fix that hole in Bangor. 


Sick patients, long transit times...


Rural department = very large catchment area (there are more sheep than people in much of our catchment area!) with potential for long pre-hospital transit times.... there’s plenty of time for patients to deteriorate en route as their disease process progresses. It can take 90-120 minutes to drive by road from the outer edges of our catchment area if road conditions are bad due to snow or tourist traffic! We receive a lot of very sick patients via helicopter, both from Welsh ambulance’s Helimed, and the SAR helicopter, now operated by Bristow on behalf of the MCA.


And yes, this does mean that you have time to go to the loo (or sometimes even go for lunch) between the pre-alert phone call coming in and the patient actually arriving. Which means that, even at night (when the middle grade and seniors are on-call from home) it’s very likely that a badly injured or very sick patient will arrive to be greeted by experienced staff, as your consultant will have arrived from home by then!


Opportunity to use your brain: less tickbox medicine, more clinical freedom


Rural department a long way from tertiary services = time to use your brain.... a burned hand from Dolgellau, at the South of our catchment area, has already had a 50 mile drive to hospital, and it’s another 100 miles to Whiston hospital in St Helens where our regional Plastics centre is.


Do they really need to go? Or can we actually manage the patient within ED skill set?


How about the corker that actually happened: what would you do at 10pm on Sunday night with a 16-week old baby with complex congenital maxillofacial abnormalities, whose mum had slipped on the stairs and dropped him down the whole flight, who’s got a GCS of 13 and needs a CT... but he won’t keep still and he’s got the airway from hell and the weather is so awful that even the RAF (it was a good few years ago!) might baulk at doing a SAR helicopter transfer, and your friendly neighbourhood anaesthetist points out that even the regional Children’s Centre (in Liverpool) would call in their Infant Difficult Airway anaesthetist? (which, clearly, we don’t have available in Bangor) .


The answer of course is to call your friendly on-call ED consultant (who still has nightmares about that case 11 years later!) because....


The perfect place to spread your wings


Small department = friendly, supportive department (or at least it does in Bangor!).... we hear time and again from our ST4s and Clinical Fellows that they feel well supported here. We’re actually pretty good at helping new middle grades find their feet... we will let you have enough leash to feel challenged and let you cut your middle grade teeth, but we’ll never leave you unsupported or give you so much leash that you hang yourself! And we’ll give you specific support with the aspec
ts of the job that may be new to you such as Obs Ward rounds, and checking results.


We’re also pretty good at helping you through the almost adolescent-like feelings and frustrations that can accompany this stage in your career, as you spend your time ricocheting between “unconscious competence” and “conscious incompetence”!


We also have a track record in supporting newly-appointed consultants. We don’t have any dinosaurs and we all remember what it’s like starting off as a brand shiny new consultant, and we can support you through that process.


Part of the community


Small community = feeling part of the community. This is the only DGH in 40 miles. We end up treating (and, if we’re ill or injured, being treated by) our colleagues and our friends - we have to, there’s no other hospital immediately to hand.


When something bad happens, it can affect a surprising number of people. Yet when you do a good job, and you get a thank you letter from a colleague’s mum/brother/sister, it really means something. And you get to build up a network of friends and family very quickly indeed. The paramedics that you see in the ED will be the same ones you work with on the road, and some of your work colleagues from other specialties may pop up with the Mountain Rescue Teams or RNLI and you’re likely to meet them if working with Welsh Ambulance or EMRTS. 


We actually like going to work. And we enjoy ourselves.


Small and friendly department - there’s always room for a bit of eccentricity, and though we take providing excellent emergency care very seriously, we do like to have a laugh at work.


Where else would you find a website with a cake page, or an F2 dressed as a caveman at the ED “Hub” (so-called because we love Torchwood, and “staff base” is just so DULL), or teaching a hip reduction technique whose name was inspired by an alcoholic beverage? Having said that... the important stuff like patient safety & quality of care - we take very, very seriously!!!

 

Above:

F2 doctor dressed as a caveman. In the ED. For real. Actually, he was modelling for a conference poster (see “Stuck in the Stone Age” in our poster section) but we suspect this may be classed as an unusual sight for an ED.



Right:

Consultant Linda teaching a Clinical Fellow (who says he wishes to remain anonymous - black bars work so well don’t you think?!)  the Captain Morgan technique for reducing dislocated hip prostheses.

We even have protocols featuring pooping cows!