Go West, Young Man, Go West

by Richard L Stennes MD MBA FACEP
Past President ACEP 1985-86

The year was 2000. Thirty years in San Diego in the exciting practice, business and politics of emergency medicine was enough; so sayeth my wife. Time, it was, for a change in “scenery.” Her professional traveler’s vision had me as a cruise ship medicine physician and us continuing to see the world. We did, intermittently, for fifteen fascinating years of maritime emergency medicine and icebreaker expeditions to the Arctic and Antarctic.

My vision was a little different. I had, from my San Diego operations, instituted staffing in my rural Minnesota hometown emergency department (ED) in 1992 with intent to bring on full-time practitioners of emergency medicine (EM) and ultimately, physicians credentialed in EM. It was time to return and participate as a rural Locums emergency physician (EP).

What is different about rural EM? Trauma visits aside from auto accident victims are more farming or sporting related injuries from runaway four-wheelers, speedy snowmobilers, hunters falling out of deer stands, fishing misadventures, the occasional gunshot (sometimes accidental) or stabbing, and the rare severed femoral arteries from a drug deal gone bad.

The place I work has incoming helicopter traffic since we have interventional cardiology but most helicopter response in rural America is outward. You must use your well-honed broad extant skills to resuscitate, treat, stabilize, and move the patient on to definitive advanced care. The expectation is that you do all that you can do within your abilities, then call for help or refer.

The Mayo Clinic in Minnesota is a major referral center for the region and the world. Where do their patients go when acutely ill? They go to the place where the lights are on 24/7 and they trust that someone like you is waiting and often they arrive with a condition that you can’t even spell. A “simple” complaint like “something is wrong with my LVAD” is common!

For me, it is a lot more as I hail from there which means folks come in who knew me in youthful times, or knew my parents, brothers, or were from a nearby farm. For example:

Nurse Jane comes to me, with her twinkle in the eye, and says “The lady in room 2 wants to know if ‘little Ricky’ is here today. The lady exclaims, “we lived on the school bus route, remember the farm with the green barn”. The conversation on old times goes on and she seems to forget what was wrong with her.

An older man, about my age, comes with notable respiratory distress and gets the usual treatments. With improvement and upon my reexamination, he says: “Richard it is great to see you again. Remember me, I graduated high school with you.” I stopped by the mirror to see if I looked that old while thanking God for large favors in successful treatments and more youthful aging!!

Opiate OD’s are common in rural America. Early on I observed nurses trying to extract a big toneless and nearly apneic patient from the seat of a car. “Hold on” says me, remembering a learned trick from early San Diego days. Take the Narcan to the patient and then they can get out themselves…or just drive away as they often did while offering expletives in appreciation.

One of the best for me were Native Americans who had my mother as a second-grade teacher. “Stennes” they would note from my nametag. “Was your mother Ann? She gave hope and meaning to my life” they would exclaim with tears. (The mother of one of our most outstanding EP’s, a tribal judge and frequent patient, was arguably responsible for a 9 to 0 Supreme Court decision that led to the option of Natives to operate Casinos.)

There are incongruities in the farmer vernacular in the form of the diminutive that you need to understand. A talented backhoe operator, who cleared land for me before his multiple cardiac stents, presents. “What were you doing when the pain reoccurred?”

“Pounding”.

“You mean with a hammer?” “Sort of.”

“What do you mean sort of?” “Were you pounding with your sledge-hammer on some pin on your caterpillar tractor?” I ask with a bit of knowing smirk. A small wink and smile were affirmation. (One of the vistas that he cleared for us at the resort has his name on it)

You might ask, “If the demands for my EP skills are similar to the big city, what then is so great about rural medicine. Lifestyle?”. It is mainly in Lifestyle.

Like many of my colleagues (and their spouses), I have roots in the community. We have a resort that has been in the extended family since 1946, when I was two. I have all the farm “toys”. What better way to end a life and death decision making day than to maneuver my eleven-foot lawn mower with a major mindless decision being to which side of the tree do I mow. The decision makes no difference, except if you hit the tree.

Absent your own resort, you can easily go pontooning on a lake while fishing or making a barbecue, communing with nature while on a cocktail cruise or just silent on the still calm of the morning with the rising sun while relaxing and revitalizing.

Pollution free air and sparkling clear waters are extant features of country living, at least for me. It is personification of physical distancing for sure. This is where folks come to vacation and recharge. You can live it.

I look out and see the mesmerizing wonders of nature such as bald eagles, ducks, geese, deer and occasionally someone fishing (boat or icehouse). I drive 30 minutes to work while listening to EMRAP and see deer but no cars until town.

One of my colleagues bought a farm so that his kids could grow up where life lessons of independence, responsibility and self-reliance are learned, lived and are necessary for survival. Learned also are lessons on the vital importance of caring for and sharing with one’s neighbors many of whom likely are less fortunate than you are. I am eternally grateful that my father did the same for me and my brothers, moving us to the farm when I was about three. Chickens, egg picking, even a pig(s) or a cow(s) to milk or a horse(s), mowing hay, and chores attendant to farming and rural life are formative for kids. Perhaps a garden is your thing or maybe a few hundred acres just to play in. My neighbor took his kids (all five albeit one at a time) on his backpack as he trapped beavers or harvested wild rice or midwifed a calf delivery.

Should you be civic minded or politically inclined, you can start with the local township Council, if not City Council or a County Commissioner or school board. Or you can just go home to your secluded (or city) abode, enjoy nature and raise your family in the perfect environment….rural America.

Rural elementary and high school students regularly excel relative to national standards. All the usual sports are available for either spectator or personal participation. My town of 12,000 has a University. Delta can fly you through Minneapolis to anywhere in the world.

Was it Horace Greely who said “Go west young man go west” as that was “Manifest Destiny” in the 1800’s. In 2021 I say “Go rural emergency physician, go rural”.

Challenge, need, and opportunity to apply your extraordinary skills are there. Could it be your “Destiny”?  It was mine and remains so to this day.

And the cost of living can’t be beat.