The San Juans are an island chain in the US Pacific Northwest. We’re about 100 miles from Seattle but can only be reached by air or sea. I practice in the idyllic town of Friday Harbor on San Juan Island itself. The year-round population of my island is around 7,000, but we get more than a million tourists annually and our numbers have exploded lately with new “residents” hiding out from the pandemic.
We have a small critical access hospital with a highly functioning Emergency Department staffed full time by Board Certified Emergency Physicians and truly excellent nursing staff. Our department is busy, and getting busier, and we do amazing work in a resource poor environment. We have limited blood products, no ICU, no surgical or obstetric services, and no pediatric specialty care. There is no ambulance to transport patients by ferry to the mainland, so anyone who is sick enough to need care flies. I am extremely proud of the work we do and the lives we save here.
But there are things that keep me up at night. The community is small, and my life intersects with many others. My parents live here, my spouse and my children; I worry that I will be their doctor if one of them becomes critically ill or injured. I often see friends as patients, and the children of friends. I worry that I may make a mistake and let them down.
I worry about obstetrics. There is an unfortunate and growing movement for home births on the island that is terrifying. I fear that women who have elected this route do not understand the risks. I envision a peripartum or postpartum hemorrhage. We have a limited supply of blood for emergency situations. I have a scenario in my head that I envision bad weather, unable to evacuate via aircraft with fetal distress. What would I do? Use ketamine for anesthesia and perform a makeshift c-section with fetal resuscitation? I could use video assisted technology from mainland specialists for help, but I would ultimately be up to me.
And I have some true nightmares. I am most fearful of hemorrhaging patients. I had a scenario a few years back with a patient with an active GI bleed. He had a blood pressure of 60 systolic and continued to bleed; I gave him all the blood I had in the hospital and called for an urgent helicopter evacuation, and he continued to bleed. The helicopter, which carried a few units of blood, was unable to land due to weather and had to circle back to Seattle. Luckily the weather broke and there was a window of a few minutes’ time and we were able to get him to the mainland with the local fixed wing aircraft and save his life. We were lucky and he was lucky that he was in excellent cardiovascular shape, or it would not have been survivable.
These are the raw and real fears we have in rural emergency medicine that are often unknown to our patients and are carried by the health care providers at mine and similar facilities.