EDITOR’S NOTE: By the time you read this story, Belhaven, N.C. Mayor Adam O’Neal and 15 others, including iconic civil rights activist Bob Zellner, will be in the general vicinity of Mechanicsville, Va., walking their way to Washington, D.C. to call attention to the plight of America’s rural hospitals. O’Neal and company are expected to arrive in the nation’s capital on Monday, completing a journey of 283 miles. The following is a transcript of a segment on Monitor Monday by Ronald Hirsch, MD, about the mayor’s walk and the role rural hospitals have in America’s health system.

On this week’s Monitor Mondays, we were honored to be able to hear from representatives from our nation’s rural hospitals as they rally in Washington, D.C., drawing attention to the 283 rural hospitals nationwide that are facing possible closure.

Many of us are lucky to live in major metropolitan areas, where there are almost as many hospitals as Starbucks (Manhattan alone has 17 hospitals, with 57 in New York City’s five boroughs), but next time you take an airplane flight, look out the window and notice all the small communities that seem to exist in the middle of nowhere. Are the residents of these communities less deserving of healthcare than those in urban areas? Would you want to have to drive 100 miles with acute appendicitis (smooth roads are tough; imagine the pain of a pothole-filled rural road) to get to the nearest hospital?

Rural hospitals have their limitations; a rural hospital is not where you want to go for a heart transplant. But they are aware of their limitations and have transfer arrangements for patients with complex illnesses. Yet most healthcare provided in hospitals is not that complex, and those patients with a complex illness often need stabilization, which can mean the difference between life and death. And because rural hospitals do not have the advantage of the economies of scale, their payment structure needs to be different.

When we picture a rural hospital, we all imagine a small building with a few beds in the emergency department and an empty waiting room, with a couple of patients with minor illnesses receiving care. But that is not the reality.

The following was posted last week on Sermo, a physician-only online discussion group, by an emergency medicine doctor: “I recently survived a very busy shift at my eight-bed emergency room at a small critical access hospital. In the first five hours of my night shift I saw 25 patients, including one acute myocardial infarction (MI) patient given thrombolytics and transferred; two hemodynamically unstable complete heart-block patients who were transferred; three surgical abdomens (including ruptured diverticulitis, ischemic bowel, and appendicitis), two of whom were admitted to surgery and one transferred; one diabetic ketoacidosis (DKA) presenting in coma with initial pH of 6.61, who we intubated and admitted to the ICU; one hip dislocation and one shoulder dislocation, both given procedural sedation for closed reductions and then discharged home; and one ascending aortic dissection for whom I placed a central line, started IV drips to control the blood pressure, and then transferred. At midnight, the four nurses and I were juggling the dissection, the MI, the DKA, the hip dislocation, and two of the surgical abdomen patients all at the same time. All of the patients survived and were successfully managed during and after leaving my emergency department.”

This is not the typical day at a rural hospital, but it does happen now and then. Now imagine what would have happened if that rural hospital was not there. Eight of the 25 patients seen by that doctor may not have survived. I’d call that hospital’s role in the health of that community crucial. And while the majority of the country’s population does not live in rural areas, and the next breakthrough in medical care is more likely to come from a large university medical center in an urban area than from a rural hospital, any one of us may need a rural hospital on our next trip driving across our great nation. The people in those communities all count on those hospitals and they all deserve our support.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians. 

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Register to listen to Monitor Mondays, June 15 with CMS Regional Administrator John Hammerlund discusses highlights from his recent Rural Health Open Door Forum.


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