— For some perspective for my friends and trainees back in the safe zone. —

I find myself venturing farther and farther out of my comfort zone.

I am slowly drifting farther from the safety net I once knew, and as much as I Love it and re-emphasize to myself that THIS is why I do it, I find myself constantly questioning my actions. Training to be a doctor in the US in a large medical center, meant being in mostly situations where we had ALL the resources, ALL the time. It was so easy to call a specialist about a problem, or ask for more help if I was overwhelmed. We were used to receiving all sorts of patients – the best of the best, the worst of the worst. I remember as a trainee hearing phone calls from clinics and hospitals and emergency rooms hours away with questionable cases – aka, we thought they were frankly “dumb.” I loved the good ole “Bronchiolitis patient on Room Air” or the “Baby with a Heart Rate of 160” – by the way, for the non-medical, the first one is usually able to go chill at home and the second is normal. But, I was comfortable knowing that I had EVERYTHING where I was, and it was easy to see it only from that one view. Now, I’m completely on the other side of the token, and my eyes have opened so much. I no longer question why we got those phone calls, even for the ones I would have sent home from my ivory tower.

I have found myself a couple of times in the last few weeks alone in situations in which I had to contemplate my next move on limited resources and also my management based on what would happen next or the fallout of having to transfer someone far away. I have walked through the Emergency Room of increasingly rural areas where the providers saw kids come in, every now and then, but are extremely uncomfortable with children. Absolutely, of course, nothing against them – they’re amazing at atrial fibrillation in a 70 year old with COPD and Diabetes, things I know almost nothing about these days. But, I can understand so much where they’re coming from, and I understand so much all of the desperate phone calls I received as the House Officer in Residency hearing information about an incoming patient. “The kid just needs to be watched overnight, but we can’t do that here.” “The kid’s heart rate is 180, my average patient is usually half of that.” I’m calling because I need Help.

I remember seeing an obviously sick, very dehydrated, listless toddler in an emergency room 2 hours away from a large medical center, her labs indicated remarkable inflammation – we had nowhere to admit her, the staff rarely placed IV’s in her age. A premature baby born that required respiratory support with positive pressure ventilation (basically would require pushing oxygen into through a face mask to inflate the little lungs)… in a setting without the normal equipment most facilities have to do this – we rigged a ventilator to a mask to attempt the same effect as I talked my adult respiratory therapist and Labor nurse through how I would intubate if that didn’t work… We were lucky, the helicopter team made it there before we needed to and brought their own PPV (Thanks Women’s Hospital of Texas and my awesome Airlife team). A baby with low blood sugar that was on the brink of needing to transfer for an umbilical cord catheter, that I was able to improve and move away from this point, until a heart murmur popped up out of nowhere and I began to suspect a congenital heart condition – we had no machine for an Echocardiogram or Heart Ultrasound, but we’re now failing our congenital heart screen and our blood pressures are not what they’re supposed to be.

So many new questions I’ve come to ask myself that I didn’t realize before:

• Is this emergent? Or can it wait?
• Can we afford the time to go by ground or do we need a helicopter? Do I even have access to helicopter?
• It’s 8 in the morning, the ground would probably be safe but with traffic it could take 2 hours?
• Should I intubate… Just because we’ll have to travel anyways and it’ll be safer?
• How far can I go to avoid separating this baby from their parents?
• Where exactly is my boundary of skill? My boundary of resources?
• How long is too long to wait?
• Do I call prematurely and look dumb? Or do I wait too late and look reckless?
• Will my alma mater look at me as a fool for sending this kid to them? (I remember when I was on the other side of the phone call)
• Wait, who do I call again? What do they need me to say to them?
• What should I do now for THEM, the receivers? What labs are my missing? Did I save the Xray to a disk?
• What if they need more specialists?
• How do I choose what hospital they go to?

I am not afraid to ask for help, but I also try not to take advantage of this lifeline. My job, afterall, as a Doctor, is to Think about things; but, if that’s not enough, I’m not arrogant enough to avoid asking for a second opinion. I am slowly learning how to think on my feet, to take everything above into perspective and come out with a consolidated decision hopefully looking from multiple points of view.

I am no longer catching the ball, but i’m throwing it. I just hope that my feet are grounded, my options are weighed and my aim is straight so that I can get the ball where it needs to be. I love seeing from the other side, so that when I’m back on the receiving end, I can have some grace and humility.

P.S. Kudos to my friends that are more rural than I and endless thanks to the first responders and flight teams and ambulance crews that come to help us out in transporting patients.