Dr. Parker, who also serves as the medical director of the Patient Transfer Center at Riverside Health System, noted that capacity issues have made patient transfers from rural to more comprehensive facilities more difficult, often with extended delays, underscoring the need for a physician to identify critical emergencies and manage them on site for hours, even days, while awaiting transfer.

Dr. Parker asserted that in some cases it is better for the patient to be transferred by EMS directly to a facility that can manage their critical needs, even if that takes an extra hour, than it is to take them to a closer rural ED where they will only be seen by a PA or NP. According to the Emergency Medical Treatment and Labor Act (EMTALA), once they arrive at that rural ED, they can’t leave it until there is an accepting physician at a hospital that has a bed available for that patient.⁷ That could take hours or days, Dr. Parker said.

Viktoria Koskenoja, MD, who practices in the ED at Baraga County Memorial Hospital, L’Anse, Mich., population 1,873, was trained in emergency medicine in urban settings before relocating to Michigan’s Upper Peninsula.

Dr. Koskenoja

“I started seeing egregious mistakes that were made in a department where there was no physician present,” Dr. Koskenoja said. Those mistakes included patients who were transferred unnecessarily to her hospital. If there had been a physician at the department they were transferred from, they wouldn’t have needed to come all this way, she explained.

According to Dr. Koskenoja, who is past chair of ACEP’s Rural Emergency Medicine Section, a line should be drawn requiring a minimal level of training in an ED, no matter the hospital’s size or location.

“In my opinion, that line is medical school and residency training,” Dr. Koskenoja said. “There were two occasions I personally know of where a chest tube was needed for an emergency patient because of a collapsed lung—and it needed to be addressed immediately [but wasn’t]. One time the PA working in that hospital said they just didn’t know how to do that.” She also cited a missed ectopic pregnancy and two cases where time-sensitive ST elevation myocardial infarctions were not diagnosed as examples of insufficient diagnostic skills in rural EDs without physician presence.

What’s Really Going On?

In ACEP Now and elsewhere, there has been an ongoing dialogue about whether there are too many or not enough emergency medicine-trained and board-certified physicians to fill every hospital’s staffing needs, current and future.⁸ In 2019, 20 percent of emergency medicine residents reported some difficulty finding a job in a preferred geographic area or at a salary they anticipated or wanted.⁹