In the 1984 rock mockumentary This is Spinal Tap, a fictional band discusses the controversy surrounding one of their album covers. “There’s such a fine line between stupid and …” the lead singer says, realizing where they’d crossed the line of tastefulness.

His guitarist finishes his thought, “… and clever,” he says. In life, in rock and roll and in medicine, there is indeed a fine line between stupid and clever.

During my first month of practice, I was at the head of the bed in a rural ER, as Dr. Marcus Fredo stood a few steps away with his phone to his ear as he waited to speak to a trauma surgeon. The patient, a victim of a high-speed rollover, had a closed head injury and needed to get to a neurosurgeon. Stat. In trauma, doctors in rural centers have to treat patients thoroughly, while also recognizing their own limitations. Rural docs have to use clinical skill to quickly decide if, where and how patients will be transferred out to larger centers. Their patients need resuscitation and stabilization, but time can’t be wasted if their needs exceed the resources at hand. Conversely, rural doctors can’t just ship out every patient that looks sick.

Differentiating those that need urgent transfer from those who don’t is one of the many great challenges that rural physicians face.

The patient, a husky biker in his mid-forties, was barely conscious. Fredo suspected a head bleed, but the closest CT scanner was at a larger hospital, thirty minutes away. However, that hospital didn’t have a neurosurgeon — and why bother with the test when you can’t treat the problem? Hence, the decision was made to intubate the patient and transport him to a hospital two-hours away where the CT scanner came with a trauma team and a neurosurgeon. If there was indeed a bleed, the neurosurgeon could drill a hole into the patient’s skull and relieve the pressure.

The patient had also been scalped — his hair had been ripped cleanly and was clinging by an island of skin like a toupee in a convertible on a windy day. This is where I came in. The doctor had called me to tack his rug of hair back into place — a menial task perfect for a new recruit. As Fredo listened to Muzak and waited for the teaching hospital to take his call, he told me about a patient he transferred years before as he was starting his own career.

The patient was in his late sixties and had a complicated medical history: uncontrolled diabetes, a couple of heart attacks and emphysema. Along with this, he had an aneurysm — a swelling of his aorta in his abdomen. It was found a couple of years earlier, and periodic ultrasounds had shown that it was growing steadily. And as it grew, the aorta wall stretched out and weakened like a balloon inflating to the point of bursting. He was awaiting surgery at a university hospital and had just had his preoperative assessment. “In the meantime,” his surgeon had told him, “if you suddenly have severe pain in your belly, get to the closest ER. Fast. If that aneurysm ruptures, it can be fatal.”

Fredo put the phone on a counter and hit “speaker” as he continued his story. “So this guy comes in, writhing in pain. His wife shows us all his records and tells us he needs to get to a vascular surgeon as fast as possible that his aneurysm had ruptured. She even tried to call an ambulance from inside the hospital and asked if it could take him to the city. “The guy’s got a surgical belly,” Fredo said, “firm, tender everywhere, he’s guarding. I can barely touch him. His heart rate is through the roof. I ask him a few questions — he’s passing gas and pooping normally, so it’s not a bowel obstruction. His gallbladder’s been taken out, so it’s not that either.”

“His blood pressure?” I asked.

“Blood pressure was normal,” he said, “maybe a little high, but I wasn’t going to wait around for it to drop. So I call down to the city, and the vascular surgeon says to send him down right away. We grabbed a couple of units of unmatched blood, a box full of drugs, threw in two IV lines and jumped into the ambulance.”

“Oh God,” a nurse said. “I remember that.”

Fredo held up a finger to the nurse and smiled. Hold on. Don’t give the story away.

“So the entire time we’re in this ambulance, the patient is screaming in pain. He’s sure his aorta has ruptured, and that he’s going to die. It’s a two-hour ride, and his heart rate stays up the whole time, but we’re pumping him full of fluids, so, we think, we’re keeping him afloat — his blood pressure isn’t dropping.”

“More than afloat,” the nurse said.

“As we pull into university hospital, we do a final check — have we done everything right? Staff members at larger centers often look down on rural hospitals, and the worst thing is to be criticized for being sloppy or for cutting corners. There was one thing we hadn’t done — just for the sake of completeness — that we decided to do as we were parking in the ambulance bay.”

“A catheter,” the nurse said.

Fredo is laughing now. “So we put in the catheter and almost immediately, the poor guy drains three liters of urine. On further questioning, it turned out that along with an aneurysm, he had a long history of prostate trouble. Needless to say, when his bladder emptied, his pain disappeared.”

The nurse laughed with him. “We sneaked out of there fairly quickly.”

An hour later, the biker was transported out, and three hours later, he was in an operating room where the pressure was relieved from his skull. And although he had a long postoperative course that included infections and rehabilitation, he made a full recovery.

Raj Waghmare is an emergency physician who blogs at ERTales.com.

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