Recently, I was asked to write about my experience as a rural emergency physician in New Mexico. The timing was uncanny: I am in the final shifts of my first job out of my emergency medicine residency on the East Coast, having spent more than four years working in emergency departments across western rural New Mexico, primarily within the Indian Health Service.

Summarizing this experience concisely feels impossible. Every emergency physician I know agrees that your first year out as an independent practitioner teaches you more than all of medical school and residency combined. In rural emergency medicine, especially in a state like New Mexico with a dispersed and chronically underserved population and scarce medical resources, the learning curve is even steeper.

Like many emergency medicine physicians, I came from a busy academic Level I trauma center brimming with resources: Trauma teams, cardiologists, neurologists, numerous surgical subspecialties, pediatrics, psychiatry, case management, and social workers. I began residency in 2018 and graduated in 2021, deeply scarred and burned out by the COVID-19 pandemic. Short of leaving medicine altogether, I chose the next best thing: A fresh start in rural New Mexico, far from everything familiar.

From abundance to scarcity

Over the past four years, old frustrations were simply replaced with new ones. In residency, I watched unvaccinated patients die unnecessarily of COVID-19. In western New Mexico, I watched fully vaccinated patients die because they spent days waiting for transfer, victims of a statewide and regional intensive care unit bed shortage. On one shift, while trying to transfer a patient as far away as Kansas, I learned that most of New Mexico’s ICU beds were occupied by unvaccinated non-New Mexicans from surrounding states.

Our aging hospital facility was replaced by one that was somehow older and less functional, and more than once, raw sewage leaked down the ER walls from the ICU above. Difficult specialist conversations from residency were replaced by no specialists at all. In 2022, I performed a pericardiocentesis (a lifesaving procedure to evacuate blood around the heart) on a dying patient, then transferred him to the University of New Mexico. The following day, I found out he survived transfer to the University of New Mexico Hospital but died shortly thereafter because the on-call cardiothoracic surgeon was covering two major hospitals in Albuquerque (including the University of New Mexico, the only Level I trauma center in the state) and could not get him to the operating room in time.

The weight of historical trauma

Alcohol use disorder, already rampant where I trained, became extreme in rural New Mexico. A destructive consequence of European colonization, it now afflicts our region at some of the highest rates in the country. I frequently care for patients who are walking and talking with blood alcohol levels high enough to kill the average adult. Suicidal ideation, domestic violence, and child abuse, often fueled by alcohol, are daily occurrences. I regularly admit patients in their twenties and thirties to the ICU to die of end-stage alcoholic liver disease. Just as often, I discharge patients who medically require admission simply because no beds exist, sending them home to their families rather than exporting them to distant cities where they would be isolated and financially devastated.

I moved from caring for one population shaped by historical trauma to another with its own devastating legacy. Where I trained in the southeastern United States, my patients were largely descendants of Scots-Irish settlers forced into marginal Appalachian land, and Black Americans whose ancestors suffered centuries of enslavement, exploitation, and discrimination. Today both communities remain impoverished and disproportionately burdened by chronic disease.

In New Mexico, Native American communities were massacred, displaced, stripped of land, subjected to medical experimentation, and forcibly sterilized well into the 20th century. After Navajo Code Talkers helped secure Allied victory in World War II, the United States repaid them by exploiting Native labor in the uranium mines of the Four Corners, leaving a legacy of radiation-linked disease that persists today. In the modern era, exploitation takes the form of human trafficking, Medicaid fraud, and predatory “rehab” schemes. I will never forget the day one of our techs collapsed in tears after learning that her son, missing for months, had been trafficked across state lines into a fraudulent “rehab” center that drained his Medicaid benefits and let him die of an opioid overdose.

Bureaucracy versus patient care

In 2022, I tried to recruit for the Indian Health Service at the American College of Emergency Physicians’ Scientific Assembly in San Francisco. It was almost impossible. The Indian Health Service is, understandably, a hard sell. At my residency graduation ceremony, a well-meaning physician mentor once told my mother that I would only last one year. I ended up staying more than four, and that is entirely because of my colleagues. My hospital has been staffed by the most talented, mission-driven, and resilient emergency physicians I have ever known. I have learned more from them in four years than many physicians learn in a lifetime. In a setting where you are constantly forced to improvise to provide the standard of care, excellence depends entirely on people, and the people here are extraordinary. If you ever experience a medical emergency in the Four Corners region, you will receive exceptional care, not because of infrastructure, but because of the physicians standing in the gap.

As I move forward in my career, I carry immense gratitude and deep concern. Under new federal leadership, employees in my position are being asked to do more with less. Early last year, we were instructed to begin answering Elon Musk-inspired “What five things did you do this week?” emails, an irony not lost on anyone working 12-plus-hour shifts without basic resources. This was followed by pay cuts, unjustified reductions in force (RIFs), and an increase, not a decrease, in bureaucracy. Over the summer, despite being a Level III trauma center on a major interstate, we were without respiratory therapy and surgical coverage for weeks. Many of our internal medicine, pediatrics, and obstetrics and gynecology colleagues have left. Recently, our hospital functioned for days without a working CT scanner.

Health care in rural New Mexico is emergency medicine’s canary in the coal mine. Our patients were among the first devastated by COVID-19. Now, federal system changes combined with impending Medicaid cuts foreshadow a nationwide crisis. When millions lose coverage, they will come to the ER. And an already strained system will break.

A wealthy state with poor outcomes

I recently read an article arguing that New Mexico is not actually a poor state, but a wealthy state with many poor people. Thanks mostly to oil and gas revenues, New Mexico has one of the largest sovereign wealth funds in the country. And yet our flagship academic hospital is the only Level I trauma center in a state with some of the highest trauma rates in the nation. And the U.S. federal government, the richest government in the world, allowed the second-busiest emergency department in the state to function without a CT scanner.

And still, many of my patients travel hours over rough terrain, often without running water or electricity at home, to wait even longer for care. They are remarkably patient and outwardly grateful, even as the systems meant to serve them routinely fail them. Without question, their resilience and patience are extraordinary. But resilience should not be a prerequisite for receiving basic medical care, and their patience with the state and federal government’s miserly attitude toward them will run out.

These questions remain: Is this really the best our state and country can do for the people of New Mexico, and how much longer do they have to wait?

Sarah Bridge is an emergency physician.