is no thoracic surgeon, no spine surgeon. There are certain intensivists that are sometimes there, but then at other times you might have an internal medicine or family practice physician covering the ICU.
Overall, you have to make sure that you’re providing care in a manner where you’re not going to put a patient in a situation where they need a subspecialist that’s not there. You can’t count on someone else’s management.
In terms of the rural hospital, there wasn’t consistent interventional radiology coverage when I fi rst got there. Sometimes there was a radiologist, sometimes there was no one. There certainly was no clinic. From that perspective, the fi rst step was to establish a clinic and determine what critical services needed to be there, like a thrombectomy service for pulmonary embolism and the basic services for deep vein thrombosis. And we brought things that arguably you could say are critically lifesaving, although not on the same time spectrum, like vertebral augmentation, bone tumor ablation and various other pain directed therapies.
AE: You mentioned vertebral augmentation and pain therapies; what was it like setting up those services? DD: When talking about vertebroplasty or kyphoplasty, I think there’s an assumption that it exists in all settings. And when I came to this hospital, they didn’t know what it was, and it really scared a lot of people. We fi nd that most IRs come out of fellowship and assume that the nurses, techs, managers and administration are going to be comfortable with these kinds of procedures; but the whole practice had never seen a kyphoplasty. The team is extremely capable, but the concept of doing a procedure with a mallet and a sponge clamp while a patient is prone and sedated was different for them. The first response was, “This seems unsafe.” But this is a general anesthesia procedure.
To bring these services into the rural setting, it required re-initiating a lot of in-service coverage, making sure everyone was comfortable and demonstrating the basics. From there, we gradually took steps toward introducing things like neurostimulation.
You can imagine that a lot of rural areas have a very high incidence of diabetes. There’s a family practice residency in this setting that says nearly half of their clinic are patients with diabetes. And patients with diabetic neuropathy can
go through multiple classes of medications, but then they run out of choices. There are no neurosurgeons here, but there is an interventional pain specialist, so he’s able to off er opportunities like neurostimulation trials, and then relies on me to do implants. Similarly, he’ll do a lot of needle injections, but if there’s something like basic vertebral nerve ablation or mild, which is minimally invasive lumbar decompression, he’ll refer to me for that.
You fi nd very little resistance or competition in a region like this.
EA: I’ve experienced the same, even working in a small urban community. All the other specialists that we work with here, whether they’re vascular surgeons or our neurosurgeons, support a very collaborative environment. We all want everyone else to be supported and stay here, because it’s so hard to recruit a physician into a setting that’s not a big city.
Could you give us some examples of where the introduction of spine services in your rural community changed the outcomes for the population? DD: As I mentioned, doing vertebroplasty or kyphoplasty was something that seemed foreign to this region at fi rst. There were patients being hospitalized and placed in rehab facilities for very long periods of time or were bouncing back to the hospital two or three times with very high opioid utilization.
I view opioid use from the perspective of interventional pain management, wherein if we can target the pain generator, we can reduce medication requirements. One of my colleagues directed the MATTERS Network, which is focused on reducing opioid deaths across the nation. So certainly, there’s been reduced ER visits and opioid use because of spine interventions.
Another aspect is that there is medical oncology and radiation oncology in this area, but if a case is too complicated, they may refer patients to the city, which is a couple hours away. You can imagine many patients and families may decide that it’s not possible for them, either fi nancially or from an organization and support standpoint. At that point, they may decide not to undergo therapy and instead focus on hospice. And so doing simple things like bone tumor ablation, or even microwave ablation, has truly changed the quality of life for patients and their families.
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