The rural routine

As I'm wrapping up my rural rotation, I think it's worth noting what my routine has been like for these four weeks. On weekdays (except Thursdays, which I have off):

I show up at Timberline Family Practice at 8am. From 8:00-8:30, I either discuss patients or learning objectives with my preceptor, or I read my textbook Essentials of Family Medicine. I see around 6-8 patients from 8:30am-1:00pm. Most of the patients I first see on my own, present them to my preceptor, then finish them together with my preceptor. Some patients I see with my preceptor from the beginning, either observing him or having him observe me.

Lunch break is from 1:00-2:00pm.

In the afternoon, I see around 4-6 patients from 2:00-5:00pm. Then I go for a run or otherwise relax, and I do a little more textbook reading before bed.

I'm keenly aware of how luxurious this schedule is. Once I start my Internal Medicine (Hospitalized Adult Care) rotation, I expect to be working around 12-16 hours per day, 6 days per week.

There's a bug going around Granby

I spent the past weekend holed up in my apartment above the garage sick with a low-grade fever and a sore throat. I also saw a bunch of patients last week who had the same symptoms, so it's not too surprising that I got sick. This is one of the perks of being a primary care doctor.

Although, I asked my preceptor how often he gets sick; he said just once a year or so, suggesting that he tends not to catch bugs from his patients. That may be because over the years he's built up an immunity to most of the bacteria and viruses circulating through the community. The thought also occurred to me that the technique he uses when looking in the nose and throat of patients saves him from the kind of over-exposure that you might think he would get. I'm trying to pick up as much as that technique as I can.

Lucky for me, none of my patients last week tested positive for Strep throat, and all of them had been sick for less than a week.

Rural accommodations: Living on a ranch

I spent the past week living in an apartment above Kremmling Memorial Hospital. I had my own room and bathroom with a shared living room, dining room, and kitchen. There are two other bedrooms up there for various doctors rotating through the hospital, staying for one or two nights to avoid a long commute. There was usually only one doctor staying there at a time.

These accommodations worked just fine, except for the fact that Kremmling is 30 miles away from Granby where I work. I was placed in housing so far away from work because of the short notice due to some technology and communication snafus. AHEC typically tries to place students in rural housing such that their commute is no farther than 30 miles, so I was right at the upper limit. Over this past week, the AHEC coordinator bent over backwards to find me housing closer to Granby.

My new home for the next few weeks is a mountain paradise. I get to wake up to this idyllic view every morning:


I’m living on a working ranch, and the family who’s hosting me is incredibly nice. As a housewarming present, the mother gave me a dozen eggs fresh from her hens. The rooster crows in the morning just like in the children’s books, the donkeys look at me indifferently when I drive past them on my way to work, and a pair of farm dogs welcome me back to the ranch in the evening.

I’m situated in an apartment above the garage. It has a full kitchen (including a dishwasher), bathroom, washer/dryer, plenty of drawer and closet space, and a private entrance so I don’t have to bother my hosts when I come and go.

I know how fortunate I am. Can I stay here forever?

Off-roading accident in a rural emergency room

Living in an apartment above Kremmling Memorial Hospital (KMH), just shy of 30 miles away from where I'm working this month, did have its silver linings. I met several doctors who rotate through KMH; they alternate covering emergency room shifts and making rounds on the long-term-care patients. All of them were very nice, talked a lot about their experiences as rural physicians, and asked me if I wanted to be called if an interesting case came in downstairs. Yes, of course!

This only happened a few times. The most exciting case was a young guy who had an accident while off-roading. He caught some air when going over the top of a hill, landed the wrong way, and was thrown from his vehicle with it rolling over him.

He had hit his head but was helmeted and never lost consciousness. There were no signs of head trauma, and there were no neurological deficits. He denied neck pain and was taken out of the C-collar after physical exam and x-rays showed no damage to his cervical spine. He was taken off the backboard after physical exam showed no injury to the rest of his spine.

He denied any shortness of breath and lung sounds were normal. He did not have any abdominal complaints, and abdominal exam was normal. Interestingly, an ultrasound FAST exam was not done because KMH does not have a portable ultrasound machine.

The major problem was a deep wound in the medial aspect of his right lower leg that extended down to the tibia. He was able to wiggle his toes but could not plantarflex (like stepping on the gas pedal). The wound was full of dirt and gravel. We were able to stop the bleeding with gauze and pressure. X-ray showed that the bone was not broken. He was given Dilaudid to manage the pain of his leg injury and clavicle fracture.

The doctor explained to me that he had to assess whether there was tendon involvement because that would dictate whether he should send this patient to a higher level of care or just close the wound. We numbed the wound with injections of lidocaine/epinephrine and cleaned it thoroughly. The whole time, his off-roading buddies were taking pictures and video on their iPhones. With the wound all numbed and cleaned out, I could see his extensor digitorum longus tendon move back and forth when he wiggled his toes.

The doctor decided that it would be best to send this patient to a higher level of care because the patient still could not plantarflex. The two options for higher-level care from Kremmling are Steamboat Springs and Denver.

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This case was interesting to me for two main reasons, aside from the excitement of trauma. First, this trauma was the result of an off-roading accident, something that I would be much less likely to see in the city. Second, I got to see how this rural doctor, covering the emergency department of a small hospital, first assessed the seriousness of the injury and then negotiated the system in order to figure out the appropriate transfer of care. Events would have unfolded slightly differently if this were at University Hospital Emergency Department.

Heuristic trap

Since starting third-year, I've noticed that sometimes I form preconceptions of what a patient's diagnosis will be before I have examined that patient or even gathered a full history. My preceptor picked up on this when he observed me interviewing a patient this afternoon, and he talked to me about it. He calls it the "heuristic trap." To avoid the heuristic trap is to think as a physician.

Later on in the afternoon, a patient came in complaining of a dry cough that she has had for 8 months. She was also taking a blood pressure medication that can cause a chronic dry cough. The heuristic trap would have been to think that this patient's cough was caused by that medication but fail to fully think of other possible causes.

Instead, I went into the interview armed with this information but pushed myself to think of other causes of her cough. My patient told me that she also gets heartburn everyday, that it's worse when she's bending over to clean the floors, and that it gets better when she eats food, drinks water, and puts milk in her coffee instead of drinking it black. Also, she always sleeps on her side but never on her back. She denied that her cough got worse with exercise or with cold air. This history is very suggestive of gastroesophageal reflux disease (GERD), which can cause a chronic cough due to inflammation of the esophagus.

On exam, her lung sounds were clear making a chronic lung infection and asthma less likely.

Now I could give a proper differential diagnosis and plan when presenting to my attending:

1. GERD - strongly suggested by history
2. Side effect from blood pressure medication
3. Asthma - less likely; not suggested by history, no wheezes on exam
4. Chronic lung infection - less likely; not suggested by history, normal lung exam

We decided to give her a diagnostic treatment of a proton pump inhibitor (which decreases stomach acidity) and follow up in 2 weeks to see if her cough symptoms have improved. If her cough does not resolve, we will consider measuring the pH level in her esophagus to rule out GERD; we would also consider switching her blood pressure medication to one that does not cause cough to rule that out as a possibility.


My mentor says that most physicians must constantly train their minds to avoid the heuristic trap, to think broadly about what might cause a particular set of symptoms. That is, after all, part of a doctor's job description. The third year medical student is at the beginning of that mental training.

The pace of rural life

It turns out that my mentor does not work on Thursdays. So when Wednesday rolled around, I asked him, "What would you like me to be doing tomorrow?" His reply was that the purpose of me being out here is to experience the life of a country doc and that I should take the day off. Can't argue with that!

I studied in the morning then headed out to Steamboat to meet up with one of the ER doctors at Kremmling who I made friends with. He took me to the Mad Creek trailhead for a "hike" (I ran, he rode his mountain bike) that ended up at Strawberry Springs. We soaked for a little while, ran/rode back down, then I grabbed some dinner at a local diner.

Not a bad way to spend a Thursday afternoon as a third-year medical student!

Housing accommodations for my rural rotation

I finally got my housing situation figured out for my rural rotation, sort of. There was some sort of glitch with the online registration on the AHEC website and because of that the housing coordinators were not aware that I needed housing until last week. Moreover, because Kremmling is a new site, they didn't have a list of potential hosts to draw from. To complicate matters even further, it appears that my mentor's practice is in fact not located in Kremmling but instead in Granby, a town about a half-hour to the east.

Long story short: I will stay for the first few days of my rural rotation in an apartment at Kremmling Memorial Hospital and commute the 30 miles each day to my mentor's practice in Granby. In the meantime, the housing coordinators at AHEC will try to locate better accommodations for me a little closer to work.

It has been kind of strange for the past few days knowing that I will be heading off to the mountains but not having in my mind a clear idea of what to expect. I like a little adventure. I have no doubt that everything will work itself out, especially after talking with the housing coordinator at AHEC who feels so bad about my situation and is working hard to help me.

Rural Community: Kremmling, CO

I finally got my placement for Rural Community Care: Kremmling, CO!



Naturally I had never heard of this town, before, so I spent a good amount of time researching it. Kremmling has its own Wikipedia page. I was also able to find their Chamber of Commerce website, which provides a lot of insight into the character of the town and what it has to offer. Aside from being situated a stone's throw away from three national parks, I'm particularly excited that the Quarter Circle Saloon has a pool tournament every Tuesday night!

I contacted the doctor with whom I will be working. He told me that his clinic days are four days a week with Thursdays off, and that he works one weekend per month at Kremmling Memorial Hospital. He also invited me to work with him covering the Triple DHip downhill dirt-bike race in the nearby town of Granby!

I think this is going to be a great experience.