Recently, I was approached to document my journey as a rural emergency physician in New Mexico. The request came at a peculiar moment: I am wrapping up my final shifts at my first position following my emergency medicine residency on the East Coast, after dedicating over four years to emergency departments throughout the western rural regions of New Mexico, mainly within the Indian Health Service.
Condensing this experience succinctly seems unfeasible. Every emergency physician I know concurs that your inaugural year as an independent practitioner imparts more knowledge than the entirety of medical school and residency combined. In the realm of rural emergency medicine, particularly in a state like New Mexico with a scattered and persistently underserved populace and limited medical resources, the learning curve is even more pronounced.
Similar to many emergency medicine practitioners, I transitioned from a bustling academic Level I trauma center overflowing with resources: trauma teams, cardiologists, neurologists, various surgical subspecialties, pediatrics, psychiatry, case management, and social workers. I initiated my residency in 2018 and completed it in 2021, deeply affected and exhausted by the COVID-19 pandemic. Rather than abandoning medicine entirely, I opted for an alternative: a new beginning in rural New Mexico, far removed from the familiar.
**From abundance to scarcity**
Throughout the last four years, previous frustrations were merely supplanted with new ones. During my residency, I witnessed unvaccinated individuals perish unnecessarily from COVID-19. In western New Mexico, I observed completely vaccinated patients die because they endured days waiting for transfer, casualties of a statewide and regional ICU bed crisis. On one occasion, while attempting to transfer a patient as far as Kansas, I discovered that the majority of New Mexico’s ICU beds were occupied by unvaccinated individuals from neighboring states.
Our aging hospital was succeeded by one that was somehow older and less efficient, and more than once, raw sewage seeped down the ER walls from the ICU above. Challenging conversations with specialists from residency were replaced by the absence of specialists altogether. In 2022, I carried out a pericardiocentesis (a life-saving procedure to evacuate blood around the heart) on a critically ill patient, then transferred him to the University of New Mexico. The next day, I learned he made it to the University of New Mexico Hospital but passed away shortly after because the on-call cardiothoracic surgeon was covering two major hospitals in Albuquerque (including the University of New Mexico, the sole Level I trauma center in the state) and could not reach him to the operating room in time.
**The weight of historical trauma**
Alcohol use disorder, already prevalent where I trained, escalated significantly in rural New Mexico. A devastating outcome of European colonization, it now plagues our region at some of the highest rates nationwide. I frequently tend to patients who are alert and responsive with blood alcohol levels high enough to endanger the average adult. Suicidal thoughts, domestic violence, and child abuse, often driven by alcohol, are commonplace. I routinely admit patients in their twenties and thirties to the ICU to succumb to end-stage alcoholic liver disease. Just as frequently, I discharge patients who medically require hospitalization solely due to the unavailability of beds, sending them back to their families instead of transferring them to distant cities where they would face isolation and financial ruin.
I transitioned from caring for one population shaped by historical trauma to another grappling with its own catastrophic legacy. Where I trained in the southeastern United States, my patients were primarily descendants of Scots-Irish settlers forced into marginal Appalachian lands, and Black Americans whose ancestors endured centuries of enslavement, exploitation, and discrimination. Presently, both communities remain impoverished and disproportionately affected by chronic illnesses.
In New Mexico, Native American populations suffered massacres, displacements, land dispossession, medical experimentation, and coercive sterilizations well into the 20th century. After the Navajo Code Talkers assisted in securing Allied victory during World War II, the United States repaid them by exploiting Native labor in the uranium mines of the Four Corners, leaving behind a legacy of radiation-linked illnesses that endures today. In contemporary times, exploitation manifests as human trafficking, Medicaid fraud, and predatory “rehab” schemes. I will never forget the day one of our technicians collapsed in tears upon discovering that her son, missing for months, had been trafficked across state lines into a fraudulent “rehab” facility that depleted his Medicaid benefits and allowed him to succumb to an opioid overdose.
**Bureaucracy versus patient care**
In 2022, I attempted to recruit for the Indian Health Service at the American College of Emergency Physicians’ Scientific Assembly in San Francisco. It was nearly impossible. The Indian Health Service is, understandably, a challenging sell. At my residency graduation ceremony, a well-intentioned physician mentor once informed my mother that I would only endure one year. I ultimately remained for over four years, and that is solely due to my colleagues. My hospital has been staffed by the most skilled, mission-driven, and