By Jonathan Pabalate, DNP, CRNA, APRN | Founder, JPCAIC — JPC Anesthesia Informatics Corp | Nurse Anesthesia Faculty, University of North Florida
It starts as an incision and drainage.
The surgeon briefs me before the case — leg wound, needs debridement, straightforward. On paper, it is. The surgical complexity is low. The anesthesia complexity is anything but. The patient is morbidly obese, poorly controlled diabetic, with documented obstructive sleep apnea and a wound that has been quietly festering longer than anyone realized. I’ve managed patients like this before, in bigger rooms with more hands. I’ve managed them here too — alone, in the middle of rural Iowa, two hours from the nearest major medical center.
We induce. The airway is managed. The surgeon opens the wound.
What follows is not in the operative note as chaos — it doesn’t read that way. But it was hours of sustained, disciplined crisis management by one provider, with one nurse at my side. Not an ICU nurse. Not a seasoned perioperative veteran. The nurse on call that night was the least experienced person on the floor, working at the only hospital they’d ever worked at, doing their best in a situation nobody trained them for. When the wound opened, it released a cascade of vasoactive mediators that dropped the patient’s pressure precipitously and kept it there. We transfused. We pushed vasopressors. I titrated, communicated, documented, and monitored — simultaneously — for far longer than that scenario would have lasted at an academic center with a full team.
The patient stabilized. Eventually.
But here is the part that never makes it into the case report: in a tertiary center, hemodynamic stability after a vasodilatory crisis comes faster. Not because the physiology is different, but because there are more hands, more advanced monitoring, more skilled resources in the room. At a critical access hospital at two in the morning, the ceiling of your response is exactly as high as you can personally reach. That night, I was the ceiling.
What “Solo” Actually Means
People hear “solo CRNA” and picture a lighter schedule, rural quiet, a slower pace. I understand why. The reality is something else entirely.
A few months into my time at this critical access hospital in rural Iowa, I got a call from the emergency department. They needed anesthesia for a patient who needed to be intubated — or so they thought. When I walked in and assessed the patient, I realized the clinical picture was significantly more complicated than the team had recognized. The acuity was higher. The trajectory was worse. I intubated. I managed the airway. And then I stayed.
Because here’s what a critical access hospital does not have: an ICU. A critical care team. A respiratory therapist standing by to manage the ventilator. A pharmacist in the building after hours. What it has, in that moment, is you.
For the next thirty minutes — sometimes longer — I was the de facto intensive care unit. Titrating sedation. Managing hemodynamics. Adjusting ventilator parameters. Watching for the subtle signs that would tell me whether this patient was improving or not. Ordering and interpreting blood gases, because in the rush of managing a critically ill patient in an underprepared environment, those simple but essential data points often get missed entirely. Not because anyone is negligent. Because everyone is overwhelmed, and the cognitive bandwidth required to manage even one critically ill patient in an environment not designed for critical illness is enormous.
The patient was eventually transferred by helicopter to a higher level of care. The gap between intubation and departure — the window where someone needed to be present, skilled, and actively managing — was mine to hold. I held it.
That is what solo means.
The 2 A.M. Phone Call Nobody Tells You About
Not every call is a hemodynamic crisis. Some of the most important ones are quieter, and stranger.
One night I was called in not for a surgical emergency, but because a brand-new advanced practice provider — fresh out of training, never having performed a lumbar puncture independently — needed help accessing the intrathecal space on a patient who was altered and uncooperative. This was not a procedure beyond my scope. It was, in fact, exactly the kind of procedural expertise that rarely follows a clinician out of an academic training environment and into a small town in the Midwest.
I helped guide the procedure safely. The patient was protected. The provider gained experience they couldn’t have gotten any other way that night.
That call could have gone badly — not because of malice, but because of inexperience and the absence of any other resource. In a critical access setting, procedural support, institutional knowledge, and clinical mentorship collapse into a single role. The anesthesia provider is often the most procedurally skilled clinician in the building. That weight is real, and it is constant.
The Fareway Grocery Store
There is a dimension to rural practice that no residency program prepares you for, and it has nothing to do with clinical skill.
You will see your patients outside the hospital. Not occasionally — regularly. The morning after a difficult case, you might walk into the local diner and see the patient’s family eating breakfast. You might pass someone in the produce aisle who you helped through a frightening surgery six months ago. They know your name. They know your face. You know theirs.
In a large academic center, the boundary between clinician and community is maintained by sheer scale. In a town of a few thousand people in rural Iowa, there is no such boundary. You are their anesthesiologist. You are also their neighbor.
That intimacy is one of the most quietly profound parts of this work. It makes you careful in a way that is different from the careful you learn in training. Every decision carries the weight of a face you will see again.
What I’m Leaving Behind
I won’t pretend to be the thing that holds this community together. That would be neither accurate nor fair to the nurses, surgeons, administrators, and providers who have worked at this hospital far longer than I have. Rural healthcare is held together by a lot of people making a lot of quiet sacrifices, and I was one piece of that, for a little while.
But I did try to leave more than coverage.
Some of what I tried to build was clinical. Early in my time here, I identified an opportunity to help the hospital stand up a ketamine infusion service for patients living with treatment-resistant depression and chronic pain — conditions that are prevalent in rural communities and chronically underserved by the resources available there. Getting it off the ground wasn’t without friction. Billing pathways were misunderstood, patients were being turned away or quoted out-of-pocket costs that bore no relationship to what insurance would actually reimburse, and some who needed the treatment most were quietly falling through the cracks. Working through those operational barriers and getting those patients into the chair — that mattered. Not because ketamine infusion is exotic, but because in a small town in rural Iowa, the absence of a service is not a minor inconvenience. It is the end of the road.
Some of what I tried to build was in the people around me. There is a nurse here who was terrified the first time I asked her to participate in an airway management scenario in the OR. She did it anyway. She was scared to death, by her own account, and she didn’t feel better afterward — at least not immediately. But she did it. And the reason I kept creating those moments, kept pulling staff into situations slightly beyond their comfort zone when the conditions were safe enough to do so, was simple: I happened to be available. That is not always going to be the case. The night something goes wrong in that emergency department and anesthesia is tied up in surgery, the nurse who once practiced under supervision will be better prepared than the one who never did. That is not a small thing.
Some of what I tried to build was institutional. I spent time developing tools to make the hospital’s perioperative data visible and actionable — dashboards, analytics, reports that told a more granular story about surgical volume and efficiency than the native EMR reporting could produce. Data literacy in clinical environments is a slow culture shift, and I was under no illusions that I would complete it in the time I was here. But I tried to leave the infrastructure in place, and I tried to show people what was possible when you could actually see what was happening operationally in near real time.
In a final conversation with hospital leadership before my departure, I was asked to reflect honestly on where my efforts had landed and where they hadn’t. That kind of conversation — direct, constructive, without defensiveness on either side — is itself a marker of something worth preserving in a small institution. The things that didn’t land were usually not failures of intent. They were failures of timing, of audience readiness, of the simple reality that change in a resource-constrained environment moves at the speed of the people available to carry it.
I understood that. I still do.
The clinicians who are willing to practice in genuine rural isolation — far from academic centers, far from subspecialty support, far from colleagues who share their training framework — are becoming fewer. Not because the need is shrinking. Because the conditions are hard, the support is thin, and the pipeline of skilled anesthesia providers willing to take on that isolation is not keeping pace with the communities that need them.
What those communities deserve is evidence-based care delivered by skilled practitioners who practice at the full scope of their training. What they sometimes get is whatever is available. The gap between those two things is where patients are most vulnerable.
I’m not writing this to be alarming. I’m writing it because I spent five-plus years in that gap, doing my best to close it, and I think it’s worth saying plainly before I move on: rural America’s surgical safety net is held together by clinicians who choose to be there. When they leave — when we leave — those communities feel it in ways that never make the news.
Five Years
I came to rural Iowa as a skilled clinician. I’m leaving as something more — a provider who has been tested in conditions that most of my peers will never encounter, who has managed crises without a safety net, who has held a community’s anesthesia care together through call shifts and middle-of-the-night emergencies and cases that looked simple and weren’t.
I’m proud of that. I’m also grateful for it.
There is something clarifying about being the only one. About knowing that your training, your judgment, and your presence are the entirety of what stands between a patient and a worse outcome. It makes you a better clinician. It makes you a more thoughtful one. It makes you understand, in a way that is hard to articulate to someone who hasn’t experienced it, what the practice of anesthesia actually is when you strip away the team, the technology, and the institutional cushion.
It is one provider, one patient, and every ounce of preparation you’ve brought to that room.
For five-plus years, in a small town in rural Iowa, that was enough. I hope it continues to be — for the next provider, and the one after that, and all the communities like Clarinda still waiting for someone to choose them.
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