Local Medical Doctors: State-of-the-Art Healers

–Gwen Wagstrom Halaas

In an emergency room in Cambridge, Massachusetts, at Harvard Medical School, I first heard the acronym “LMD.” As a medical student, this was one more acronym to add to my brain, already swimming with acronyms and millions of bits of information. I soon realized that LMD was the house staff’s term of derision for the local doctors whose patients they were presenting. This was news to me, that other doctors would not respect their peers. Maybe I was naive, coming from Minnesota where we are “all above average.” This realization dulled the shiny image of the medical mecca that I had the privilege of experiencing.

Moving back to Minneapolis, I managed to escape this attitude for a while, training in a hospital where the family of family doctors was the valued source of patients and referrals. This attitude resurfaced as my peers joined practices in small communities in Minnesota, and I would hear them complain about how they were treated by the urban consultants.

On my rural rotation in Homer, Alaska, I was first introduced to the amazing level of care rendered in a rural setting. While on call one evening in the hospital, a man with chest pain arrived in the emergency room. He was quickly evaluated, treated with streptokinase, stabilized, and put on a Lear jet to Anchorage.

This was months before anyone in the big city of Minneapolis was considering thrombolysis for acute MIs (heart attacks). I bragged about this experience and others on my return to the city. They looked at me like I must be hallucinating.

In my professional journey, I first started my own family practice on the skyway downtown—a very old-fashioned general practice in a fancy setting in St. Paul. From there I traveled through combinations of practice, teaching and managing the business of health care until I found myself directing a program that taught medical students the basics of medicine by immersing them in rural community practices. Again face to face with LMDs, I marveled at the innovative ways they cared for families and communities. These “hick” towns have helicopters, digital X-rays, telemedicine, electronic health records, robot consultants, medication vending machines, and approaches to care that are on the cutting edge. Their state-of-the-art facilities are patient-centered healing environments.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

It always surprises me that this term of derision is still alive today. You’d think that our dependence on each other for referrals and consults would have fostered more respect. But 30 years later, I still hear students talk about some of the same derogatory comments I heard about primary care in the 1980s.

It takes a lots of smarts to know a little about the wide range of health care issues patients face today. It also requires a lot of wisdom to know your limits and when to ask for help. Some personalities may be better suited to the wide swath of general knowledge and others may do better with deep and narrow. Pay attention to what you hear and remember, putting down someone else certainly helps one feel better about his or herself.

 

Learning to Walk the Healer’s Path

–Erik Brodt

Three minutes and thirty seconds remained in the fourth quarter of the Minnesota Section 6A boys’ basketball final. Showcasing a fake plant step, our All-State point guard sends his opponent to the floor again. Dribbling around the flopping contender, number 5 pulls up and sinks a fifteen-foot jumper to put Cass-Lake up by four. But there is a turn of fate. Floating down from his jump shot, our point guard landed on the foot of another player, twisting his ankle inward and sending him to the floor in agony. Hearts dropped with the crowd’s deep gasp. Silence. I gulped nervously as my time was at hand. I composed myself and strolled onto the court to help our star as thousands looked on.

“Three minutes and thirty seconds!” she shouted as I threw myself into my disaster gown. “Estimated time of arrival, three minutes and thirty seconds!”

My hands quivered cold with sweat as my fingerprints formed though my  latex gloves. Confusion rested on my shoulder. I didn’t know what, but I could feel something horrible happening. That day, now eternally etched into my mind, had begun as a splendid day. Each step was light, walking between medicine clinic and the women’s health wardto visit a laboring mother and evaluate a baby I had delivered in the morning.

Wearing a wide grin of connection and accomplishment, I fought to contain the giddy chuckles of becoming a doctor. When all is well, being a doctor is bliss. Pulling the hospital door, it didn’t budge. Puzzling. Why was our rural hospital locked in the middle of the day? My pager sounded, I was needed in the ER immediately. March 21 will never be another day to me. No day will.

As a third-year medical student I performed a nine-month rural clerkship at North Country Regional Hospital in Bemidji, Minnesota. I chose Bemidji to be close to my family and the three largest Minnesota Chippewa Reservations. I am Anishinaabe (Chippewa) and it was the perfect opportunity for me to invest in the Native community during medical school. Little did I know how profound an impact the experience would have on me, especially on the afternoon when a young man entered Red Lake High School, shooting thirteen people and killing eight, including himself.

Reprinted from The Country Doctor Revisited (Kent State University Press, 2010) with permission from the author.

As a medical student completing a 9-month clerkship in a hospital near the Red Lake reservation, Dr. Brodt cared for the victims of a tragic shooting. It was particularly challenging because he had spent summers with his grandparents on the reservation and knew many of the victims and their families. Triaging and treating the patients injured in this kind of disaster is difficult for any health care provider. Because Dr. Brodt knew the families, it added another layer to the calamity. Because the community had just celebrated the men’s basketball team competing in the state finals, the community’s elation quickly crashed with the tragedy.

In earlier posts we have talked about the blurring of boundaries that occur in small communities. Our patients are often our friends. This is both positive and negative. Together the community mourned, but as a nurse or doctor that day, Dr. Brodt and his colleagues had to put their feelings aside and do what needed to be done. I often think of it as pushing a hold button on my feelings so that I can do the A,B, Cs–airway, breathing, cardiac . . . Once the work is done, I release the hold button.  In his essay in The Country Doctor Revisited, Dr. Brodt reflects on how he and the community struggled to heal from that tragic day.

As physicians we witness the best and worst of times in the lives of our patients and the communities we care for. In order to stay healthy ourselves, so we do not become jaded and cynical, it is important that each of us figures out how to care for ourselves. We may see some colleagues turn to alcohol, drugs, too much work or other behaviors that keep them from facing the real issues. Life is filled with good times and bad times and ultimately we have very little control.

Avoid medical-speak

From Good Will

–Donald Kollisch

“Like a sponge,” Elwin was thinking, sitting in his father’s old chair. “The doctor said my lungs are filled up like a sponge that they need to wring out.”

He pictured a large sponge—the kind his father used to use to wipe down the horses after a full day’s work, knobby and heavy and dripping in his hands. Elwin held the image in his mind as he tried to clear his laboring lungs. Some sections were softer and more supple; others were stiff and scarred. Water was stuck in the stiffer cavities so he wasn’t able to squeeze it out. That was what made his breathing fast and shallow—the way it had been ever since he’d come in from moving the John Deere into the barn.

(Excerpted from Good Will and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Elwin was a retired farmer. His doctor gave him a concrete image to understand his congestive heart failure. Avoiding medical-speak is important. Sometimes when we are new to medicine we like to use the big words to impress or friends and colleagues. When presenting to attendings and preceptors we are supposed to use the proper medial terms. But when explaining illness to patients medical-speak doesn’t work.  Translate medical lingo into concepts and images your patients will understand. That may vary depending on a patient’s culture and experience. In the above story, Dr. Kollisch was talking to an old farmer –he understood sponges and water and washing his draft horses. One of the magical moments in talking with patients is when your patient helps you identify the image that makes sense to him or her.  Share one of those moments with us if you can. . .

Sometimes patients repulse us…

— Lorence Gutterman

I knock, enter the room, and introduce myself. Carter rolls over to look at me, a grimace on his face. I step back as the musty air of his room reaches me, reminding me of my high school gym locker room. I brace myself and ask him why he became a rodeo rider.

“My uncle and older brother rode. I wanted to be like ’em. Doc, you want to try it?” He laughs through his obvious misery as he pushes himself into a sitting position, his reedy legs now dangling beneath the flimsy, gray-checkered hospital gown.

“I’m too chicken to sit on a bucking horse,” I say and place my chair a safe distance from him. Not so far away to be rude, but I need some space.

“Man, what are ya’ afraid of? Thought Docs could do everythin’.” His grin changes to a frown as he crosses his legs.

“Believe it or not, doctors get scared.” What would my colleagues think of me, admitting vulnerability?

Carter shuts his eyes and rubs them. He clenches his jaw. “Can you give me something for pain? I hurt like hell.”

“Of course. I’ll talk with your nurse.” I quickly leave the room to find his nurse who is counting tablets and putting them into a tiny paper cup. I ask her to increase Carter’s dose of morphine. I reenter Carter’s room. The odors have not changed. I return to my chair, the cracked vinyl squeaks.

“Hey Doc, ya gonna get me feelin’ better?” He has returned to lying down.

“I’ll try. Can’t promise you though. Could you control the bronco the first time you sat on it?”

He tries to prop himself up on his right elbow. “Doc, ya never can control that animal.”

“Kind of like your fever, until I know more about you,” I say fidgeting with his chart.

“Those shakes last night, damn! Bounced me around more than any bronc.”

“Fever caused your shakes.” I stare at the plastic bag filled with clear liquid hanging on a metal pole on the corner of his bed. Its slow drip is hypnotizing, calming. I decide to get to know him before I start quizzing him about risks for AIDS. Taking a sexual history has never been a comfortable task for me.

(Excerpted from Hanging on for Your Life and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

In this selection the author appears repulsed by this patient. It may be the patient’s profession, it may be the smells of illness, it may be the patient’s personality. We are human, we all have reactions to patients. My toughest patients are those who are morbidly obese and come in with complaints related to their excess weight. Obese patients are hard to examine. My feelings are real, I can’t get rid of them. The important thing to remember is that I cannot act on my feelings. I need to recognize them, then set them aside and figure out how to meet the patient where he or she is. Likely the obese patient is embarrased about their weight and has been the recipeint of cruel comments. I try to find some empathy for that patient.  Partnering with a patient demands figuring out what if feels like to walk in their shoes–that saying may be cliche, but its a good place to start. Empathy can help me put my repulsion aside. This is part of professionalism. We may have unsavory feelings, but we don’t act on them.

Sometimes to let off steam, we may joke with colleagues and co-workers about a patient or the situation. Be careful about this. You never want to do that in a location where the patient or his/her family/friends might over hear you. Humor helps us to cope, but eventually you need to set it aside and return to a position of empathy.

The author also talks about being scared. Feelings of fear are human too. Sometimes we are afraid and we need to ask for help. However, sometimes we need to set our fear aside and do what needs to be done.

As you spend time in clinic and the hospital you will see health professionals who are empathetic and kind to some of the most difficult and repulsive patients. Watch them, ask them how they do it.

Responding to the need for high quality emergency care in rural America

–Darrell Carter

Another cold blustery January night in northwestern Minnesota, and you hope everyone stays home and your hospital’s emergency department remains quiet. As the night charge nurse on duty, you are responsible for overseeing the care your night staff (one other RN and an LPN) gives to the twelve inpatients in your twenty-two bed Critical Access Hospital (CAH). These twelve patients include a mother and her hours-old newborn and an eighty-two-year-old female who is two days post-op after a hip pinning and who is exhibiting increased confusion and agitation. You hope to let your on-call doctor get some sleep since she was up much of last night delivering the baby in your nursery. The only other practicing physician in your community is gone for a much-deserved five-day break to Cancun.

 All has remained routine until 1:00 a.m. when the squawk from your ambulance paging radio disturbs your charting. The Basic Life Support ambulance is dispatched to a motor-vehicle-crash involving two vehicles and an unknown number of victims. At least two of the patients sound seriously injured. Reluctantly, you shift your role from more mundane tasks to organizing the team for the soon-to-be-busy emergency department.

 In the twenty-first century, seriously ill or injured patients benefit from a growing amount of advanced technology for diagnosis and treatment of their ailments or injuries. Highly trained specialists are now available to help manage a wide variety of complex conditions, and well-trained and highly skilled teams staff emergency departments. Unfortunately, this is true only in the larger population centers of the United States. Rural health care facilities do not have immediate access to this wide variety of specialists and frequently lack the more advanced equipment needed to diagnose or treat the seriously ill or injured patient. Rural providers frequently lack the organized team, knowledge, and skills to rapidly perform the life-saving procedures and treatments needed by the more seriously ill or injured patients. Extensive distances lengthen the time required to transport patients to specialized urban medical centers for life- or organ-saving procedures. It is little wonder that rural trauma victims have a higher mortality rate than their urban counterparts. In 2004 the Minnesota Statewide Trauma System reported that fewer than 30 percent of all motor vehicle crashes occurred in rural areas, but 70 percent of the fatal crashes are rural.

 There are many obstacles to our delivering the highest and most modern emergency and critical care to rural patients. However, the medical legal standards of care and the general public expect similar care to be delivered in both urban and rural communities. Disparity in the availability of advanced emergency care has adverse consequences. In rural areas, these include: higher rates of trauma deaths, increased burnout among providers, difficulty recruiting staff for existing health care facilities, and an increase in medical-legal risks for practitioners due to the inability to rapidly deliver emergency care or obtain easy consultation for some critically ill or injured patients.

 So what is the solution to this developing crisis in rural medicine? Some recommend more helicopters to rapidly transport the rural patients to urban centers. Others promote equipping rural communities with all the latest equipment, as well as hiring skilled specialists to respond to the infrequent events.  But is society willing to finance the cost of such solutions? Others claim living (and vacationing and driving) in the rural parts of our country is simply more dangerous, so if you elect to live in, or even venture into rural areas, then you need to accept the inherent risks.

(Excerpted from A Night in the Life of a Rural Emergency Care Team and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Darrell Carter and his colleagues responded to this need by starting CALS—comprehensive advanced life support.  http://www.calsprogram.org/

This innovative program combines ACLS, PALS, ALSO and ATLS with a rural focus and a team response approach. In the 21^st century, many rural areas are filled with innovative ways to respond to the desire of health care providers and patients to provide and receive high quality care.  What is happening in the community where you are rotating?   Please share some innovations on this blog.