Category Archives: patients

Disconnected US health care–Part 2

The Dressing Change – Part 2

–Tara Frerks

As I worked, I listened as Mr. Friedrikson repeated some of the particulars of their story. It was clear that he was angrier than his wife, maybe feeling some guilt. He clearly had taken the lead in trying to secure help.

I washed off the remaining betadine and dried blood, then patted the patient’s hand dry, careful not to hurt her. “Want to take a look before I wrap your hand?” I asked.

Mrs. Friedrikson emphatically shook her head.

Using supplies from their bag, I carefully placed Telfa (no-stick gauze) over the healing lacerations, then wound gauze around the fingers and thumb, wrapping the thumb separately and keeping the fingers visible to just below the nails. I’d watched many dressing changes, but this was the first I’d done on my own. I gained confidence as I worked.

Two hours after entering the clinic, I sent the couple on their way. They left with a neatly applied dressing and two hours of telling their story. Now more confident in my wound care, I realized that today I’d made a valuable contribution to Dr. Brown and the clinic team. As a medical student I had the luxury of spending time with patients, listening and talking and hearing every detail of their nightmare in a way that Dr. Brown could not. Now, my challenge over the next years of training is to learn how to demonstrate the same humanistic care in a more compact interval. And maybe with advocacy on my part, I might see a saner health care insurance system during my career.

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

We’ve talked before on these pages about the student’s luxury of time, what a gift that is for the patient and the clinic. Pay attention to what you can learn because of the time you have to spend with patients. You’ll gain not only techniques and skills, but a wealth of information about health and healing and  the resiliency of the human body and spirit.

 

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Everyone Did Their Part, But

–Therese Zink

Late in the afternoon, the effects of my midafternoon cup of coffee were dwindling. I picked up the chart of a new patient with the chief complaint, “Needs a home health nurse.” He sounded like a good patient for Melissa, the nurse practitioner student who was working with me, to see and sort through the
concerns. In the meantime, I saw two other patients.

Melissa emerged from the exam room. “You better sit down for this one.”

“Be as concise as you can,” I said as calmly as I could.

The patient, eighty-seven years old, had not seen a doctor for twenty-five
years. Retired from farming, Mr. Gains and his wife lived alone in a farmhouse
outside of town. Their son worked the land, and their daughter ran the dry
cleaning store in town, just minutes away. The daughter said she cared for them
twenty-four hours a day, made their meals, bathed them, everything. It was
getting to be too much. Two days ago, her father quit walking and eating. Her
mother used a walker. They needed someone to come in and help.

Melissa and I entered the exam room. The daughter, a middle-aged bottle
blonde, who was generous with her makeup, rose from her chair. I introduced
myself and told her that Melissa had filled me in. “What’s your main concern?”
I asked.

“It’s getting to be too much. I need some help. I thought maybe a nurse once
a week,” she said as she moved toward the door.
Mr. Gains was frail, wearing a feed cap and overalls. When I addressed him,
he made eye contact but didn’t say much. We learned that he spent most of
the day in a reclining chair, that he was usually incontinent at night. He never
had much of an appetite. Both the daughter and son checked on the couple
throughout the day.

“Dad doesn’t have insurance, so my brother doesn’t want much done,” the
daughter said tapping her toe on the linoleum floor.

“But he’s over sixty-five. He should have Medicare,” I said.

“Neither of my parents have it.”

Strange, I thought, and asked the daughter to step out of the room while
Melissa and I did an exam. She was reluctant to do so, so I walked her down
the hall and reassured her that we would bring her in as soon as we were done.

“Please, they don’t have much money,” she told me.

I reiterated that we would do the best we could.

When I returned to the room, Melissa had helped Mr. Gains onto the exam
table, which was low to the floor, making it easier for elderly patients.
“Pretty unsteady on your feet, aren’t you Mr. Gains,” Melissa said.

“Do you hurt anywhere?” I asked.

Mr. Gains shook his head.

I asked the usual questions about vomiting, fever, chills, diarrhea. . . . Mr.

Gains denied all. Finally, I inquired, “Is anyone hurting you?”
Again, Mr. Gains shook his head. As we removed his flannel shirt, I noticed
a layer of brown oily scum around his neck and under his arms. His odor was
pungent, not like urine, but similar to that of overripe fruit. His T-shirt was
gray. His lungs were clear, and his heart rhythm was regular. No murmurs.
We removed his overalls; they were clean, as were his undershorts. The brown
scum was also accumulated at his beltline and in his groin. Melissa removed
his threadbare socks. Near his ankles were two quarter-sized bedsores.

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

As health care professionals–nurses, doctors and social workers– we are mandated reporters of suspected abuse for adults in most states and for child abuse in all states. These are always difficult situations. This one was particularly complicated.  Read the rest of the story. When I talk to students about managing families who are living with abuse, I always remind them that as a physician it is not my job to decide who is right or wrong, but to link the family with support and the people who can make that decision.

 

Lost On Call

–Ann Neuser Lederer

was on call, and tense. Newly employed as a visiting nurse on the edges of
Appalachia, I had recently moved to this place
from a large rust belt city hundreds of miles to the north.
Our territory extended down to the river cliffs,
and outward through patchworks of farms.
I didn’t know it very well, especially in the dark.
It was a weeknight. I was tired from the day’s work.
The beeper jolted me awake.
I fumbled into my clothes, neatly folded nearby, awaiting.
I was called out to a place I had never been, on the edge of the county,
to a death of a patient I had never known.
It was the middle of the night. There were no lights anywhere.
I peered at the directions written on the paper.
Ever so slowly I made my way down the winding tree-lined lane.
It was one of those roads with steep drops on both sides and no shoulders.
Only the halo ahead, created by the headlights,
hinted which way the next curve might lead.
As I turned a bend, I spotted from the corner of my eye an odd red glow,
low to the ground, seemingly coming out of nowhere.
Slowly, I realized it was a pile of something smoldering.
I did not know anything about field fires then.
Wondering, tempted to imagine, I forced myself to attend to the task at hand.
I could not find the turn-in for the house. I must have passed it, so I backtracked, tried again, a little scared. A full moon rose over the bare tree limbs, soothing me with its steady presence. I followed a twisty road up a hill.

Far to the back of a farm, a trailer was parked. This was the place.
They sat, awaiting my knock.
They had no running water. The corpse had soiled himself,
maybe a good while before dying. They wanted him clean for the mortician.
They brought a bucket and I tried my best.
Fresh diaper, and shirt, buttoned to the neck. Hair brushed. Mouth closed.
Ready.
Now, the red glow in the dark field, the white moon above,
lighting the road up the hill are permanent reminders of potential surprises,
against the nights of dread.

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

Nurse Lederer was called to help in a setting quite different from one familiar to her. She was called outside her comfort zone to care for a patient who was poor and dying. As she describes the setting, I felt her fear and discomfort. Sometimes medicine calls us outside of our selves, to walk in the shoes of another, to see what it feels like to live in a world different from the one we know. You don’t need to go to another country to experience a different culture. We have reflected on this in other blog entries [December 19, 2011 and January 9, 2012].  It may be the same culture, but it might be a different sense of personhood—what it feels like to be old or disabled or have a mental illness. So far in your career, have any patient encounters given you the chance to experience life from another perspective? If so, tell us about it, preserve privacy please, no identifying information. What did you learn? How did it alter your view of the world?

Read other work by Ann Neuser Lederer.

Asking the Right Question

–Therese Zink

“Two blocks into my paper route and I can’t peddle my bike,” Joe complains. He tells us the pain started when he was playing Hacky Sack. He rotates his hip out and balances on his left foot, his right knee protrudes from his denim shorts like a doorknob. Ankle-high red tennis shoes squeak on the linoleum floor. I marvel at his flexibility considering all the pain he describes.

“Sometimes my knee locks up and I have to massage it to release it,” Joe says and demonstrates. “Twenty Ibuprofen in two hours doesn’t touch it!” His blonde ponytail flips from one shoulder to the other.

Joe and Doug, the patient and the medical student, are in their early twenties. Both are tall; their clothes hang on them like a dress shirt drapes a hanger. Doug listens intently, making notes on his clipboard from his post on the exam room stool. Near the end of a nine-month rural rotation during his third year of medical school, he has seen patients at the local hospital, clinic, and nursing home and learned about the community’s health issues. He’s rented a trailer home in the town’s trailer park. As faculty in the Rural Physician Associate Program at the medical school, I am here for one of six visits to assess his progress, observing his interactions with patients and doctors, the professor monitoring the student.

Doug methodically uncovers the how, when, why, where, and what about Joe’s pain, what makes it better and what makes it worse. Shifting his focus between his notes and Joe, he pauses and runs his long fingers through his short brown hair. I hold my tongue during the pregnant silences and Doug always comes through with the appropriate next question. I quietly applaud him. So far, Doug has documented Joe’s history of present illness, past medical history, and family history and is working through social history. As Doug concludes the interview and prepares to conduct the physical exam, I decide to interrupt and ask Joe where he lives.

“In my van,” he responds.

At this, Doug’s gaze locks with mine and he settles back on his stool, crosses his legs and begins a new line of questioning, probing where Joe gets money for food and cigarettes.

Reprinted from The Country Doctor Revistied (KSU, 2010) with permission.

Doug had done a good job of understanding Joe’s problem–the PQRST of pain, but he and I broadened our understanding of Joe’s situation when we asked about where he lived. Homelessness is an issue in rural areas. Because it is often more hidden than in urban areas, we forget that it is a problem. Rural homelessness, like urban homelessness, is the result of poverty and a lack of affordable housing. In 2005, research shows that the odds of being poor are between 1.2 to 2.3 times higher for people in nonmetropolitan areas, than in metropolitan areas. (National Coalition on Homelessness) The current mortgage crisis hit rural areas across the US. The challenges in rural areas are magnified because resources are more limited.

As you spend time on rural rotations, think about poverty and ask who and what organizations create the safety net in the community.

Spring Planting

—Richard M. Berlin
                 For Julianna A. Luntz Van Raan, 1950–1998
A morning call wakes me:
something hard and fibrous in her leg
growing fast and uncontrolled
that can’t be weeded out.
Through my bedroom window
I study winter rye in April
swinging on strong stems.
I wish I could plant Julie’s leg
in a warm tangle of earth,
turn her face toward the sun,
and let her nurse on spring rain
like the dandelions waiting
to fill the meadow with stars.

Reprinted from The Country Doctor Revisited (KSU, 2010) with permission.

Dr. Berlin celebrates Spring and reflects on his wishes for his patient who is dying of cancer.  We grow attached to our patients. Their losses can become our losses. Although we need to maintain a certain professional distance so that we can contiue to care for them, we can still feel sad and should make the time and space to feel our own grief.

When you grieved the loss of a patient for whom you cared, did you talk with someone about it? Did you cry? Write a poem or story? Go for a run or a walk? We may be scientists, but we have hearts and we are human.

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. . .

Who lives rural today

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer of German ancestry who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

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

 The global age with its increasingly diverse communities is now true in many small communities across the US. In Minnesota many communities settled by Scandinavians or Germans now integrate communities who speak such languages as Spanish, Hmong or Somali. Integrating immigrants into a new community takes some planning. Local leaders need to reach out to leaders in the new communities.  Health care settings need to adapt with interpreters, patient education that is appropriate for the cultural values and eventually staff who are from the immigrant community. Health care professionals need education about the beliefs and values of the immigrant community.

 If the community where you are rotating serves diverse ethnic groups, how well has the hospital /clinic reached out and prepared for the different communities? Do not mention the name of your community in your response. Consider the availability of interpreters, patient education materials, diverse staff and the relationships between the hospital/clinic and the community.