Category Archives: Rural health care

Blog: Rural Mississippi—Aftermath of Hurricane Katrina

–Shailendra Prasad

August 2005. I planned on flying back to New Orleans after a conference in Arizona. My wife and son had accompanied me. We watched Katrina grow like a weird reality show—a petulant child gaining weight, becoming unruly. There was talk about this being bigger than Ivan from the year before, even bigger than Camille from 1969. “No,” my friends and patients in Mississippi told me, “nothing gets bigger than Camille.”

Our flights home were canceled. Then we learned our neighborhood was under mandatory evacuation. Evacuation was not foreign to us. We’d participated in four drills during our seven years in Mississippi. “Hurricane parties,” we called them. We’d lock the shutters on the house, secure the garage door, and remove the yard implements that could become missiles in the sixty plus mile-per-hour winds. Then along with our two satchels filled with a change of clothes, our son’s favorite toys, and copies of our important documents we would drive to a safe home, a friend whose home was not in the path of the storm. We’d spend the night playing cards, talking, and waiting out the squall. Usually we could go home the following morning.

We hoped this, too, would pass and called a friend who had a spare key to our house.

“Sounds like a bad one,” our friend said.

“Can you get our hurricane satchels? There are two of them, in the closet in the master bedroom.”

“Sure. I’ll lock up the house too. Anything else?”

“Yeah, put the birdfeeders in the garage. The birdbath too.”

“Of course. Be safe. I’ll be in touch.”

That night in Phoenix I watched the television. Reporters talked about the rain and wind in surrounding areas. Counties in both Mississippi and Louisiana were evacuated. I called every number in my cell phone. No answer at the hospital, the clinic. My practice partner did not respond at his home phone or cell. I could not reach our neighbors or local friends.

Our county, Pearl River, and our town, Picayune, were orange on the weather map. The Internet news pages said nothing more. I could not eat dinner. I continued to make calls. I phoned my dozen sickest patients whose numbers I kept just in case they needed me. No one answered. I worried about my three-year old patient waiting for a renal transplant at Tulane. He’d just gotten a match.

What would happen now? No answer. And there was complicated Mr. Shirley who I just referred to the neurologic unit in Birmingham, Alabama. Would he get there for his appointment? When was that appointment? No answer. Then there was my dialysis patient. Where would she go? No answer. Feeling restless and helpless I walked down to the business center and opened this blog:

Pearl River County Katrina Survivors

This is my attempt to help in the aftermath of Katrina. I work in the Picayune area and have very dear friends in the area. The only precondition to this blog is this—respect your fellow bloggers.

Please blog away to add on to the information on Picayune/Pearl River County,Mississippi.

posted by sprasad @ 8/30/2005 07:54:00PM

By midnight there were thirty posts. I am looking for . . . I am trying to reach. . . does anyone have any information on . . .

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

Dr. Prasad felt an obligation to his patients during Hurricane Katrina. Medicine is rarely something you can walk away from when you leave the hospital or office. Often you carry patients with you – think about them, worry about them, pray for them. In a small town you often see  patients as you run errands at the hardware or grocery stores. This raises the issue about how one sets boundaries. How one cares for his/herself.

Talk with your preceptors and other staff in you clinical setting and see how they manage these challenges. 

Modern rural

–Tom Bibey

And yet before you misunderstand, let me reassure. We are modern. We use the same medicines as our city counterparts, and we are only a helicopter flight away from the latest technology, not that it solves all of our problems. We take the same competency tests as our colleagues, and I’ll bet we do just as well or better. (Maybe my old professors did a little better, but they got to write the questions.) We have access to the same information too. My computer is just as fast as the ones over in Raleigh.

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

Dr. Bibey addresses with humor the impression that rural means backward. It is easy to judge the choices another provider made when you aren’t in the trenches with him/her.  In other entries, we’ve examined the innovative efforts to adapt to the quickly changing world of modern medicine that have originated in some rural practices. Examine your setting. Who are the innovators? What are the qualities they have that keep them thinking and moving forward? Is it curiosity? Is it the desire to serve their patients well? Is it the need to keep learning and stay engaged?  

The changing face of rural America

–Therese Zink

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 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 author, published in The Country Doctor Revisited, KSU, 2010)

How do we meet the needs of patients that extend beyond the clinic.  These are often called the social determinants of health. These play an important role in keeping people healthy and helping them achieve health.  Health care professionals need a team to address these issues and that team includes public health, social workers, as wells a policy makers and community advocates.  Pay attention in you community.  Is your preceptor aware of the other factors affecting a patient’s situation?  An alcohol problem? Housing problems? No money for food? Family problems?

Sometimes new Americans or immigrants have a more difficult situation because supports do not yet exist to help them and language barriers make it hard to communicate. If you community has immigrants, how are they welcomed into the health care setting?  Interpreters? Signage? Specific patient education? Multi-lingual providers? Art on the clinic walls?

If you were in charge what would you do differently?

Cattleman

–Michael R. Rosmann

Kent raised the manure-splattered tailgate of the livestock trailer to let his cows enter the chute into the Farmers Livestock Auction stockyards. This was the last truckload of his 130 cows that were scheduled to be sold at today’s auction. Most of the red and white cows hurriedly tramped down the sloped chute to reach the more solid footing of the concrete alleyway leading to their pens. There they would wait for prospective buyers to inspect them. Kent was familiar with each animal as she passed and knew all their ear tag numbers and names.

He remembered how he helped Sally give birth to twins in April 2003. Sally’s first calf was coming with one front leg turned backward. Despite Sally’s contractions, Kent pushed the calf ’s head and chest back into her uterus and reached inside to pull up the errant leg. After grasping both front feet, he quickly pulled the wet calf into the outside world. The second calf was less fortunate, for Kent discovered that its umbilical cord had become twisted earlier during its detained emergence.

Wincing from the hollow feeling in his stomach, Kent watched as Belle scrambled down the chute, and he remembered that she had produced the high-selling bull in his annual production sale twice in the past five years. “I’ll miss you.” Then Molly came to the trailer doorway and briefly locked onto his gaze as she gingerly placed one hoof ahead of the other into the chute. They had an eleven-year relationship. “Sorry, old girl.”

When all the cattle were unloaded and chased into their holding pens by the sale hands, Kent visited the auction office to tell the clerks that he had delivered all his cows. With a Styrofoam cup of steaming coffee quivering in his thick hand, Kent headed to the holding pens in the adjoining shed to take a last look at his pets.

. . .

A heavyset neighboring farmer in coveralls lumbered to catch up with Kent
and protested, “Kent, why is that cow bellerin’?”

Kent stopped in his tracks, turned, and responded, “She’s wondering what
she did wrong that she should have to be sold.”
The hefty man momentarily paused and put a hand on Kent’s shoulder. “Yeah,
it’s too bad,” he murmured.

Shivering, Kent struggled to maintain his composure. He remembered the
words of his psychologist whom he had consulted last week for his depression.
“Why don’t you keep a few cows for yourself; they’ll help you maintain your
self-respect.”

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

Part of loving rural is the relationship with animals and nature. I have my own relationships with a miniature donkey who has inspired many stories due to his onwry personality, a horse Indy who is a terrific riding partner. An experienced rider told me the relationship with a horse is 60-40. I am the sixty. Sometimes he’s right about the way home or recognizes the hole in the trail I miss. Then there are the cats, precious for the mousing abilities and their willingness to hang out in the garden with me when I weed.

In this selection Kent has to sell his cows due to financial hardship. Dr. Rosmann explores the challenges of depression and access to mental health services in rural areas. Ask questions about the mental health services in your area. Where do patients go for psychiatric help and how long is the wait? Where can patients go for counseling services, for substance abuse assessment and treatment? Often rural providers manage more complex mental health issues because consultants are few and the wait is long.

National Rural Mental Health Association has a journal and other resources.

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.

 

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.