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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Disconnected US health care

The Dressing Change

–Tara Frerks
I shook hands with Mr. Friedrikson and touched Mrs. Friedrikson on her thin shoulder to avoid the bulky dressing on her right hand.
“I need my dressing changed,” she said in a grandmotherly voice. She cradled her right hand in her lap and shielded it with her other hand and arm.
Mr. Friedrikson, a few strands of gray hair combed across his bald head, sat on the edge of his chair, tapping his left foot on the linoleum floor. “Do you know that you are the fifteenth contact we’ve made trying to find someone to help us?” He thrust a paper bag filled with dressing supplies into my hands.
I placed the bag on the counter and then settled onto a stool to listen. I enjoyed the independence and array of experiences I’d encountered in this small Minnesota community. I asked one open-ended question, “What can we do foryou?” and the Friedrikson’s story came pouring out.
A few months ago, they had retired to a house on one of the nearby lakes. They were new to this town and clinic. Helping her husband of forty plus years with a kitchen project, Mrs. Friedrikson had been trying to steady a two by four he was sawing. Her hand slipped and the blade of the circular saw sliced deep into the flesh and bones of her right hand. With blood soaking an old towel, they drove to the town’s emergency room. The ER physician deemed that the injury was too complex for the local surgeon to repair. An air-ambulance transported her to a trauma center for microsurgery. “We were discharged home last week, and they told us to get checked up here within the week,” Mr. Friedrikson said.
“We couldn’t find any clinic that would see us. Finally, we just went to the local emergency room this weekend. I have to tell you, the surgeon who changed the dressing was kind of nasty.”
“Now Herbert,” Mrs. Friedrikson said. “He was probably very busy.”
I controlled my smile, I’d worked with that surgeon.

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

It doesn’t take much experience to see that our health care system is broken. Patients work hard to locate what they need and even with persistence, their needs often go unmet. This week we learn whether or not the Supreme Court declares the Affordable Care Act’s (ACA) mandate that patients purchase insurance unconstitutional. While the ACA has many problems, it was an attempt to address the fragmentation of the US health care system which spends exorbitant amounts of money and has little to show for the effort. Granted, many of the medical miracles achieved by technology are tremendous, but too many citizens don’t get the basic care they need.

Pay attention in your setting to what works and does not work about patients’ access health care. Whether or not the ACA’s mandate is declared unconstitutional or not, much needs fixing in the current US health care system.

A Psychiatrist Waits for His Ten O’clock Patient and Imagines He Is Han Shan

 

–Richard M. Berlin

Daughter gone,

hair gone, my father

dead for half my life.

Patients I saved from suicide

lived until old age,

died from cancer instead!

Twenty years of hospital work.

Twenty years pruning apple trees

on the west flank of Cold Mountain.

Once they were sticks.

Now the branches bow with ripe fruit.

A faint wind stirs them.

I’ll share a bushel with the crows,

another with the worms!

 

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

Dr. Berlin, a psychiatirst and poet whose poems we've shared in other blog entries, reflects on life's rhythms and transience mimicking the Chinese poet Han Shan. Han Shan referred to himself as Cold Mountain. Dr. Berlin lives on Cold Moutain. Han Shan was a cynic and a hermit who liked to poke fun at the self-importance of the other monks. Enjoy this brief reflection on all we try to do and hope to do as healers/physicians and what it all amounts too.

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.

Early Marriage: West Virginia

–Ann Floreen Niedringhaus

I
The other nurses called them brambles:
prickly creepers climbing up the rock face.
Stopping the car I gathered
blackberries to make an offering
for you—crystal jelly, all seeds
strained out through a dish towel.
Patients warned me later, “You better
watch for copperheads on those cliffs.”
You came home from hospital duty,
tired and distracted,
spread my ambrosia thickly and said,
I’d rather have Welch’s.

II
Driving to home visits, I took as a road
a dry creek bed overhung
with branches and vines.
It ended at a sagging porch,
the family processed a pig,
newly slaughtered, on the kitchen table.
Drawing me in near the carcass,
folks spoke their maladies: blind staggers,
drizzlin’ shits, a head gatherin’
that went away with white lightnin’.
And you walked home from your shift
in the emergency room
with your own stories: a man impaled
throw the chest with a telephone pole,
a woman with a neck goiter the size
of a cantaloupe; a child
whose smilin’ mighty Jesus
was spinal meningitis.
We talked in the dark before you fell asleep
feeling like Lewis and Clark.

III
Perched on the steepest hill in town,
our house was two stories high on the street,
four stories high in the back.
The gleaming Monongahela River
filled the winding valley bottom far below.
Years later my mother told us,
There was a hole in the bathroom wall.
I worried about rats.
We were surprised.
We couldn’t remember a hole.

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

Ann Floreen Niedringhaus, a registered nurse, holds a master’s degree in social work and was a public health nurse in a federal Maternal and Infant Care Program based in Morgantown, W.Va. She is retired, continues to write, and lives in Duluth with her husband.

Nurses, social workers and public health nurses are important members of the health care team in both urban and rural America. Given the focus on health care home, their roles are underlined. I think of home health as the eyes and ears of the clinicians who spend most of their days in the hospital or clinic.  Often a phone call to the public health nurse gives provides me with insights into how I can help a patient manage their health challenges. 

Read another poem by Ann.

A Modern Country Doc–playing the game

Tom Bibey

The insurance companies love to play doctor. Take my noncompliant diabetic patient with a hemoglobin A1C that does not meet goal. (We explained this in an earlier blog post.) The first order of business, since I wish to stay in practice, is to send him to an endocrinologist. If possible, one should bolster the case by the choice of one from a medical center. A year later, the patient will still have the same numbers, unless he comes to Jesus and decides to change his life. The cost of the endocrinologist changed nothing but increased the bill to insurance, and my risk as a target for the blame is dramatically lowered due to the referral.

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

Here Dr. B is referring to our effort to meet certain treatment goals with patients. Some insurance companies reimburse physicians with extra money if a certain percentage of their patients reach the recommended goals. This is called Pay for Performance and sometimes referred to as P4P.

A large randomized controlled trial on diabetes–ACCORD— helped to outline the goals management of  patients with Type 2 diabetics. Here is an easy explanation.

The challenge is to motivate patients to change their behavior, often easier said than done. In earlier posts we’ve talked about Motivational Interviewing techniques to help patient weigh the pros and cons of continuing to do what they do. As you spend time in clinic, you’ll see different attempts to help patients quit smoking, lose weight, start exercising, be compliant with their medications. It is no easy task. However, I don’t want to leave you with a downer. When you do assist someone in making a behavior change, there is nothing like it—it can make your whole day or week for that matter.