Tag Archives: Minnesota

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.

 

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.

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.

Thank God for My Ass

–Therese Zink

I am not referring to my backside, although I do have a well developed gluteus
maximus due to my stocky German build and fifteen miles of running every week. My ass is Jimmy, a shy miniature donkey (think Shrek’s pal) who has been the companion of my horse, Indy, on my twenty-acre farm for almost four years. Recently Jimmy saved my ass. Please pardon my crass language, but it is the truth.

At about eight one evening, my cell phone chimed as I was driving home.
The local nursing home needed help with an elderly gentleman who had been
admitted three days earlier. My partner had given him some furosemide late
that afternoon for congestive heart failure, but Mr. Olson was still edematous
and very short of breath. “The family is upset and wants me to do something,”
the nurse reported. “His hemoglobin is four and his potassium is six. Will you
talk with the daughter?”

A hemoglobin this low would require a transfusion of several units of blood,
and the potassium suggested kidney failure. “Sure,” I responded. Not wanting
to be the student who lost her homework, I said, “But I don’t know him. Please
read me his diagnoses and tell me what meds he’s on.”

It took the nurse several minutes to tick off the list, which included some
dementia and repair of a thoracic aneurysm seven years ago.

“How old is he?” I asked wishing I was not the one on call.

“Eighty-eight,” she informed me. “He’s very sick. DNR-DNI. The family is
pushing me to do something. The daughter is really upset.”

As I drove in the darkness toward home, I took a deep breath and readjusted the
phone next to my ear. My new challenge flashed like a neon sign—the distressed
family of a new patient who I didn’t know. “Any thoughts?” I asked the nurse.

“The daughter is a handful. Good luck.”

“Put the daughter on,” I said and prayed for inspiration.

“This is Janet,” the voice said. “You know me. My husband and I borrowed
your donkey for our church’s Christmas nativity pageant.”

I thanked God for the connection, some place to start this conversation. “Of
course, Jimmy. That was a cold day.” I said and remembered that the shepherds,
kings, even Mary and Joseph, wore snowmobile suits under their cloth costumes. Thick Sorel boots peeked out beneath their flowing robes. Jimmy was insecure without his buddy, Indy. So this manger scene had had a horse and a donkey. Janet and her husband had given me the digital photos that I had cut and pasted into my Christmas letter to family and friends. “I am glad to talk with you again, but I am sorry about the circumstances. Tell me your understanding of what’s going on with your Dad?”

Janet cleared her throat. “My mom cared for him at home for six years. He
started having trouble walking two weeks ago, so I started coming every day
to help her. We decided he needed more than we could do and looked for a
nursing home. There was an opening here, so we moved him last Friday. He’s
gone downhill since.”
I heard the frustration and recrimination in her voice: Why was he doing
worse, not better at the nursing home? “The nurses tell me he has a lot of fluid in his lungs,” I said. “We can help him breathe easier.”
“Can you help him get better?” Janet asked.
Read the rest of the story

First published in JAMA,299:16 (2008):1879–80, used with permission in The Country Doctor Revisited (Kent State University Press, 2010)

Building trust is an important ingredient to the doctor-patient relationship. In the 4 habits model, Dr. Frankel ARTICLE  presents a very practical model for thinking about how to approach the patient. Sometimes trust must be built rapidly, such as in an emergency or crisis. In this story, I was faced with the angry daughter of a patient I did not know. Luckily my miniature donkey gave us a place to start the conversation. If you are on a rural rotation, what have you observed about how doctors and nurses build trust with patients?

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 21st 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.