Tag Archives: rural

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. 

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.

 

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 Modern Country Doc–The EMTALA end run and more

 –Tom Bibey

Over the ensuing decade, I did learn how to circumvent EMTALA (Emergency Medical Treatment and Active Labor Act). I call it “the EMTALA end run.” If by chance a doc has a patient who wound up in the wrong facility and can’t find anyone to accept a transfer, you do “the EMTALA end run”: tell the family to check the patient out AMA (Against Medical Advice—I try not to use abbreviations). Arrange for an ambulance to take the patient to a facility that has the specialist they need, such as neurology or cardiac surgery. Once there, the family can demand their loved one receive the specialized care not available at the first institution. This is an insider country doc trick, and it works every time. Oversight of medicines would be even more humorous, if not so sad.

One elderly patient came to see me and complained of being weak, nervous, and dizzy. Being the smart doc I was, I figured the three diuretics she was taking had something to do with it, so I changed her regimen to one that reflected current clinical rationale. In short order, she spun out of control, and became incoherent and combative. She was hospitalized for an intensive evaluation, only to find the resolution to the problem to be the urgent reinstitution of her old regimen. She returned to normal in a few days and again was weak, nervous, and dizzy. I knew the chart jockeys would come around in six weeks, and no one would understand, so I arranged a nephrology consult. (This guy was one of the smartest docs on our staff—the cats that get acid/base are always quick.) I’ll never forget the nephrologist’s thorough review of the entire medical record, and that poor woman doing her best to answer all those questions again. In the end, he told me it made no scientific sense, but he would continue her antiquated regimen. We all do our duty, I guess. I am still the patient’s doc; the patient is still weak, nervous, and dizzy; the nephrologist left town for a big-city practice where he can make some real money; and the chart jockeys still send letters. Some things never change, and all these government folks who believe they can morph these country people via legislation are naive as to medicine and human behavior.

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

I love Dr. B’s cynicism and humor. What he says is often quite true. #1 Despite the high technology and money we spend on health care in the US, the system is broken. This is evidenced by the need for Dr. B’s EMTALA end run. It won’t take you much time on the wards or in the clinic to see what does not work about our health care system. This is one of the reasons we need energetic, young students interested in advocating for their patients and working for change.

#2 All the science doesn’t explain why some things work for certain patients and not for others. Sometimes they just do. Our scientific studies look for the average, but some patients are beyond the standard deviations of the norm. I don’t want to diss science, it helps me take better care of patients, but at times there is no rational explanation. This reality keeps one humble and also reminds me to see each patient as an individual.

Inside the Mind of a Modern Country Doc

–Tom Bibey

I have seen a lot of changes in my three decades of practice. Technological advancement offers new treatments, and I am grateful for them. Heck, I have partaken of this myself. Last fall I had a retinal detachment, and with modern ophthalmology I was back to 20/20 in no time. Don’t get me wrong, I’ve nothing against being modern.

Computers have improved our ability to compile data, but also have rendered privacy obsolete. Sure, I know the Government enacted the HIPAA privacy rules, but that was only to keep everyone else from cutting in on their business.

Look at it this way: HIPAA was enacted by the same crowd who invented the Social Security number. I don’t know about you, but that scares me a bit. As a small businessman for years, I know the importance of the bottom line. Years ago, the staff and I agonized about increasing office visits from fifteen to eventeen dollars. We were very concerned as to how a two-dollar increase might play in the local circles. My aunt would hear about it and talk bad about me in Sunday school. In small towns, you have to be careful about a bad PR rep at church or in the beauty shops. A local restaurant owner who got greedy and went up a full dollar on a perch plate was out of business in a month. When you live with people, your decisions tend to be conservative, and we were sensitive to local economic issues.

Our bottom line was how our patients fared. If they were happy, and we cleared enough to go another year, we counted it a success. It was like one of my patients said, “I want you to make enough to retire, Doc, just not in a few years.” I agreed and found it good counsel.

Somewhere along the way, medicine evolved into big business. Once the bottom line became a stockholder report, the rules began to change. An old doc, Dr. William Gray, had the same answer for every problem. “I don’t know what’s wrong here, but it’s got something to do with money.” Well, old Doc is long gone, but I think he’s still right.

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

You may encounter gray-haired physicians like Dr. B on your rural rotations. They are often nostalgic about the “good old days of medicine” as portrayed by Barnard Hughes in Doc Hollywood (1991), a movie that starred Michael J Fox as a hip plastic surgeon headed to LA, long before his Parkinsons manifested. You catch the same flavor in the TV sitcom Marcus Welby MD.  In the good old days, little came between the physician and the care of the patient. Most physicians were in solo practice or in small groups and ran their own businesses. They had a lot more autonomy. As with everything, there are pros and cons. In the next blog posts we will explore Dr. B’s take on the good old days meeting modern high tech medicine where lots of “Chart Jockeys” monitor the care that is provided to patients. Dr. B also blogs about blue grass, has written a novel and has another in the works. 

As you shadow and talk with these practitioners who have seen the changes in medicine over the past three decades what do they see as the losses and gains? What changes do they imagine that you will witness over the span of you own career?