Amanda N’s Blog Back to 2013 Students
Custer, South Dakota
Tuesday: On my first day, I was able to spend time in the ER as well as in the hospital. When we did not have any ER patients, I was following the nurses to get a feel for how inpatients are cared for which involved administering medications, changing wound dressings, and performing laboratory tests such as a urine dip. The ER was busier than normal today, so I was able to see a number of cases and procedures. The most memorable and emotionally-challenging case involved a toddler who had sustained significant trauma and had to be transferred to a larger facility via Life-Flight. Perhaps the most difficult aspect was trying to comfort the family members who were in shock while maintaining a professional, composed demeanor. Additionally, I was able to observe the repair of a thumb and nail which had been lacerated. Providers in rural practice do not just see patients but also perform any necessary procedures within their scope of practice since they do not have the “luxury” of routinely referring patients to specialists. I find the ability to “do” and not just “see” rather appealing about rural medicine.
Wednesday: Today was slower-paced as my partner Amber and I spent the day with a pharmacist in a skilled nursing facility reviewing patient charts. This involved making sure each medication was associated with a diagnosis along with looking out for any potential drug-drug interactions. We learned that certain medications such as anti-depressants and anti-psychotics must attempt to be weaned down every 2-3 months. Another responsibility of the pharmacist is to make sure that each medication is being monitored appropriately (i.e. regularly checking TSH for patients on Synthroid or monitoring liver function for those taking a statin). Additionally, we participated in checking med carts for expiration/open dates on all of the medications. Finally, we helped the pharmacist and the RN with med destruction and were able to see what is involved with that process. As a Physician Assistant student, I was able to become more familiar with the role of a pharmacist in the management of patients in long-term care facilities. I also learned more about the interaction and collaboration between the pharmacist and provider in the medical care of patients.
Thursday: Dr. Daniel Custis of Destination Dental was kind enough to let us spend the day at their clinic to learn about everything they are able to do in the field of dentistry. I was impressed to see how new and updated their facilities and equipment are. Before today, I was not familiar with how crowns are designed, milled, and fitted. At Destination Dental they have specialized technology and a machine which allows a crown to be digitally designed based upon pictures which are taken of the patient’s teeth. Once the dentist has formed the ideally-shaped crown, the image is sent via radio waves to the machine which then carves out the exact replica of the image. The crown is then heated at temperatures exceeding 900⁰F for 13-19 minutes. This entire process is done right in the dentist’s office and allows the patient to have the complete procedure done within a few hours instead of having to return a few weeks later after molds are sent to an outside facility. As a result, patients have better access to many procedures and are able to spend less time at the clinic by utilizing new, time-saving technology. Such advancements are not available only in larger cities, but rather patients in rural areas are also able to receive state-of-the-art care. As a Physician Assistant student, Dr. Custis also showed me how to do a thorough exam to evaluate the muscles of the face, jaw, and skull which will be helpful in the clinical setting. This experience has improved my understanding of what dentists are able to do as well as given me a better idea of when it may be appropriate for me as a healthcare provider to refer a patient to a dentist.
Friday: To end the week, we met with a variety of people to discuss various topics. Helen Nichols, RD met with us in the morning to give us her perspective as a dietician. She was very helpful with sharing pointers on things we should be considering from a medical standpoint when patients have dietary restrictions or are receiving enteral/parenteral nutrition. Next, Dave Ressler from the Chamber of Commerce treated us to lunch at the Buglin Bull. He gave us a thorough background on the community of Custer and then took us on a tour to see the main organizations as well as the infrastructure and government buildings around town. Finally, Judy, RN at the Community Health Services building explained all of their programs to us including the WIC program, nutrition counseling, family planning services, and immunizations for children. This day as a whole showed me that there are many services offered in rural communities, and there are many activities, events, and opportunities for community service/involvement.
Saturday: Amber and I were fortunate to have a once/year (or twice/year for 2013) opportunity to participate in the Volksmarch at Crazy Horse monument. The Volksmarch is a 10K “organized hike” which travels around and up the mountain and ends on the arm face-to-face with Crazy Horse. This is the only time when visitors are able to approach and climb the monument. We completed the hike in <2 hours and spent some time at the museums afterwards.
I spent the morning seeing patients in the walk-in-clinic with Dr. Joy Falkenburg. I was able to see a variety of cases and help with procedures such as suture removal, cryotherapy, and splinting. Over the noon hour, Amber and I went with Veronica Schmidt, CEO of the hospital and clinic, to the Custer Rotary meeting and luncheon where SD Secretary of State Jason Gant was visiting and giving a presentation on his duties. Afterwards, we volunteered with the Rotary club at “Bike Rodeo”, an event for the children of the YMCA programs to learn about bike safety and get fitted for a free helmet. Amber and I helped run the obstacle courses for the children to practice bicycle maneuvers.
During the morning, Amber and I spent time in the radiology department. We observed a CT scan of the abdomen/pelvis with contrast of an elderly female patient who was experiencing persistent abdominal pain and chronic UTIs. We then followed Nicole from Black Hills Ultrasound. She performed 2 kidney/renal artery ultrasounds for patients with hypertension of unknown etiology. She also did a follow-up echocardiogram for a patient with known aortic stenosis. After having lunch with and meeting with a Pharmaceutical representative, we spent the afternoon in the laboratory learning about all the lab tests such as CBC, CMP, urinalysis, cultures, and more. The more complex tests and less-commonly performed tests are sent to Rapid City due to cost effectiveness.
In the evening, Amber and I helped out the Relay for Life team at a fundraiser downtown involving an Elvis impersonator concert put on by the local magic show magician and crew. We helped the team sell popcorn for donations and had great success! The event was also quite entertaining and allowed us to meet and interact with other community members. The Relay will be this Friday, and we will also be helping out that night in addition to setting up a table to present our community project.
Today I saw Home Health patients with Rod Elliott, RN in the Custer and Hill City regions. This involved checking vitals, examining the patient, addressing any concerns, and completing the documentation. For any urgent issues, or if vitals were out of the parameters, we were to contact the primary care provider to advise them. Often there is a delay in the response from the provider, so sometimes the nurse needs to make a decision if any other measures need to be taken at the time. The benefit of Home Health allows the patients to transition from a hospital or other facility back to their own home. Receiving care in the home often leads to decreased hospital readmission rates and better outcomes for the patients.
In the evening, Amber and I went to Hill City for a free concert put on by Brulé, a Native American band which plays traditional and contemporary music in conjunction with Native American dances and rituals. The concert was wonderful, and it was a great cultural experience!
We were at Carson’s Drug all day for a pharmacy day with John Carson, RPh. Amber and I were able to help fill prescriptions, call other pharmacies for Rx transfers, provide counseling, help with reordering medications, and register new patients to fill prescriptions. We were also able to see the process involved with ordering a medication which is not normally kept in store. John was very helpful and took the time to show us how to use inhalers, EpiPens, and topical medications in a patch form.
Today I was in the Physical Therapy clinic mostly following Betina Basso along with Jim Simons and Cheryl. Being a Friday, the day was slower-paced, but I was still able to see a variety of cases including vertigo, total knee replacement, joint pain, and rotator cuff rehab. For one of the cases, we were able to meet the patient outside at the high school track to complete the therapy session. This is a unique aspect of rural health and probably not something that is done in an urban setting. The therapists really get to know their patients in the rural setting and are able to be flexible in regards to where the sessions are carried out as well as what they are able to do. Betina and Jim also did home visits today, although I went with Cheryl to see an inpatient during those times.
Tonight was supposed to be the annual Southern Hills Relay for Life. The event went on for a few hours until we got rained out. Amber and I presented our community project during the first part which involved educating the public on obesity and how to prevent or reduce it. In addition to handing out brochures, we created a Personal Health Assessment so participants could get an idea of their areas of needed improvement. Along with answering questions relating to dietary, exercise, and other lifestyle-related issues, they were able to have their blood pressure, weight, BMI, and waist circumference assessed. After presenting to those who were interested, Amber and I were able to walk a few laps before the storm came. It was a fun event and a great way to be involved with the community.
Interesting case this week:
On Monday, I saw a patient in the walk-in-clinic for hematuria (blood in the urine). Due to the absence of other symptoms along with the patient’s other medical conditions and current situation, we decided not to treat him for a bladder infection as the blood was likely resulting from trauma during catheterization. The following day (Tuesday) when I was in the lab, I noticed his urine culture had come back positive indicating there was also an infectious process going on. Then, on Thursday while I was in the pharmacy, I saw the patient come in to fill his antibiotic prescription. I found it interesting to follow this patient throughout the entire course of treatment from initial presentation in the clinic to taking home the medication.
What an adventure-filled day! Our site arranged for Amber and me to spend the day at Jewel Cave. In the morning, we did the Scenic Tour which is the most popular tour of the cave. On this tour we were able to see some unique formations including dogtooth spar, a 23-foot strip of bacon, and beautiful crystal and calcium oxide formations. We then drove a mile down the road to the natural entrance to go on the Historic Lantern Tour which was an experience of a lifetime! It started at the historic cabin built by the CCC in 1936. There are no lights in this part of the cave, so about half of the 20 participants on the tour were given kerosene or LED lanterns. The views are much different with less lighting and with hand-held lanterns, but it made for quite the adventure! On this 1.5-hour tour, we hiked about ½ mile total, and this involved a lot of stooping, crouching, climbing/descending steep stairs, and even a trap door where we had to climb down 4-5 feet. A few cave bats also made an appearance flying around our heads. We were able to experience total darkness on both of the tours. Following the tours, we hiked the 3.5-mile Canyons Trail in the park.
This morning we were at Lammers Chiropractic Clinic following Dr. Tony Lammers. He was very helpful in explaining the role of the chiropractor in medicine along with demonstrating various techniques and modalities to us. I learned that chiropractic medicine involves more than just the spinal column. As a Physician Assistant, I may consider making a referral for any joint issue that seems appropriate for chiropractic treatment. Dr. Lammers also discussed with us the importance of getting to know practitioners in other areas of medicine in rural communities. He mentioned that everybody often knows everybody else and becomes familiar with how they practice. This allows for closer collaboration which leads to a higher quality of patient care. Such cooperation often does not occur in urban medicine where interdisciplinary teamwork is more difficult to achieve due to the vast number of practitioners who may not all know each other.
Today I spent the morning with Dr. Nathan Wiederholt at Premiere Family Eye Care and was able to observe eye exams for children, adults, and geriatric patients. Some exams were routine vision exams while others were for prevention of secondary complications such as diabetic retinopathy. Dr. Wiederholt also took the time to show me various computers and tools used in evaluating certain conditions. He showed me examples and explained several cases of pathologic conditions of the retina and macula. This experience gave me a better idea of when to refer a patient to an optometrist versus a surgeon or other subspecialist.
Spent the morning seeing patients in the walk-in-clinic and the ED with Dr. Lisa Brown. Saw a challenging pediatric case involving complicated pneumonia with possible allergy to the antibiotic. The patient also had autism and a bad history of shaken baby syndrome as an infant. The family was on vacation from another state, so they were out of their home environment. Also saw a patient in the ED who was in a rollover motor vehicle accident. Because she had been wearing her seatbelt, she was in good condition and was discharged after a few hours. It could have been ugly had she not been wearing a seatbelt; this is a good lesson for us all!
In the afternoon, Amber and I went along with staff members from the U.S Forest Service to help out at a 4H camp for an education day. There were different stations where the kids could learn about meteorology, general wilderness safety, fishing, and “Leave No Trace” etiquette in the wilderness. It was a great day to be out in the park, and the kids also enjoyed it!
We sat in on a few care conferences at the nursing home this morning with Christina Knect, Director of Nursing; Jody, Social Worker; and Tracy, CNA Supervisor. These meetings also usually involve the family member(s) or Power of Attorney, the resident, and the Dietary and Activities directors. The care conference is a quarterly (or more often if needed) opportunity for the residents and family members to review the resident’s condition and express any concerns about his/her care. Amber and I then had lunch with Rich Knuppe, Joey from HR, and Veronica Schmidt, CEO.
After we were full from lunch, Amber and I went with another friend from Custer to hike up to Harney Peak and Little Devil’s Tower in Custer State Park. The hike was awesome and we had some amazing views of the Black Hills, Cathedral Spires, Needles, and Mount Rushmore! Climbing up and sitting on the top of Little Devil’s Tower was a pretty cool experience also!
Today I was in the walk-in-clinic all day seeing patients with Dr. Brown. We saw a number of patients with acute illnesses such as strep throat/pharyngitis or bronchitis which involved procedures like X-ray, rapid strep test, or throat culture. A few of the patients were returning after an initial treatment had failed. It is always a challenge to see these patients and determine what, if any, further work-up should be done as well as what other treatments may be appropriate. As a student, I enjoyed the more challenging cases since they are often interesting and a great way to learn about complex illnesses.
I spent the morning with Laurie Morgan from the Department of Social Services. She showed me what her work at the offices involves and explained all of the different services offered to various clients. We then went on a home visit to see a patient living in a government-sponsored apartment building. The individual had suffered a heart attack within the last year and was recovering from some of those effects. Laurie went through a survey with him asking various questions about how satisfied he is with his care, privacy, autonomy, etc. It was interesting to observe the follow-up that occurs with patients after they return home from the hospital or other nursing facility.
Amber and I gave a presentation on our experience in the REHPS program over the lunch hour at the clinic/hospital. In the afternoon, we went to Rapid City Regional Health to meet with Becca from pharmacy. She showed us both the long-term care/outpatient pharmacy and the hospital pharmacy. She also travels to Custer and Sturgis occasionally to manage the medication dispensing machines at nursing homes and assisted living facilities.
On my last day, I spent the entire day in the clinic seeing patients with Dr. Joy Falkenburg. The morning was quite busy, so we were able to see a variety of patients and cases. We did not see as many patients in the afternoon, but we were still fairly busy since a crew from the Rapid City Journal was with us. They were interviewing Dr. Falkenburg and some of the patients and taking photographs as part of a story on rural health care. During the few hours they were with us, we saw an infant, an elderly patient, a young pregnant patient, and a few patients returning for chronic health issues. Dr. Falkenburg had also done a home visit in the morning as well as taken care of patients in the hospital and nursing home. She additionally takes care of many of the family members and friends of her patients which is another unique aspect to rural health. It was great the timing worked out for the crew to see the wide spectrum of care involved with rural healthcare, and I was also glad to end my REHPS experience with such a diverse day. Rural family medicine never gets boring because of the variety of patients, along with all the procedures that can be done by the trained provider!