Week 1 Philip, South Dakota
I arrived in Philip at around 7:30 pm. I am staying at a small cabin that is part of a hunting lodge. I met with the people who run the place. I then got settled into my “new” home for the next 4 weeks.
Today started off by meeting with the HR person, Jennifer Henrie. She gave us a tour of the facility. I was a little surprised by all of the services offered. Philip Health Services is a community-owned health care system which was recently rebuilt in 2002. The facility consists of an 18 bed critical access hospital, a 30 bed nursing home, and a rural health clinic. In addition, there is an emergency department, physical therapy department, eye clinic (Tuesdays), lab, and digital imaging departments. We met with staff as we took our tour. Jen then took us around town to see what Philip has to offer. We drove by the chiropractor office, dentist office, assisted living, and pharmacy. Over the next 4 weeks we will spend time at all of these places. I was surprised to find that Philip has a movie theater, a livestock auction barn, and an implement dealer. In all honesty, that’s more than my hometown has! We then met Cheri for lunch at the steakhouse. After lunch we attended a staff meeting for CNAs. The nursing home has recently switched over to using medication cards. So this was the main topic of discussion along with typical nursing home issues. I also found out that the local pharmacy in town is in the process of switching owners.
We met with Dave Webb, PA and discussed career path options for PA students. There was a possible ER visit of a broken arm and broken leg. The patient did not show up to the ER. According to staff, this is common for someone to call and not show up. We then spent time with Mindy, a radiology technician. She explained some of the past cases that she has seen. I found this really interesting as I have little experience looking at and interpreting x-rays. In the afternoon we had an ice cream social and met more of the staff. We worked on our community project for the rest of the day. For the evening we went to a dance at the nursing home. After that we watched the softball league game.
We started out our day with a radio interview with a station out of Fort Pierre that was traveling as part of a “hometown” tour. Following our interview, we spent the day at Dakota Country Pharmacy, formerly Zeeb Pharmacy. As a pharmacy student, it was great to see the aspects associated with independent pharmacy. It was also neat to see the transition of ownership. The new owners are renovating and updating the pharmacy. Dakota Country Pharmacy not only fills walk-in prescriptions but also fills the medications for Philip Health Services including the nursing home. They will soon be filling medications for the nursing home in Kadoka as well.
To start the day we met up with the pharmacist at the hospital. She showed us the process for recording inventory and ordering for the facility. We spent the rest of our day at the assisted living getting a feel for all aspects of care. We talked with and helped the UAP, who wears many hats around the facility. We discussed operation and protocols for the facility. We then shadowed the LPN as she did a dressing change for a resident. We then wandered around the facility and met many of the residents. We helped serve lunch. We also tried to help with a puzzle and play Kings in the corner.
Today we shadowed in the lab at the facility. It was exciting to see all the technology in place. The lab techs told us all about each machine. Over the course of the day we witnessed several blood draws, urinalyses, and chemistry panels. We also ran tests for cardiac enzymes and HCG. We looked at slides as the techs had to complete manual differential counts for some samples. Most of what we saw was confirmation of bacterial infections such as UTIs. We did look at some chest x-rays in order to see pneumonia. We had one ER visit for chest pain. We looked at EKGs for this patient and determined that a heart attack had not occurred. Following this we looked at EKGs from past patients. Brittany, the PA student I am paired with, explained to me what to look for and what different variations mean. After leaving the clinic we went to the Philip Rodeo and street dance.
6/14/14 & 6/15/14
Since it is “Scotty Philip Days” we went to a parade on Saturday morning. In the late afternoon we went to a demolition derby and ate supper at the steakhouse. On Sunday, I went for a two mile walk with my fiancé who came out to visit for the weekend. After he left, Brittany and myself went horseback riding at one of the lab tech’s ranch. Her daughter went with us and we moved a group of bulls from one pasture to another. After we got back to the ranch, we watched her remove the shoes from her roping horse.
6/16/14 Today was a busy, busy day in the clinic! We started off the day by seeing a patient for a UTI. The next patient we saw was a young female with a hoarse voice. We completed a strep test which turned up negative. We met with another patient with a chief complaint of leg pain and history of DVT. The patient was sent to Rapid City for an ultrasound which later confirmed a blood clot. The patient was started on Lovenox and Coumadin. Our next patient was following up with the clinic after being treated for two hematomas in his leg. He was restarted on warfarin the week prior to the appointment and had his INR checked today also. We then looked at x-rays of a child who sprained an ankle. There was not a break, only swelling. Next, we met with a patient who had a history of cancer and had previously been seen in the clinic for a H. Pylori infection. The patient did not feel that the infection had cleared as weight loss and poor appetite were still occurring. The PA continued treatment for one more week. Around lunchtime, we had two ER patients. One was admitted for infection that had previously been treated with cefuroxime and clarithromycin, which were ineffective. The chest x-ray did not confirm pneumonia and according to the radiologist looked like tuberculosis. The PA consulted a pulmonologist on the issue and concluded it was not TB especially with the patient’s presentation. The other ER visitor presented with ataxia and general malaise. This patient was admitted as several issues and comorbidities needed to be addressed. In the clinic later in the afternoon, we saw a case of Osgood-Schlatter disease. I knew nothing about this until Brittany educated me on it. The patient presented with knee pain in a certain spot when pressure was applied. An x-ray confirmed that the patellar tendon had slightly avulsed part of the tibial tuberosity. This mainly occurs in growth stages in teenagers as the bones may grow more quickly than the connective tissue. Later in the day, we saw a radial and ulnar greenstick fracture, which was splinted today and will be put in a hard cast in a couple days. We saw a case of strep in a child who presented with a rash and cherry red tongue. The last patient we saw presented with a fever and abdominal pain. Chest x-ray confirmed pneumonia. At around 8 pm we were called into the ER to see a patient who had hematemesis. The patient also complained of pain in abdominal cavity. After looking over a few x-rays and labs we found nothing significant. The creatinine and BUN were slightly elevated. IV fluids were started along with an oral stomach cocktail of lidocaine, Donnatal, and Mylanta.
Today was really interesting as there was so much going on. I witnessed the compounding of a “banana bag” consisting of folic acid, magnesium, thiamine, and an IV multivitamin. Since I haven’t exactly had much hospital pharmacy experience this was new to me. I did medication reconciliation for one of the ER admits. I also helped the PA student obtain a PMH for two patients. I also got a feel for all the documentation required as I listened to the PA and PA student complete dictations for each patient seen.
6/17/14 I traveled with three home health nurses for the majority of the day. We first stopped at a patient’s home to change a colostomy bag, fill a weekly medication tray, and draw up insulin for the patient to administer. The home health nurse also completed a weekly assessment of the patient. We then visited another patient to complete an assessment and fill meds. The last patient we saw for the day has recently been released from the hospital. The nurse stressed the importance of physical therapy exercises, as the patient was not completing them. We filled a medication tray, which will eventually be the patient’s responsibility. According to one of the nurses, Philip Health Services has started a new program where a home health nurse follows up with patients who have been discharged once a week for two weeks after discharge. The purpose is to hopefully decrease the rate of readmission, better educate patients, and increase compliance. Upon returning to the facility, I helped the pharmacist submit an order and record the transfer of CIIs from the pharmacy to the med room. I spent the remainder of my day in the clinic. We got to see a patient with cerumen impaction and the removal process. We saw another patient for a pre-operation clearance. After leaving the clinic for the day, we played on the women’s softball league that we were invited to last week. The Philip Motor Team (our team) lost the first game and won the second game against Weta (a town in the Badlands). Games are every Tuesday! Surprisingly, I did pretty well considering it’s been about six years since I’ve played!
6/18/14 We started the day by putting a long arm cast on a patient. We then had an ER visit. It was ironic because I had just seen the patient on a home health visit yesterday and they seemed great. The patient presented with shakiness, fever, and extreme lethargy. Later on in the clinic, we saw a patient with chief complaints of knee pain and chest congestion along with cough. The knee pain was ruled out as osteoarthritis. The patient had been sent home with a Zpak several days ago. Labs indicated the infection was still present. Levofloxacin was prescribed for the patient. Upon examination of the patient the PA discovered the patient was tachycardic. Since the patient also had a pacemaker, the PA ordered an EKG. According to the EKG, the patient was in atrial fibrillation. In the chart, there was no history of this anywhere to be found. Medication options were discussed between myself, Brittany, and the PA. The patient wanted to speak with their doctor at Mayo Clinic before making any decisions. We then saw a patient for knee pain. The patient has history of a tibial plateau. An x-ray indicated no problems with hardware. The patient was referred to Rapid City for a MRI to check out the joint.
It was a little eye opening in that the facility still uses paper charts. They are in the process of switching over to EHR. By mid-October everything should be switched over. In speaking with staff in the clinic and hospital, many are not looking forward to this change. Brittany and myself were discussing the pros and cons to switching over. After reviewing several charts in the clinic, we decided it is difficult to piece together a history by flipping through tons of paperwork.
6/19/14 We spent the entire day in the clinic again. This time it was with a MD rather than a PA. I like working with different providers just to get a feel for the process. Everyone has their own unique process and way of thinking. We saw a couple different things today that were new including a patient with a corneal tear. I had never seen the process of placing dye in the eye and using a black light to inspect it. We saw a couple patients for a yearly physical. We also met with a couple patients who were in for testosterone injections. Another unique case from today was a patient who presented with a rash on nearly the entire body. The rash was not itchy or raised. It was determined to be an allergic reaction and antihistamines were recommended. We visited a patient that was admitted yesterday. The patient was experiencing aphagia with slight confusion. It was found that gram + organisms were present in the blood. We are still waiting for cultures to come back before switching antibiotics. I was also put on the spot to calculate a creatinine clearance for this patient. One of the last patients we saw for the day presented with multiple complaints including fatigue, decreased appetite, and stomach pain after eating. After ordering labs, it was determined the patient had a viral infection and was also positive for H. Pylori infection.
Overall, today was quite educational! The MD we were following asked us tons of questions and had us give our own assessment and recommendations for each patient. It was a good way to review what we knew and to learn what we didn’t know.
6/20/14 I started out the morning by shadowing at the nursing home. I followed the UAP and asked her questions about medication administration. I found that the facility has recently switched to having a med aide administer medications rather than a RN. After spending the morning in the nursing home, I hopped over to the clinic to see what was going on there. We saw a 6 month-old baby for a check-up. We had a patient visit for a yearly physical. We also met with a patient who was experiencing stomach pain after eating and has had a history of stomach issues. The patient was already on omeprazole. The doctor ordered an H. Pylori test. After finding it was negative he referred her to Rapid City for an EGD (scope procedure). Next, we saw a patient in the ER who did not want to wait for a clinic appointment. The chief complaint of this patient was constipation. The patient was examined and eventually sent home with magnesium citrate. The patient was also educated on staying hydrated, adding fiber to the diet, and possibly adding polyethylene glycol as needed.
6/21/14 & 6/22/14 I drove back to Sioux Falls for the weekend to finish last minute wedding plans!
~20 days til the big day!!
Today we started out in the nursing home. The nursing manager showed us the facility and introduced us to many of the residents. We then shadowed the activities coordinator as she helped a patient with restorative therapy. We asked residents if they were interested in going out to the daily morning activity. After gathering residents, we participated in the activity by reading to the residents. Later on, we watched two wound dressing changes. We also helped seat people for lunch. For the afternoon, we were in the clinic. I watched a nurse administer three immunizations to a 6 month old. We also saw a case of ORF in a ten-year old. ORF is caused by the parapox virus and is normally carried in sheep and goats. The case was interesting because humans don’t commonly become infected with this. The patient has been known to spend much time with her goats and also milks cows by hand.
I spent the morning visiting with the county health nurse. She did not have any appointments. She explained all the services offered through the department of health. She also explained her experiences and major duties in community health. After spending a couple hours at the court house, I returned to the clinic for the remainder of the day. The first patient we met with was in the swing bed unit of the hospital. The nurse observed a sore in the patient mouth when dentures were refused. The patient was also having difficulty eating. The patient was started on Augmentin as Ludwigs angina was a concern if an infection or abscess developed. The patient was also referred to a dentist. In the clinic we met with a 2 year old experiencing extreme stomach distention and pain. Roughly 10 days prior to the appointment the patient experienced gastroenteritis. After x-rays and labs indicated no blockage or values out of range, the distension was ruled out as gas. We also saw a patient for chest pain. After thoroughly checking into labs and an EKG, the pain was ruled out as musculoskeletal. To end our day we played softball against the other Philip team, winning of course!
As soon as we arrived at the hospital this morning there was an ER patient waiting for us with lower leg trauma. X-rays and CT showed no fractures or breaks. The patient was sent home with a pain medication. We spent the remainder of our morning down at the pharmacy. We filled prescriptions and helped put away the order. We also watched the process of filling unit dose cards for the nursing home. For the afternoon we worked on completing our surveys for our community project and report.
We spent our day in the clinic as the chiropractor was unable to meet with us. We saw several different things today. The first patient was visiting for follow-up on an incision. We removed the steri-strips and inspected the incision for possible infection. The next patient was diagnosed with a UTI and prescribed Septra. The PA student and I picked an antibiotic and calculated the dosing. The PA then approved our decision and showed us the dosing method he uses from the Tarascon pocket pharmacopoeia. We then checked on a patient admitted to the hospital earlier this morning. After this, the x-ray technician showed us the CT scan from yesterday and explained the different views. She also explained when contrast would be used and when it would not be used. Brittany and I then met with another ER patient who presented with diarrhea and stomach cramps. The patient later said there was blood in the stool at times. After a thorough work-up, the patient was sent home with Cipro for infectious enteritis. We later met with a patient with a skin laceration. Since more than twelve hours have elapsed since the cut, stitches were not an option as they could increase the risk of infection. We cleaned the wound and placed steri-strips on it along with Poly-Sporin and gauze. The patient was also prescribed cephalexin for prophylaxis of infection. We met with two patients and evaluated INR levels. Both of the patients required changes to their current regimens. The last patient we met with visited for a steroid injection in her knee. The PA explained the administration technique and the reasoning for therapy.
We spent the day in the clinic. We saw two patients for cough. The PA ordered a chest x-ray and CBC with differentials for both patients. The work-up revealed no underlying pneumonia or infection. The next patient we saw presented with the classic signs of hand foot and mouth disease. Since it is a viral infection there were no treatment options. The parents were educated on hygiene and decreasing the spread of the virus. Our next patient was visiting for a steroid injection for allergies. The patient was educated on the importance of continuing antihistamine therapy and being compliant. Kenalog was also administered to alleviate current allergy symptoms.
6/28/14 & 6/29/14
On Saturday, I went to Rapid City for the day while Brittany stayed in the clinic for the morning.
We were called into the ER on Sunday for several patients. The first one we met with was an elderly patient who had fallen at church. The patient was admitted for observation as a history of falls and Parkinsonism were present. The next patient was involved in a four-wheeler roll over. X-rays confirmed no breaks, but possible ligament damage. The patient was put in a sling and is to follow-up in the clinic this week. We had two cases of fishhooks imbedded in the skin. Lidocaine was administered in both situations. The fishhooks were pushed through the skin and the barb was clipped off. The rest of the hook was then easily pulled out. Our last patient was elderly and experiencing confusion. A CBC and urinary analysis revealed no underlying infection. The patient was sent home and is to follow up in the clinic. Home safety and long-term care were discussed with the patient as well.
6/30/14: We spent most of our day at the dentist office. We saw multiple fillings along with the extraction of a tooth that had previously broken off. We saw a patient with periodontal disease, in which case the dentist cleaned out the gum line and referred the patient to a periodontist. We observed the dentist fitting temporary partials for a patient. We then witnessed the prep process for molding/casting a crown. The patient had previously had a root canal. A temporary cap was placed over the surface after the impression was taken. It was then sent to Rapid City where a crown will be made and shipped back to Philip. The patient will follow up in a week or two for placement of the permanent crown. The next patient we met with had swelling in the parotid gland. The patient had previously been at the clinic and placed on antibiotics. Little improvement was shown according to the patient. The dentist referred the patient to an oral surgeon as decreased saliva was present and a ductal obstruction could be causing the problem. These were all the patients that had been scheduled for the day so we walked back to the clinic to see what was going on. We met with a patient who had been previously seen in the clinic for possible pneumonia. Since the last appointment on Saturday, a rash had developed along a dermatome indicating shingles. The patient was prescribed famciclovir, triamcinolone cream, and gabapentin. We then visited with a patient with a chief complaint of hematuria. After evaluating the lab results, the doctor discussed further investigation with the patient as a UTI was not present.
After a day at the dentist, we both decided we picked the right career path. It was awesome to see all that dentists do. Looking at it from a patient perspective, it’s probably better that the patient can’t see what’s going on, especially on the tooth extraction case! Today was definitely an eye opening experience!
7/1/14: We started off the day in the clinic. The first patient was re-visiting for cryotherapy on a wart. The callous surface was scraped off followed by liquid nitrogen application. The next patient was following up for removal of a long arm cast and replacement with a short arm cast. We met with another patient who wanted several moles to be checked out. Upon exam the PA stated that it was seborrhea keratosis. The patient is to monitor changes, especially if rapid, and follow up in two to three months. Our next patient was visiting to have earwax removed. The nurse tried several times to wash out the cerumen with no luck. The patient was instructed to place olive oil in the ear to help dissolve the wax prior to a follow-up appointment on Monday. Our next patient presented with right lower quadrant pain. After a thorough exam, a pneumonia was found. We later witnessed the aspiration of a ganglion cyst on a patients shoulder. For the afternoon, I ventured over to the eye clinic to shadow the optometrist. I watched a couple eye exams and learned about the process involved. We also discussed the transition to electronic records. I also asked about the eye clinic closing in Philip. The main eye clinic is in Rapid City and they visit once a week in Philip. The same services aren’t offered at the satellite site and many patients are not following up properly. Many of the patients seen in Philip visit the Rapid City clinic since there are more services offered and a greater selection of frames.
7/2/14: Today we worked on our wellness coalition papers and perfected our PowerPoint for tomorrow’s “Farewell Fiesta”
7/3/14: We started our last day by preparing for our presentation. We met with a couple patients in the morning, including the PA who had a steroid injection for a trigger finger. The doctor observed as Brittany administered the medication. We had two patients in the ER also. It was definitely a busy morning! At 11:30 we gave our presentation to about ten people. We ate lunch and talked more about our experience. I then said my goodbyes and headed east.
Overall, the REHPS program was a great experience for me. I enjoyed seeing what other healthcare professionals do on a day to day basis. It was also nice to gain insight to the full picture of what goes on prior to a patient filling a prescription. I learned much from the PA student during my time in Philip. I also thought it was helpful to show Brittany what the role of a pharmacist is across different settings.