Amber Z’s Blog       Back to 2013 Students

Custer, South Dakota
Week 1

Monday: The majority of my day was spent traveling to my new home for the next four weeks, Custer! After I got settled in at Wedgewood Regional Senior Care, I was able to get reacquainted with my partner Amanda, who is a physician’s assistant student. Later in the evening, Amanda and I took a trip to the Crazy Horse Memorial. It was amazing to learn about the huge memorial and to learn about what the future held in store. We ended our night watching the Legends in Light Laser Show at Crazy Horse, which was awesome!

Tuesday: I was really excited to start my experience at Custer Regional Health!! Amanda and I spent the day assisting doctors and nurses in the hospital and the ER. Throughout the morning, I followed one of the hospital nurses as she dispensed and administered medications to the inpatients of the hospital. Since there was no pharmacist in the hospital, all orders are sent to Spearfish or Rapid City Regional Hospital for verification. It was my first experience taking medications out of a Pyxis machine, so it was very interesting. When the drugs came from Rapid City Regional, I helped her restock the ER Pyxis machine as well as the inpatient Pyxis. Throughout the day, the hospital was also changing from the Pyxis machine to an Omnicell machine. There were plenty of differences between the two, so it was nice to observe. By using the Omnicell machine, it will make things easier for the nurses who are dispensing medications.

From atrial fibrillation to head trauma, the afternoon was packed with ER patients. It was amazing to see how all the x-ray technicians, medical assistants, nurses, and doctors worked together to treat each patient. I got to look at x-rays, labs, and medication sheets to determine what each patient had going on. There was a young child with head trauma who was stabilized at our hospital and then sent by Life Flight to Rapid City Regional. I was surprised at the quick action of the ambulance and helicopter crews. It was quite a change of pace for me, but I really valued the experience.

Wednesday: Today, we spent our day at Custer Regional Senior Care, which is the only nursing home in Custer. There are currently 71 residents at this facility. We followed an ambulatory pharmacist, Kerri, throughout the day as she did chart reviews and nursing home recommendations. She only comes once a month from Rapid City to do medication reviews. We were also able to witness and participate in medication destruction. Later in the afternoon, we did charts reviews at the assisted living as well. Kerri explained all the pharmacy laws for nursing homes and what the Centers for Medicare and Medicaid Services (CMS) expect. I will definitely put this knowledge to use later on in rotations and my pharmacy career.

Thursday: Our next stop this week was Destination Dentistry. It was an amazing experience to partake in cleanings and other various procedures. We got to see how all the dental hygienists check for periodontal disease in each patient. There was a complex procedure in which Dr. Dan Custis had to take out three cavities and do fillings. Dr. Dan explained all the injections that he was giving and what he was doing at all times. So, it was very interesting to watch. Amanda and I were also able to see how a crown is made. Dr. Dan got pictures of the tooth needing the crown and then used CEREC digital software to reshape the tooth until it fit correctly. We got to see a milling machine shape the porcelain crown in five minutes, and the crown was hardened by heating at really high temperatures, over 500 ºF! We also got to see some root canals, implants for dentures, and how impressions are made. I also was able to learn the six most common prescription drugs that Dr. Dan usually prescribes. Overall, it was an amazing experience!

Friday: This morning, we met with the dietician that works with the assisted living and nursing home here in Custer. She explained the complex planning that goes into all the meals that the residents receive. Some residents are under restricted diets, such as gluten-free diets. We also discussed carbohydrate counting for diabetic patients, total parenteral nutrition (TPN), and tube feedings. From there, we got to meet Dave Ressler, who is with the Chamber of Commerce. He showed us around the town and explained the major income and employment areas for the town. Custer has a lot to offer, more than I even knew!!

After meeting with Dave, we spent the afternoon with Judy at Community Health Services. She explained all about the WIC program, which stands for women, infants, and children. She also explained how most of their services are income-based. Thus, if a family cannot afford it, they don’t have to pay for it.  The Custer Public Health Service can provide immunizations, family planning, and education and training about various topics, such as nutrition and physical activity. They also stress a lot about baby care, whether it is education about Sudden Infant Death Syndrome (SIDS), infant nutrition, or breast feeding. This first week has gone by so quickly, and I look forward to another week here in Custer!!

Saturday: We participated in the Volksmarch today at the Crazy Horse Memorial! The march is a 10K, which is a 6.2 mile hike around the memorial up to the top. It was an amazing view from the arm of Crazy Horse! It is 6,700 feet high, so it was quite an accomplishment for me!! It was totally worth it! I also spent the afternoon exploring the city of Custer, which was great!

Week 2

Sunday: Amanda and I spent a majority of the day hiking the Black Elk Wilderness Area. The area is so beautiful and peaceful. We hiked over 13 miles today, which was quite a workout. Our hike ended with an amazing view of Mount Rushmore, which made it totally worth the hike!

Monday: Today, I spent the morning with the ER nurses. There was only one ER patient, so it was pretty slow. I got a chance to get acquainted with the new Omnicell machine and how it functioned. One of the nurses also explained to me how vancomycin resistance was becoming common. She explained how the hospital was using precautions to prevent the resistance because it tends to be the drug of choice for major infections. I also got to see how the clinic functioned for a little while. Amanda was working in the clinic during the morning, so I got to step in and listen on a few patients with her. She is going to be a great physician assistant someday!

Our afternoon was great! We got to meet the CEO of the hospital, Veronica Schmidt. We went to a Rotary Meeting with her, which is an organization that brings together major people within the community to promote service. We also got to hear a speech from the South Dakota Secretary of State, Jason Gant. Following the luncheon, we got to help out with a bike rodeo. This is a small community event that the Rotary Club sponsors to promote bicycle safety. There were around thirty kids that all got bike helmets, and they all got to do little obstacles with their bikes. It was a fun day!

Tuesday: We started out in radiology today with Joni. She showed us how their 16 slice CT scanner worked. It was cool to see the results that it produced and how it broke down one picture into multiple images. We also were able to work with Nicole from Black Hills Ultrasound. She showed us a couple renal arterial doppler ultrasounds and an echocardiogram, which were both pretty cool to see. She pointed out all the vessels, arteries, and veins as she went along. In the afternoon, we followed some of the lab technicians and assistants to see how they drew labs. We got to see how the tests were run and how they culture certain specimens. It was a lot of information packed into one day!

We ended the night by helping out at a fundraiser for Relay for Life. This is the first year that Custer is having Relay for Life, so it is an exciting event for the whole town. The Custer Regional Hospital has a team, and we sold popcorn for a good cause. There were a lot of community members there to have fun and listen to an Elvis impersonator. It was a great night full of food and fun!! I cannot wait for the actual event on Friday!

Wednesday: Today, we worked with home health and hospice. Amanda was placed with Rod, while I got the opportunity to be matched with Perri. Our first patient was in Hot Springs, and our second patient was back in Custer. On the way to Hot Springs, we went through Wind Cave National Park and saw herds of buffalo!! There were hundreds of them and you could get so close! It was amazing to see them all! When we visited each patient, I got a chance to see how a home health nurse works. She did a lot of assessments, charting, vital checks, and pill binders. It is very convenient for these patients to have a nurse visit occasionally to make sure things are going alright. Thus, it keeps them at home instead of in a nursing home or assisted living. We ended the night by going to the Brule Native American Experience in Hill City. The Native American culture is so interesting, and the music was amazing!

Thursday: We finally got the chance to work at Carson Drug!! I was really excited since this was the only pharmacy in town. I got to learn a whole new computer system which was really interesting. At Carson Drug, they get a lot of new patients daily with tourists being in the area. I bet we had four new patients within the first half hour!! The pharmacist, John Carson, was really helpful and wanted me to do as much as possible. I was able to input new prescriptions, count medications, and counsel patients. Throughout the day, I also got to do quite a few transfers from other pharmacies.

John explained the major differences between his pharmacy and some of the chain pharmacies. He orders medications through McKesson, and he receives them the next day. Just because Carson Drug is in a rural area does not mean that they have limited services. Since I grew up in a small town and worked in a small-town pharmacy, I knew exactly what he was talking about. One of the best parts about small-town retail pharmacy is the patient interaction! I love interacting with all the patients and hearing their stories. When a patient comes in and you can have his or her medication ready when they walk up, it shows how much you value their business. This is just the type of pharmacy atmosphere that I want to end up in someday!!

Tonight, we got the opportunity to go the Grand Magic Show in Custer. Before we went, we had heard that the show was the same or even better than Las Vegas shows! So, we were eager to see the show ourselves. The Grand Magic Show was awesome, and the illusions were mystifying and amazing! Duane Laflin, the magician, and staff did a great job, and he left us wondering how he did it every time. It was great, and I would recommend it to anyone!!

Friday: Friday afternoon, I got to spend time at Premier Family Eyecare with Dr. Nathan Wiederholt. He has had his own practice here in Custer for the past five years. He does a lot of eye health exams for various patients. Since I have never personally been to an optometrist, it was interesting to see all the gadgets and machines that he uses to examine the eye. He also tends to emergencies that may come in. Today, he helped remove a small chunk of grit from a woman’s cornea. He has seen patients with diabetic retinopathy, macular degeneration, and retinal detachments as well. Furthermore, Dr. Wiederholt showed me three specific machines that are used to see things within the eye. One machine tests patients with their side vision if they have potential glaucoma. His second machine is able to differentiate the ten different layers of the retina to determine specific problems. His last machine is used to see other problems with the eye, such as histoplasmosis. He was very informative and explained how he determines the prescription for a patient’s eyes. He is a great eye doctor, and he even gives back to this small community!!

Friday night, Amanda and I got to participate in Relay for Life. We started out with the team lap for the Custer Regional Hospital team. After that, we had a booth set up to present our group project. Since Custer does not have a lot of obesity education, that was our main focus. We decided to make a brochure to hand out and a personal assessment for community members to fill out when they stopped by our booth. Physical activity, healthy eating, and daily living habits all affect weight, so we stressed those items a lot. If people were willing, BMI scores were calculated and explained.  Community members were also able to get their blood pressure checked as well. If it was high, we would explain how obesity or excess weight could affect that. Overall, it was a very successful project until a storm came in. That ended the night pretty quickly. It was a lot of fun though!

Saturday: I spent the afternoon in Hill City, SD. They had a lot of shops on their main street, which were pretty cool to look at. Amanda’s grandparents came to visit as well, so we went to the Prairie Berry Winery to do some wine tasting. That was a lot of fun! We ended the evening by eating at the Bumpin Buffalo in Hill City. For a small town, they have a lot to offer!

Week 3:

Sunday: We spent the afternoon in Hot Springs, SD, which is a nice, small town south of Custer. We took a trip to Cascade Falls, which is about ten miles south of Hot Springs. The cascades were beautiful!! I loved it there. We also got to do a short little hike to the Battle Mountain lookout, which was pretty cool!

Monday: Instead of a day at the office, we got to spend a day in the depths, of Jewel Cave that is. It was amazing!!! It was my first cave tour, which made it even better. Jewel Cave is the third longest cave in the world, which stretches out over 170 miles. There are still thousands of miles to explore as well. It is one of the few dry caves remaining, and it is generally around 50 degrees in the cave. We went on the scenic tour in the morning, where we got to see all the stalagmites, stalactites, and numerous other formations. Everything looked miraculous in the cave! At a point during the tour, they turned off all the lights, showing us how the first explorers would have seen it. We went down to 300 feet below sea level too! The largest room in Jewel Cave is called The Big Duh, which measures about 600 feet in length. In order to get there, cave explorers must pass through the miseries. The miseries span about a third of a mile, but the path is only eight and a half inches by 24 inches!! They have very unique names for some of the cave rooms and formations, but it makes each place memorable!

For the second part of the day, we got to go on the historic lantern tour. This was even better! We got to go into the historic entrance, which was the first original path into the cave. With this tour, it was just lit by the lanterns that each couple carried. Our group chose to do the dungeon route! We had to squeeze through some small crawlspaces, some as small as two or three feet wide. We got to go along Fat Man’s Misery, which is a slim, narrow path and even to Tall Man’s Misery, where tall people have to duck. We ended our trip at Jewel Cave National Monument with a hike around Canyon Trail, which was a 3.5 mile loop. I had a great time, and it was so much fun!

Tuesday: Today, we spent the morning at Lammer’s Chiropractic Clinic. Dr. Tony Lammers was very welcoming and taught us a lot about his work. With each patient, he would explain which part of the spine that he was adjusting. Back “cracks” that people hear is actually just a vacuum effect that occurs in the joint capsule. The most common adjustments include the neck region, upper back, and lower back. He is also able to work on returning feeling and function in the feet for patients with peripheral neuropathy. Dr. Lammers explained how chiropractic work is different from other medical areas in that his line of work follows natural movements for realignment. He generally recommends different home exercises for each patient to exercise the muscles and keep the joints moving.

We got the afternoon off, so I made a trip to Sturgis to see my friend Laura!! I hadn’t seen her in quite a while, so it was nice to meet up. Laura and her family had moved to Sturgis over a year ago, so she showed me their new home. After the tour, we went and hiked Bear Butte. The view from the top was amazing!! We went out for supper in Sturgis at The Loud American, which had the best steak tips ever! After supper, Laura and her husband Eric took me out to Fort Meade. Since Eric works for the army, he was able to tell us a little history about the base. He showed us the Fort Meade National Cemetery, which was very touching. We also got to see Camp Fletcher and what remains were left of this POW German camp. This was a great end to a fabulous day with friends!

Wednesday: I got a chance to work with rehabilitation services today, specifically physical therapy. The physical therapist, Danielle, had a variety of cases including some total knee replacements and lower back pain. With total knee replacements, they try to work the knee quite a bit to get it to bend around 130 degrees. One interesting case involved a man who complained of lower back pain. For a little background, a normal kidney weighs three pounds and this gentleman had one weighing thirty pounds! They removed it, and his replacement kidney was placed in the front, near his right hip. This causes strain on the spinal cord because it tends to bend towards that area. It was really interesting to see! Unfortunately, this man will never be pain free, but therapy helps to reduce the amount of pain.

Danielle explained the pharmacy connection with physical therapy in which a couple prescriptions are used for iontophoresis. They have used acetic acid to help with calcium deposits in one patient. Dexamethasone can also be used with this type of therapy as an anti-inflammatory. Modality is also an option, but it is not done very often in this clinic. With a lot of the patients, Danielle would use kinesio tape, which would manipulate the muscles for the patient outside of therapy. If a patient is in pain, the therapy is not working. So, Danielle recommends various exercises based on the functionality of each patient.

Thursday: Our schedule got switched on us last minute. For a couple hours in the morning, I was at Carson Drug. I had a great time with Kristie and Missy, the technicians. John Carson had a lot of meetings this morning, so his staff put me right to work inputting new prescriptions into the computer. I was surprised at how well I remembered this computer system after only one day. John would occasionally come out and do the final verification on the medications. It definitely helped me build my confidence because I was taking prescriptions from doctors and counseling patients. I actually got the feeling of being an actual pharmacist in a small town!

In the afternoon, we got to participate in a 4-H education day at Camp Bob Marshall. We followed the forest service out to Lake Lakota, which is about a half hour from Custer. There were about 75 students, so they were split into four groups. One group did a short hike and learned about all the necessary supplies you should bring on a hiking trip. They also learned a little bit about the geology in the Black Hills wilderness. The second group got to partake in a fun little game to test their knowledge about keeping our wilderness safe. The third group got to learn about meteorology with some grad students from the South Dakota School of Mines and Technology meteorology program. The last group went fishing on Lake Lakota. All the groups rotated throughout the afternoon. The kids had a lot of fun, and it turned out to be a great day!

Friday: We started out with care conferences at the nursing home, which are required quarterly. Family members can be present, call in, or choose not to be present.  The director of nursing, director of social services, CNA supervisor, activities coordinator, and dietary assistant are all present at these conferences. They discuss each patient’s dietary needs, activity participation, medications, and any other concerns. This provides a great check on each patient.

For lunch, we met up with Veronica Schmidt, the CEO of Custer Regional Hospital, and Rich Knuppe, our preceptor. It was nice to talk to them in a relaxing environment. While we were eating, we even got to see General George Custer walking down main street! In the afternoon, Amanda and I went hiking with our friend Laura. We climbed all the way to the top of Harney Peak, and the view of four states was amazing! We also got great views of the countryside for miles and even the Cathedral Spires. On our way back down, we also got a chance to hike Little Devils Tower, which was a lot of fun! It was a great day!

Saturday: This morning, we made a trip around the Wildlife Loop at Custer State Park. It is so beautiful and peaceful out there. We saw some pronghorns, white-tailed deer, and lots of buffalo. We got within a few feet of some buffalo!! It was an amazing experience! In the afternoon, we got tickets to go to the Crazy Horse Stampede Rodeo. This was Amanda’s first rodeo, so we had a good time!

Week 4

Sunday: It was a beautiful day, so we thought we should fit in some last minute hiking on our last Sunday here. We got a chance to hike Poet’s Table, an inspirational secret spot where locals can go to clear their minds, and Sunday Gulch, which was very beautiful. It was a great end to our last weekend here in Custer!

Monday: I got another chance to work at Carson Drug! Since Monday is a busy day, there were two pharmacists in the morning, John and Jim. They both encouraged me to try whatever I wanted. I did a lot of inputting prescriptions into the computer, doing transfers from other pharmacies, counting pills, and counseling patients on their medications. I also got to attend another Rotary meeting with John, which was very interesting. Dick Brown talked about all the new improvements with Custer State Park and the Mickelson Trail. In the afternoon, I kept busy with all the ins and outs of Carson Drug. I always make the effort to remember names and faces because it brings people back into the pharmacy. I haven’t been in Custer long, but I know a lot of people already!

Tuesday: Today, I got to spend part of the day at the Department of Social Services with Laurie Morgan. She explained how she does six month reviews and quarterly reviews depending on each patient’s situation. These people can qualify for the program either by disability or other reasons based on need. If a patient needs certain things for his or her disability or incontinence, she can get those items as well. Her job is focused around making sure each patient has a better quality of life.

Wednesday: Our final presentation was today, which was bittersweet. It was sad that we will be leaving soon, but we had a great experience in Custer. As we were giving our presentation, it was amazing to see all the things we did. We sure kept busy, and it has flown by! In the afternoon, we took a trip to Rapid City to see the outpatient pharmacy at Rapid City Regional Health. Becca showed us the outpatient pharmacy, which does about 450 prescriptions a day for the general public and regional employees. She also quickly showed us the inpatient pharmacy and the carousel that they use for medications. The long-term care center, which is located in a brand new building, supplies the Talyst machines for the senior care centers in both Custer and Sturgis. They will soon be adding a specialty pharmacy to the center in the next month as well.

Thursday: This was my last day with the REHPS program, and I got the privilege to spend it at Carson Drug! I had a great time with the pharmacy staff, and they all taught me a lot. It is really interesting when you see something begin in the clinic, a culture created in the lab, and end with the patient receiving a prescription in the pharmacy. There is better communication with patients in a rural retail pharmacy, and you get to know them a lot better. This experience has been nothing short of amazing! I have met so many new people, and I have had a lot of fun! By participating in this program, I feel like I have had better hands-on experience in all aspects of healthcare! Thank you to everyone who has made it great!