Claire C’s Blog Back to 2013 Students
Miller, South Dakota
My four-week rural experience actually began about 10 miles before I reached my destination of Miller, when I saw a tractor cruising down the highway. And by cruising I mean taking up the ¾ of the road and moving about 15 miles per hour. A friendly wave from the gentleman driving the tractor was a warm welcome in itself as I pulled into Miller. The next rural experience moment I noticed was when I gave my roommate directions to the hospital. I told her she would come to a stop sign with a cow statue, and to take a right at the cow. Usually, “take a right at the cow” is not typical when giving directions. I also told her to tune into 96.9, as it was the only radio station that worked! Finally, we both arrived at the Avera Hand County Memorial Hospital and Clinic, eager to see what was in store.
First, we were welcomed with a taco feed, and a good handful of the staff came to eat, introduce themselves, and welcome us into the community. This was a wonderful introduction, and made me feel that the staff was just as excited to have us, as I was to be there. Shortly after the taco feed we were given a grand tour of the hospital. I was absolutely blown away. For a rural area, Miller has a state of the art facility. It is absolutely gorgeous, with brand new hard wood floors, exceptional room sizes, and a beautiful granite entrance nearing completion.
Once my partner Becka and I got all settled in, we were able to start our healthcare experiences. I had the opportunity to shadow a nurse practitioner, pharmacist, and physical therapist the first week. I spent my time in the clinic with Cassandra Gutzmer, NP. We were able to see two patients that afternoon. I learned something new from each patient. For instance, one patient’s profile said they had allergies to nearly every antibiotic class and sure enough, the practitioner needed to prescribe an antibiotic. When asking the patient about what reactions happened from the antibiotics with allergy flags, the patient was not even aware of any allergies. Cassandra was still able to chose a 1st line antibiotic for the infection from a different class of antibiotics not on the allergy list. We felt confident in the antibiotic choice, knowing there were no severe allergies. This emphasized the importance of communicating with patients to optimize their care and treatment plan. It’s interesting to see how she prescribes medications on her end and all the charting involved.
The second day I was able to spend at Rexall Drug, with Travis Anderberg, the pharmacist. I was excited to spend the day with him based off of how much respect the community has for him. I have heard over and over multiple community members how lucky Miller was to have Travis return back to his hometown. My dad owns a hometown pharmacy also, so it was fun comparing the similarities and differences between how the two pharmacies operate. I noticed while I was there that Travis did not have to ask a single person their name. Whenever someone walked in the front door, he had their profile pulled up or their bag ready to go when they got to the front. Now that’s great service! One patient had a unique circumstance; this patient previously had esophageal cancer. The Mayo Clinic removed the cancerous portion of the esophagus and stretched the stomach up and attached it to the ending of where the esophagus was removed. So essentially, this patient’s stomach stretches from the upper chest down to where it normally connects to the intestine. The patient felt great and it was nice to be able to talk and learn about the procedure and recovery process. I am excited to be able to spend more of my time at the pharmacy in weeks to come.
The last day of the week I spent with the physical therapist, Noelle Tvedt. We saw many different patients, each with a unique case. We had therapy sessions for a hip replacement, an MCL sprain, back stretches for a patient with knee and back pain, therapy for a patient recovering from a motor vehicle accident, a rotator cuff surgery, and strengthening for a patient with loose tendons and ligaments who had a recent shoulder dislocation. It was so interesting to see all the different movements and the range of motion our bodies are capable of. From belt stretches to medicine balls, Noelle had all sorts of different ways to help these patients recover. She was so enthusiastic with all of her patients, making their recovery process a little more enjoyable. This concluded week one, and I am looking forward to see what is in store for week two!
I spent most of my time on Monday with all of the nurses. I was able to see what they do each time they round on an inpatient. The nurses primarily take vitals, make sure the patient feels well, give the patients their medications, and then finish with charting. I also had the opportunity to see a central line placed. Midway through the morning, a patient came into the Emergency Department, so Teresa sent me into the ED with Dr. Schroeder. I watched him give a patient 14 stitches on his shin. It was the first time I had ever seen stitches performed, and it was not quite as bad as it sounds. The patient had a very large laceration right on the front of the shin, and we were able to see the tibia. The stitches were done in no time, and the patient was able to head back to work.
Tuesday I spent my day with Michele Wiesler, NP. It was a pretty slow day in the clinic. We saw a few patients, none with any major problems. One patient had a UTI, another had some ear problems, and the last patient with a sore throat. Michele is very friendly, and was a great person to spend some time with. She was very patient with me and made sure to explain all her steps to ensure I was getting the most out of my time. She even let me listen to heart sounds and look in a patient’s ear.
Wednesday I was able to return to Rexall Drug to spend some more time shadowing the pharmacist, Travis. We discussed a little bit about Medication Therapy Management (MTM), and how he is just getting started with offering these services. MTM is a service I am interested to provide to my patients when I am out of school. This service is typically covered by a patient’s insurance plan and it consists of a pharmacist reviewing a patient’s medication list, looking for therapy duplicates, cost saving alternatives, any interactions, and making sure the patient is on all necessary therapy. It can save both the patient, and insurance company, money in the long run and it ensures the patient’s therapy is optimal. The rest of the day I spent either listening or helping out with the patient consultations. I really enjoy my days with Travis, as I am interested in a small town community pharmacy setting. He really brings forward a strong business sense and intriguing ideas on how small town pharmacies should work together to keep their voices heard. He also encourages me that staying rural is the direction I should take, even with my concerns that they are starting to die out. He reassured me that patients stick with pharmacies where they receive quality care, and that if I can give them the care they deserve, it would not even matter if a big chain such as Wal-Mart were in the store right next to mine.
Wednesday nights are always Becka and my favorite, as we get to spend the night at the golf course for Ladies Night. The ladies at the golf course have been so unbelievably nice and are letting us golf with them while we are here. It is a perfect way to meet the ladies in the community and a nice way to relax at the end of the day. The only bad part about golf night is the dang mosquitoes that continue to show up uninvited! This Wednesday we also signed up for a 2-person scramble golf tournament on Saturday called the Wine on Nine, which we are looking forward to! At this tournament a different restaurant or business sponsors a hole, and at the hole they provide a drink and an appetizer to the contestants.
Thursday morning I had an opportunity I will probably never have again in my lifetime. Becka and I were able to watch cataract surgeries through the microscope alongside the ophthalmologist. It was an incredible experience, and the surgeries were no longer than 30 minutes each. I still cannot believe you can cut into the eye, chop up the lens, suck it out, and replace it with a new lens. The surgery is as simple as that, but in more technical terms, and very delicate methods. The surgeon was phenomenal and he took the time during surgery to explain everything he was doing to Becka and I.
I had the opportunity to spend the last day of the work week with Joel Huber, MD. The morning was busy, but most patient cases were fairly uncomplicated. We saw a patient with osteoporosis, COPD and arthritis for a routine check-up, and the patient seemed to be doing fine with the exception of left foot pain. The next patient was elderly and came to the clinic to get a growth removed off of her lip. Dr. Huber first checked to see if the growth had sensation, and it did, so he numbed the area with a lidocaine/epinephrine shot. After the medication’s onset, he froze the growth off with liquid nitrogen. The whole process only took about 10 minutes.
This week has been another great week in Miller! I was able to start off the week by rounding at the nursing homes with Dr. Turner. First, we went to the nursing home in Highmore, SD followed by the nursing home facility in Miller. It was interesting to see how nursing home medication orders are written, reviewed, and adjusted. As far as the overall process goes, Dr. Turner (or whoever the rounding physician is that day) has a set list of patients to see at each facility to do their routine check up. The head nurse also goes through the patients with the doctor with any recommendations for any of the patients. If the nurse thinks a change needs to be made with someone who is not scheduled for his or her visit, Dr. Turner made sure to go talk to the patient and see what she thinks. I also really enjoyed seeing PRN meds that have not been used for a great while being discontinued. Sometimes med lists for nursing home patients can get very lengthy, with a lot of unnecessary therapy. Dr. Turner and the nurse really took their time going through each patient to see if any medications could be discontinued, and I thought that was great care. Some of the patients we saw had either Alzheimer’s, Dementia, Parkinson’s, or different types of infections. A few patients did not have an underlying disease state, but were not deemed fit to take care of themselves at home. All of the patients we saw were so nice and some of them so funny! I asked one lady how she was feeling today and she responded, “with my fingers.” She was a hoot!
This week Becka and I also were invited to attend the medical staff meeting. Dr. Huber, Chief of Staff, called the meeting to order. We were surprised to see the first item on the agenda was to “Welcome REHPS Students”. That was very nice of them to take time out of their meeting to recognize and thank us for joining them. In attendance were the doctors, nurse practitioners, nurses, the local pharmacist, and hospital administrators. I enjoyed listening to each person’s perspective and seeing what opinions they had from their area of specialty. This was a great way to start off the morning, not to mention they fed us an awesome breakfast! The day only continued to get better, as we were able to spend the morning and afternoon with cardiologist, Dr. Nagelhout. He is an outstanding physician and really took interest in Becka and I. With him, we were able to listen in on routine check ups, see the sonographer do a cardiac ultrasound on a pediatric patient, and also see a stress test performed. The stress test was very interesting, because when we were in the consultation room before this was performed the patient really downplayed the severity of the condition they were in. The patient had only complained of shortness of breath that seemed abnormal. For the stress test, the patient was hooked up to electrodes and had to walk on a treadmill and get the heart rate pretty high up. Once the heart rate was where it needed to be, the patient immediately had an ultrasound on the stressed heart. The patient had chest pain from the stress test and was given a nitroglycerin tablet sublingually. The patient actually failed the stress test, meaning there was more than likely a blockage in one of his arteries, and had to make another appointment with the cardiologist to see if a stent needs to be placed.
Later in the week we were scheduled to watch colonoscopies with general surgeon, Dr. Werth from Aberdeen, SD. Both Becka and I did not know what to expect going into this day. I was anticipating it to be rather unpleasant. However, it was not unpleasant at all. As it turns out, the preoperative PEG Electrolyte solutions (the drink 8 oz every 15 minutes until gone stuff) works like a charm. The colons were entirely clean for the most part, making it very easy to look for any polyps or masses. Fortunately, we did not see any abnormalities this day! Dr. Werth was so nice to Becka and I, and explained each part of the colon as he was performing the colonoscopy. Between procedures, we were able to small talk a little with Dr. Werth. I asked where he was originally from, and he was raised in Aberdeen. He looked awfully similar in age to my dad, who also is from Aberdeen, and it turns out they were in the same graduating class, Aberdeen Central Class of ’74! Not only that, his assistant graduated with my aunt, and they both remembered who my grandparents were before they passed away. You have to love good ole’ South Dakota connections, where everybody knows everybody. Dr. Werth really enjoyed our company that day and invited us to shadow him for a day at his office in Aberdeen to sit in on different surgeries, so we will be going to Aberdeen for a day next week! We are really looking forward to that.
I ended the week in the lab at the hospital. This day was very informative. I was able to see how each different lab test is ran, and see how the machines perform the test. The lab manager, Nicole, was a lab expert, and knew exactly how each machine worked, and explained how the tests would be ran if the machines were to malfunction. She also performed blood typing on my own blood. She did it two different ways, and it turns out I am A positive. She was able to go through each machine and tell me advantages and disadvantages as well. It was also fun spending the day with her, because we both went to SDSU, and had many of the same professors because she started out as a Pre-Optometry major.
This week was also the start of our community project, Women’s Health Week. Our first event was not very successful. We were hoping to talk to teenage girls about health, life, college and any topics they were interested in. We made chocolate bars, popcorn, peanut butter balls, and had drinks ready, but no one showed up! We were a little disappointed at first, but we later realized many girls that age had a softball game that night which we were not aware of. The second event of the week was more successful. This was our women in motion motive; we had many women interested in learning how to use machines at the wellness center, stop by for a personalized session. We had 5 ladies show up, and we were able to go through each machine with them, and let them try it out to make sure they felt comfortable with them and gave them proper instruction on how to use them. Many of them did not even know how to adjust the resistance before this session. They seemed to really appreciate our help! Not only did they like the demonstrations, but we had lots of treats and recipes for them as well. Overall we considered this much more successful. We also offered the same session the next day at noon for hospital employees and had a similar turnout. The response was the same, everyone was very appreciative and eager to learn what workout routine is the best for their physical conditions.
This week was our last full week at REHPS. The time has flown and we have met some of the nicest individuals along the way. This week we were able to sit in on Avera’s CARE camp. This is for new employees of Avera to strengthen their personal skills with patients. CARE stands for Communication, Attitude, Responsiveness, and Engagement. We formed teams to help brainstorm ways to demonstrate the different CARE components. This was a fun way to start out the morning as there were about eight of us in attendance. Becka and I spent the rest of the day preparing our power point presentation for the final portion of our women’s health week project. Only one lady showed up to our presentation. We provided information covering osteoporosis, breast cancer, and hypertension. The lady in attendance was able to provide unique insight, as she is a breast cancer and ovarian cancer survivor. She was also at risk for osteoporosis because she is very petite and small, and also is postmenopausal. It was a very interactive session and we were able to learn from her as well.
The last physician I had left to follow this week was Dr. Schroeder. Dr. Schroeder and I saw about five patients in the morning. He thoroughly discussed with one patient pros and cons of a PSA test, and how new research is showing it may not be the most accurate diagnostic tool for prostate cancer detection. He also let me listen to a patient’s heart that previously had a stent placed. The clicking sound it makes is very distinct and is a good sign the stent is working properly. The time spent with Dr. Schroeder was pretty short because he had a conference call and no patients scheduled for the afternoon.
Last week when Dr. Werth from Aberdeen Surgical Associates was doing colonoscopies, he invited us to come shadow him at his facility in Aberdeen. So this week, we made the trip to Aberdeen and had the opportunity to observe a day in the OR. This was really exciting for me, as this is probably one of the only times in my life I will be able to watch surgeries. The first procedure was supposed to be a laparoscopic hernia repair. When Dr. Werth’s laparoscope was in the patient, the hernia was more wide spread than localized and he had no other option but to perform open surgery. The next case was a colorectal cancer patient, there to get two separate portions of his colon removed. Once removed, they allowed us to feel the cancerous portion of the colon. Once removed, the colon remaining was reattached. The two surgeons we followed, Dr. Larson and Dr. Werth, did not have any free time the entire day. They are on the go all day long and the only time they have to sit down is when they are dictating. We were also able to watch a few umbilical hernia repairs, endoscopes and colonoscopies performed. These procedures do not typically take much longer than 15 minutes and they were performed one right after the next. Our last procedure we watched was a breast cancer removal with Dr. Larson. Both Dr. Werth and Dr. Larson thoroughly explained each procedure and made sure we could see, which we were both very appreciative of.
The entire REHPS process has been so much fun and a great learning experience for both Becka and I. We have made some really close connections here in Miller, and we could not have asked for better mentors throughout this process!