DANIELLE’S BLOG – BACK TO STUDENTS

Parkston, South Dakota
Week 1

Monday – I started the day very excited for what the next four weeks will bring!! I arrived at Parkston in the morning and met Megan, my partner for the month. All of the providers were finishing up a meeting so we were introduced to them. We jumped right into action and spent a couple of hours doing morning rounds with Dr. Honke, Dr. Boschee, and the hospitalist/Nurse Practitioner, Lindsay. We got to watch a couple of procedures with Dr. Honke including a signoid colonoscopy and an intrathecal nerve block for a woman in the maternity ward. We had lunch with Kassy, who gave us some insights about Parkston (since it’s her hometown!). We spent the first part of our afternoon moving into the apartment and getting settled. Later in the afternoon we got a tour of the campus and a tour of the town. I am amazed at all that Parkston has to offer for such a small community. The hospital has so many resources and is so well developed, especially for being just 20 miles away from Mitchell! I’m looking forward to a great experience in this community!

Tuesday – We started the day off with a few meetings. The first one was an interdisciplinary meeting with doctors, nurses, the CFO, and a few department heads that is held every week to discuss any trouble shooting/problem areas that needed to be addressed. After this, we attended a meeting regarding the construction to the nursing home that is going to be started soon. Next, we attended a meeting with a representative from the American Cancer Society that was here for follow up on the Cancer walk/run that was recently held in Parkston. We spent the afternoon working on getting stuff organized for a community babysitting class that we will help with next Wed. We stuffed folders with information the kids will get taught and also watched a babysitting basics video that we will be showing them as well.

Wednesday – Today we went to ‘Our Home.’ This is a residential treatment facility for troubled youth. We sat in on the plan of care conferences for a few of the youth, along with Dr. VanderPol, the psychologist, and the treatment team assigned to the youth. This was very interesting and very heartbreaking at the same time. Most of the care conferences we sat in on involved children with a history of physical and emotional abuse, and a few that suffered from drug and alcohol addictions. It is great that programs such as this are available to get these kids the psychological treatment they need, and wonderful that a community, as small as Parkston, has this to offer. During the afternoon we developed a brochure for Rita, the CFO, for an upcoming conference she is organizing. In the evening we attended a meeting at City Hall to discuss the upcoming Fourth of July festivities. Megan and I will be helping with the children’s parade and will have a booth set up to teach sun safety to the community. After this, we headed to Boogs Bar & Grill for dinner and enjoyed delicious burgers!

Thursday- This morning we spent time finishing up the brochure and I spent some time in the clinic seeing patients with one of the PAs, Mary. In the afternoon we met with Phyllis in HR. She spent a few hours with us discussing the history and mission statement of Avera. It was very interesting to learn how the whole system started with a group of nuns! The Benedictine Sisters started the first hospital which was just 12 beds! After this I packed up for the weekend to head back to Sioux Falls for class for my LAST weekend of my summer class. Overall it’s been a great week!

Week 2
Monday – We started out the day in Radiology. It was really interesting that Parkston’s radiology unit has so much to offer along with traditional x-ray including a dexascan, mammography and CT scan. We were able to observe a carotid ultrasound in an elderly woman who has recently undergone some neuro changes and were able to see minimal plaque formation in the carotid vessel during the ultrasound. The mobile MRI was here for the morning, so we also got to observe a patient who utilized this service. The MRI truck comes every Monday which is very helpful for communities such as Parkston who don’t have their own MRI. Everyone was very helpful in explaining their job role and answering all of our questions. The afternoon was spent helping with a project for HIM and alphabetizing all of the nursing home records. In the end, we had 22 boxes full of charts, so quite the alphabetizing job!

Tuesday- We started the day with speech therapy. We observed a cognition evaluation on a man who had suffered questionable anoxic brain injury after a major cardiac event. In the afternoon we went to the elementary school to observe and help with a summer reading program. In the afternoon we traveled to Lake Andes to visit the outreach clinic which is pretty much run by a PA with the help of a local NP, along with Dr. Honke who travels there on Tuesdays. Dr. Honke is on vacation this week, so we got to work with Dr. VanderPol who was filling in for him. We were able to interview a new patient as well as observe a couple obstetric appointments. One of the OB patients was 22 weeks along and the other around 35 weeks along. Both had ultrasounds so it was interesting to compare the differing size of fetuses between the two patients. In the evening we visited the mobile simulation lab. This was very interesting and such a great resource for the communities.

Wednesday- We started out the day at ‘Our Home’ with Dr. Boschee to listen in on care conferences. This, again, was very interesting and heartbreaking. The staff provided us with more in-depth background on each of the kids in-between their conferences to provide us with a little more history as to why they are at ‘Our Home,’ which I found to be very interesting. I have a huge amount of respect for the staff members who work at ‘Our Home’; I can only imagine how hard it would be both physically and mentally. During the afternoon we worked on a project for Rita, the CFO of the hospital.

Thursday – Today I spent the day with Dr. Boschee in the clinic. We saw a case of acute conjunctivitis, otitis externa, cellulitis/leg ulcer, a couple of cases of GI distress, an employee physical, a few sports physicals, and a few well visits. During the latter part of the afternoon, I spent about 45 minutes giving blood, as the mobile blood bank was at the hospital. Thursday evening, Rita had us over for dinner and we had the best meal since we’ve been here!! It was nice to get a good home cooked meal and spend some time getting to know her better. Parkston is packed with such wonderful people!

Friday – Today was very interesting – we traveled to Oak Lane which is a Hutterite colony outside of Parkston. We helped with educating children (varying in ages from 5-16) about safety, specifically in relation to caring for younger siblings in the home. We covered topics such as first aid, choking, healthy eating habits, CPR, poison control, bike safety, seatbelt usage, and wound care. Three other colonies came to join the education which took place at the school in Oak Lane, giving us around 50 kids! I have very little exposure to colony life so it was a very educational day. It was very interesting to be present in their surroundings and natural environment as opposed to caring for them when they seek care in town. It was a huge eye opener! We got back in the afternoon and helped Rita with another project. Another great week completed…this is flying by! Can’t believe we are half way done!

Week 3
Monday – Today I spent the day with Dr. Boschee in the clinic. We had a fairly steady day and saw a pretty nice variety of patients but a couple of the patients stood apart from the others. The first was a patient who had gotten stung by a catfish three days prior. I didn’t even know catfish had stingers! It had gone completely through the patient’s shoe and left a puncture wound in the medial side of his foot. The patient reported that the pain had intensified over the weekend so decided to come get it evaluated. One of the diagnostic tests ordered was an X-ray which revealed a foreign body…the end of the stinger had broken off inside the patient’s foot! The crazy thing was that it was lodged a good 2-inches from the actual puncture site, making it difficult for Dr. Boschee to know where to make the incision to remove the stinger. Instead of going at this alone, Dr. Boschee arranged for the patient to come back the next day when Dr. Wickersham would be in-house to allow for another set of hands to successfully remove it and avoid having to dig around and potentially make a larger incision than necessary.

The other interesting patient we saw came in at the end of the day. The patient had lost the top of his middle finger while trying to fix a vacuum. The patient’s spouse reported the patient had taken the whole vacuum apart and the motor mechanism somehow sliced off the tip of the patient’s finger. It was only about ½ inch of the tip that was missing but the patient was on coumadin so it was difficult to get the bleeding under control, especially since it was a clean slice and very little that could be sutured closed. An x-ray revealed that the patient had also broken his third distal phalange. These two cases made for an interesting day!

Tuesday – We started the morning in the ER, where the patient from yesterday had come in to get the catfish stinger removed from his foot. It was pretty interesting! It took a little work to remove it after the incision had been made because they only had the x-ray to go from to try to estimate the location of it under the skin. The stinger was about 2 inches long. You could see the pointed side of it where it had punctured the skin with entry while the other end was jagged where it had broken off from the base of the stinger that exited. There were also teeth (like a saw) along one side making it easy to see how it latched on to the inside of the patient’s foot. The incision only required three sutures, so the incision itself was probably a little smaller than the actual stinger so they did a great job of locating it and removing it.

DThe rest of the morning was also very interesting. Dr. VanderPol does ‘memory clinic’ every Tuesday. This is a service for patients who have diagnosed or suspected signs of Alzheimer’s. It can be done to diagnose Alzheimer’s as well as track Alzheimer’s progression in patients who have been previously diagnosed. Most patients with a previous diagnosis come in every six months to a year, depending on the progression of their disease. The first woman I observed was very early in the disease process. She did very well in her evaluation and exam and showed a very slow progression of the disease. They have a standard examination to evaluate progression and staging of Alzheimer’s which includes items such as drawing a clock (including numbers) from memory, reciting back a sequence of numbers, simple math, following basic directions, remembering four words over a span of time and more.

The second woman I observed had very advanced Alzheimer’s. It was very interesting to compare her examination with the first patient who had a nearly negative exam. The first task was to draw a clock face which was very interesting to observe. She drew a circle but instead of numbers, she filled in all 0’s for each number (and included more than 12 0’s within her clock). The whole time she did this she talked about a variety of subjects, some very off-the-wall. Sometimes her conversation would shift to talk about her watch and how it broke, which I found interesting. The next part of the exam involved observing how many animals she could name in one minute. When asked to name animals, she would only say numbers even after explained numerous times that we needed her to name animals. We actually couldn’t do much of the testing at all because of how advanced her Alzheimer’s was. It was pretty sad to see, especially compared to her results from just six months prior showing how fast this disease can progress. Her husband accompanied her, and it was interesting to hear him describe her deterioration and what he observes on a daily basis. He cares for her in their home and goes to regular support group meetings for spouses of Alzheimer patients. This is such an interesting, but sad disease process. The memory clinic helps manage Alzheimer’s through close monitoring of the disease progression and making changes in medication and doses as needed for better management of the patient.

The rest of the afternoon was spent getting ready for our community project which we will do tomorrow at the 4th of July celebration. We finished our brochures, printed out our information, and put together our poster board presentation.

Wednesday – Today we did our community project in the park during the 4th of July celebration. We started the day helping out with the kid’s parade. There were a variety of activities in the park for the kids to participate in including face painting, musical entertainment, a slip-and-slide, and other water games. We decided to do our project on Sun Safety. We set up a booth with a poster presentation that included information about heat exhaustion, heat stroke, and ways to prevent these processes from occurring. It has hit 100 degrees most days we’ve been here in Parkston, so we felt this was very pertinent information! We also had packets of sunscreen samples to hand out and had information on the new sunscreen recommendations and the sunscreen label changes that have recently been released by the FDA. We handed brochures out with our sunscreen packets that included information on sunscreen and correct usage. Also, we had a short quiz that people could complete to test their sun safety IQ.

Later in the afternoon we headed to Lake Mitchell for some R&R and to enjoy the beautiful weather. Megan’s family camps there every year over the 4th of July. My husband was also in town to visit so we headed to the lake and spent the afternoon canoeing which was a ton of fun! Later that night we came back to Parkston for a fabulous fireworks show!! It was very impressive and made the 4th complete!

Thursday – We started out the day at a care conference with the Bormann Manor staff which is the nursing home connected to the hospital. This meeting included nursing staff, social workers, therapy, activity director, and nutrition specialists to evaluate the needs of patients whose review date was up. It was interesting to evaluate this process and nice to see the holistic aspect that this conference provides, having all these specialties joining together to discuss the patient.

During the afternoon I spent some time with Dr. VanderPol in the clinic. I got to observe a couple of procedures. The first was the placement of implanon which is a method of birth control that is implanted in the arm. The other procedure was the placement of Mirena which is an intrauterine device, which is another form of birth control implanted in the uterus. I have seen these procedures before but it is always good to see and compare how providers evaluate readiness, discuss education, side effects, etc. with these products.

Friday – We started the morning in a water aerobics class. It was a great way to start the day! The hospital has a wellness center and indoor pool and classes are offered daily. Some of the water aerobics classes are targeted at helping those with joint problems stay fit and keep joints mobile. Since we already had our swimsuits on and nothing else on our schedule for the day, we decided to head to the lake and take advantage of the 100 degree weather!! It was a fun and relaxing way to end the week!

Week 4D
Monday – Wow…I can’t believe this is our last week. When I read the journals from last summer I saw they all said that it would – now I believe them!! Today I was in the laboratory. This was pretty interesting, especially since it has been quite a few years since I’ve taken microbiology. I was with Becky (small world department – she is one of my coworkers mother!) and we spent a good portion of the day going over how specific cultures are isolated after they grow on streak plates. When I took microbiology it included the use of the Bunsen burners, inoculating loops, etc. which I learned is a thing of the past! It was a great review and refresher to observe how bacteria are identified based on form, elevation, margin, size, color, texture, and opacity in relation to hemolysis. Also, I found it very interesting that a machine is responsible for determining antibiotic sensitivity and resistance! Becky pulled up a couple of files from previous patients that showed that some people have developed a lot of resistance to common antibiotics over time. One patient had a UTI and was resistant to all forms of oral antibiotics so had to be hospitalized and receive IV antibiotics. I know from my experience in clinicals that patients often come in wanting antibiotics after only having symptoms a few days and no elevated WBC, temp, or other indication of a bacterial infection. I’ve seen them get upset when not given a prescription for an antibiotic. This was a huge eye opener. I know that over-prescription of antibiotics is a huge issue in family practice but seeing the effects first hand helped solidify this. Educating that most illnesses are viral is so important in order to prevent this type of resistance to occur.

Tuesday – This morning I went to a meeting that discussed new technology in nuclear medicine. Typically, adenosine is used for stress tests but a new drug has been approved to use that doesn’t require physical stress on a treadmill to perform a stress test. This is beneficial for patients who have trouble walking due to physical limitations, arthritis, asthma or other underlying health issues. The drug is called Lexiscan (regadenoson) and comes in a standard dose, regardless of height, weight, and BMI unlike regular adenosine which was dose administered based on weight (which simplifies it for the healthcare provider administering the drug as well!)

We spent the afternoon in group diabetic sessions. This is a fairly new program at the hospital geared at bringing multiple small groups of diabetics together for open discussion regarding diet, exercise, and basic tasks of living with and managing diabetes. It is education based and includes the assistance of the dietician, a physician, a nurse, and the mental health personnel. It meets monthly over the course of six months. I found this very interesting, as there were varying levels of education and awareness within the small group I sat in with. A particular point of interest (and concern) was a lady that expressed that she has been living with diabetes for over 20 years. At one point in the discussion with the nutritionist she asked the question “What is a carbohydrate?” I couldn’t believe this and felt so horrible that the healthcare system had failed for this individual. Knowing how to manage blood sugar is the primary method of maintaining diabetes, and carbohydrate control is crucial in this balance. She admitted to never receiving proper education about her disease. This just goes to show that programs like this one are so essential!! I’m sure that this individual will gain more insight on her disease in the next few months than she has gotten in the last 20+ years! It also showed me that regardless of how long someone has had a diagnosis, their personal perceptions and educational level regarding their disease should always be evaluated in order to provide them with the necessary information so they can adequately manage and maintain the disease.

Wednesday – We spent most of the day at a nursing inservice that included a lot of good information regarding hospital happenings and a couple of educational opportunities. The highlight for me was a great review of EKG interpretation – one of the best reviews I have ever been to! Part of the Helmsley grant provided EKGs for all EMS in the state which are linked with corresponding ERs. In the occurrence of chest pain with EMS response, the paramedics and EMTs get an EKG that is sent directly to the ER and read while the patient is en-route. This provides a speedy process of interpreting EKGs to triage cardiac patients more efficiently, often times bypassing the ER and heading straight to cath lab for an intervention, if need be. South Dakota is the first state to have this service provided statewide. It will no doubt deliver improved quality of care due to this efficient protocol.

We had lunch provided by a drug rep that came to talk about Pradaxa. I’ve heard of this drug some but it was interesting to hear the discussion that the providers had with their concerns related to cost, maintenance, etc. They came up with some very valid points and good questions for the rep. Pradaxa would save patients from coming in to have routine coumadin levels drawn but it costs more than similar products such as coumadin and plavix. Also, there isn’t a reversal agent for Pradaxa but it does have a shorter shelf life than similar products.

Thursday afternoon we visited an Amish community outside of Parkston. This was very interesting. There are about seven families who, within the last two years, have left their community in Wisconsin and have come to settle right outside of Parkston, near Tripp. The culture of the Amish is very interesting and I learned quite a lot about them today. They don’t believe in electricity or modern technology…meaning, no lights in their homes, no telephones, no vehicles, etc. All of their farm equipment is pulled by horses, and to travel in to town they ride by horse & buggy. One of the families we visited made beautiful rugs – I had to buy one! They were kind enough to show us how the rugs were made. Also, the loom they used to make the rugs was from the 1920s! It was fascinating to watch how they make them. The Amish families were very friendly and great at answering all of our questions.

Thursday – Today is our last day…I can’t believe it! The time here in Parkston went by sooo fast. I have really come to love this community and the people here. Kassy came for our final presentation regarding our experience and our community project. I thought our presentation went well and we had a pretty good turnout from department heads. Dr. Honke and Mr. Walker also made time to listen in and give us feedback on our time in Parkston and discussion of what our plans were for after graduation. I’ve learned so much during my time here in Parkston and feel like I have such a better grasp on what ‘rural healthcare’ really is. I have such a stronger appreciation for those who work in rural health, as well as for the communities that come together to support it. During my month here I would often ask the community members about the healthcare system in Parkston. There was an overriding theme of pride and commitment to the providers, the heath care system, and their community. I’ve always wondered if I would be cut out for ‘small town living’ and after this experience I can see that it would be easy to find a place in this community, as well as lead a very fulfilling career as a provider in a rural community like Parkston. I am so thankful for this opportunity and want to thank the community of Parkston and Avera St. Benedict – you’ve all made a great impression on me and have positively influenced my perspectives regarding rural health. Everyone has been so warm and welcoming, truly enriching this experience!