Joshua Ohrtman
Week 1 at Custer

I have just completed my first week in the REHPS Program in the Custer Regional Facilities.  I cannot overstate how impressed I have been with the hospitality and level of patient care provided by the staff here.  Michael Delano and Veronica Schmidt have actively sought to provide Austin and I an extensive exposure to practicing health care in a small community. In just the three days we have been here, I have been actively involved in the Custer Regional ED and Walk-in Clinic.  It is incredible how fast I went from feeling overwhelmed by the many new faces and places on my first day, to feeling like a member of the Custer Regional Health family. My questions have been answered beyond satisfaction and my professional ideas have been respected. I know the hospitality extended to me by the Custer Regional Health Staff will make the experience very rewarding.

What is perhaps most striking to me when reflecting on my first week in the REHPS Program, is just how high the quality of patient care can be in a rural setting.  While the external surface of the Custer Regional Health Clinic building may not appear updated, the quality of staff and patient care provided inside the building is remarkable. On my first day Michael Delano emphasized to my partner Austin and I that putting patient care front and center is paramount. The health care providers at Custer Regional Health certainly adhere to this principle and the patients that I have interacted with agree.  

I am also very impressed with my REHPS Partner, medical student Austin Huber.  He is excited to be participating in this experience and is interested in learning and contributing to the experience as much as possible. Austin has been a great person to bounce ideas off of and his passion for helping patients is incredible.   I feel very fortunate to have him as a REHPS Partner.

Week 2
I have just completed my second week with the REHPS Summer Experience in Custer.  On Monday I observed Dr. Brown seeing scheduled patients.  On Tuesday I observed Dr. Waddell seeing patients in the walk-in clinic as well as emergency department.  Observing Drs. Brown and Waddell allowed me to experience different provider styles and treatment approaches.  I was amazed by the wide array of patient conditions each doctor must be ready to treat at a moment’s notice.  Without missing a beat, each Dr. moved from room to room treating routine cases such as strep throat or managing complicated disease states such as congestive heart failure.  Each Dr. appeared to enjoy the challenges and rewards of working in a small community where they treat newborns, seniors, and all ages between.

I was grateful that Dr. Brown allowed me to sit in on each of her scheduled patient visits.  As a pharmacy student, compared to students from other health care fields, my clinical medical knowledge is somewhat limited. Dr. Brown did a fantastic job of explaining things to me and describing her rationale for each patient treatment option.  As a mentor, Dr. Brown was very patient and it was clear that she expresses a genuine care for the wellbeing of her patients.  My day with Dr. Brown ended with what I thought would be an interesting case…. removal of great toenail.  I was expecting a very complex and involved process.  I imagined a new-age laser, complicated machine, a brand new medicine, or possibly some kind of very high-tech technique that would be multifaceted and bizarre.  Instead removal of the nail simply consisted of a few lidocaine injections and a very strong and sharp pair of scissors! 

People do not stop getting sick when they are on vacation; as a major tourist destination, the doctors at Custer Regional Health experience several unique clinical challenges associated with a transient patient population.   While observing Dr. Waddell in the walk-in and emergency department, I recognized some of the complications associated with treating patients from out of town.  For example, several patients in the walk-in clinic were unsure of their past medical history. Those that did recall, often only provided superficial information.  To overcome the challenge of incomplete past medical history, it is essential that Dr. Waddell, and other doctors of Custer Regional Health, build instant rapport with their patients and ask concise but relevant clinical questions to ensure appropriate treatment.  I was impressed with Dr. Waddell’s thorough and clinical knowledge.  He was concerned and made certain that each patient be well taken care of.  Dr. Waddell also did a great job of probing my pharmacy knowledge and helped me to better understand how medicine and pharmacy combine to improve patient wellbeing.

Early in the week Austin and I also had the privilege of participating in a training exercise called SIM-SD.  SIM-SD is a mobile training unit that travels around South Dakota providing emergency department and other health care providers with mock scenarios and training exercises.  This was an incredible experience.  Not only were Austin and I able to see how Regional Health ensures their medical staff are on the cutting edge of treatment, Austin and I also gained invaluable clinical insight. In our SIMS-SD exercise we experienced a mock emergency room simulation treatment of a severe burn victim (>30% of the body), a myocardial infarction.  We were also trained in using a LUCAS resuscitative machine. 

On Wednesday Austin and I met with Katie Weiderholt, the director of a Custer Regional Health affiliated adult Living Center called Wedgwood.  Our meeting was extremely informative on many levels.  First, we were able to experience how an adult living center fits into the continuum of adult health care.  Katie, Austin, and I discussed the various challenges and rewards of working with the population of the adult living center.  We were also able to discuss the roles that a certified medication administrator plays in providing medication to those patients requiring assistance. Both Katie and the part-time nurse Lisa were happy with the support and care residents are receiving from the providers at Custer Regional Health. 

As a next step in the adult care continuum, in the afternoon, Austin and I met with Rhonda VanWinkle, director of the Custer Regional Health Senior Home.  Our afternoon at the Senior Home was quite interesting.  Austin was briefly considering an alternative to practicing medicine and decided to become the guest caller in an intense game of afternoon bingo.  While Austin was busy with the game, I was able to visit with a nurse in the facility about their automatic pharmacy Talyst Machine.  I was amazed to watch how fast the machine was able to accurately package each resident’s medication. After finishing his bingo game Austin was able to see the tail end of the machine filling over 400 individual dosage units in less than twenty minutes!

On Thursday Austin and I met with John Carson and the friendly Carson Drug Staff.  It was a fantastic experience to spend time in a small community pharmacy that is truly a key player in the health care of the community.   Carson Drug is not just a spot for people to pick up medicine, it is place for community members to meet, shake hands, argue, gossip, and hug.  As the pharmacy owner, John Carson joins a lineage of pharmacists dating back to the original Custer pharmacy from the late 1800s.  Located in the middle of Custer along the main street, Carson Drug stays very busy selling medications as well as souvenirs, toys, gifts, and greeting cards.  Although practicing in a small community, John is interested in further developing medication therapy management and practicing novel pharmacy techniques to greater improve patient care.  I was very impressed with the ability to provide patient care in Carson Drug.  I have become even more optimistic about my future practicing high quality pharmacy care in a small community after visiting Carson Drug. 

To finish up the week, on Friday Austin and I met with Dr. Tony Lammer of Lammer’s Chiropractic Clinic.  Dr. Tony Lammer is a very personable and knowledgeable healthcare provider.  Dr. Lammer explained that oftentimes patients enter the chiropractor clinic nervous or in pain.  To make patients feel more comfortable with treatment, Dr. Lammer uses humor and light conversation. Dr. Lammer creates a peaceful environment where the patient is comfortable and thus allows muscles to relax.  When the patient is relaxed Dr. Lammer is able to perform adjustments of the neck, spine, and pelvic areas.  I was most surprised to find that that Dr. Lammer has treated patient ages ranging from just eighteen months up to senior. He reminded Austin and I of the importance that chiropractic care can play in health care process.  I feel very fortunate to have been exposed to chiropractic practice at an early stage in my health care career. I feel that I now have a better understanding of how chiropractic care can play an important role in patient wellbeing and the importance of chiropractor care in a small community.

Friday afternoon and evening I assisted in The American Cancer Society Relay for Life event.  This was the first time I had ever participated in The Relay for Life.  The opening speaker was a breast cancer survivor that shared her story.  Despite the rainy, cool, and cloudy weather, a large group of family, friends, and community members gathered together in the Custer Track Center for the event.  I felt fortunate to be a part of something so emotionally charged.  It was a time to remember those that have lost the cancer battle.  It was also a time to garner hope and courage to push on for those that will battle cancer in the future. If it were not for the REHPS Program and being invited to help by a Custer Regional Health employee (Lori Buhnam sp?!!, sorry Lori!),  I might not have ever been part of this incredible event.

Week 3
On Monday morning Austin and I met with Custer High School Principal Derek Barrios.  We discussed the challenges associated with the Custer School District including a wide student demographic group spread across a large geographic area.  However, as an ambitious and excited recent member of the Custer School System, Principal Barrios outlined the many exciting ways that his school is overcoming the challenges to improve the wellbeing of students. By offering nutritious meals, anti-tobacco programs, and a wide variety of exercise programs, the students in the Custer school district are building wellness habits that will help them to become healthy adults and community members.

After meeting with Principal Barrios, Austin and I visited Custer Regional Radiology and Lab individually.  The lab technicians showed me the many complex machines and testing devices that they used to help the doctors make decisions on appropriate treatment options.  I was able to see the device used to test blood chemistry values, microscopes, and incubators in action.  Perhaps most fascinating for me, as a pharmacy student, was to see the Vitatek II machine.  This machine helps the technicians determine the best course of antibiotic therapy for an individual’s unique bacterial infection type.

The technicians in radiology showed me the CT scanner and all of the imaging equipment available in the facility. I got to observe a patient getting a CT scan, X-ray, an ultrasound of deep veins, and a DEXA osteoporosis screen.  It was great to see the machines that we have discussed in school being used.  I was shocked by the wide range of abnormalities and disease conditions that can be detected when the X-ray and CT scanner are used effectively.  After my visit with the clinics last week and visiting the lab and radiology today, I better understand the importance of the relationship between testing and treatment.  Overall I was amazed at the wide range of measurements and tests that are capable of being performed in a small community. 

Austin and I were invited to lunch with the Rotary Club of Custer.  I had limited understanding of what a rotary club does.  After meeting many individuals from the community, I was impressed by the genuine kindness and welcoming atmosphere.  I was surprised by how many ways the Custer Rotary Club functions to improve the community at the local, national, and international levels.  Because of such a positive experience with the Custer Rotary Club, I foresee myself potentially becoming a member of a rotary club in my future community of practice. 

On Tuesday I spent several hours at the Fall River Health Facility in Hot Springs observing operations there.  I was provided a tour of the new facility and shown the many treatment options available for patients in Hot Springs.  I observed patient rounds with a healthcare team and was exposed to a team-based patient care approach.  I was very excited and impressed by the numerous opportunities pharmacists have there for patient interaction and providing input for patient treatment.  Finally, I observed family discharge meetings in which patients and family members discussed future care options that often required difficult decisions for end of life care

On Wednesday morning I was in the Hill City Regional Health Clinic.  It was a great experience to observe PA Zach Peterson see scheduled and walk-in patients.  During my observation Zach did a great job of explaining his rationale for making a clinical decision.  He also did a great job of asking me about my opinion on several pharmacy based topics. Because Hill City and Custer are so close geographically, both clinics face many of the same challenges to providing care. Zach explained that having a good team of provider peers to bounce ideas and converse with, helps to overcome several of challenges of providing quality healthcare in a small community.  

On Wednesday afternoon I spent several hours with Dr. Preuss in the Custer walk-in clinic. I was very impressed with Dr. Preuss’s patient interaction skills and care.  She carried a positive attitude despite being extremely busy with patients that had some very serious health issues.  Dr. Preuss also asked me several pharmacy related questions and was very respectful of my ideas.  While observing Dr. Preuss, I was further reminded of the broad spectrum of cases the providers in a small community see and must be able to treat.

On Thursday morning Austin and I met with Custer Regional PT staff Betina and Danielle.  Betina and I immediately went to the hospital to assess and provide therapy to an inpatient being considered for discharge.  It became immediately apparent to me how important it is to have a physical assessment of the patient before discharge to reduce the risk of the patient returning due to a physical accident. Next, Betina and I met with several patients in the PT building; each patient required varying levels of physical therapy.  To form connections with patients, Betina used a variety of personal communication techniques to help her patients feel more comfortable and it is clear that she is very committed to helping her patients get better.  It was amazing to watch Betina push her patients during therapy but also maintain a strong sense of empathy. She expressed genuine concern for each patient and I was not surprised to find out she has received patient care recognitions. 

Prior to REHPS I had virtually no experience with a physical therapist and had very little understanding of what physical therapy entailed.  I was so surprised to find out the science and research that has been done to make physical therapy such an incredible healing tool and important part of the healthcare process.  While watching therapist Betina work with patients, I could not help but notice the parallels between PT and medication therapy.  For example a medical doctor listens to a patient describe symptoms, orders appropriate tests, and decides the best treatment for the patient’s individual needs.  Similarly, a physical therapist meets with the patient, listens to symptoms, performs movement tests, and then decides the best musculoskeletal based treatment regimen to restore strength, mobility, and improve quality of life. 

On Thursday afternoon I observed a pharmacy resident present a primary research article on a novel cardiovascular medication at the VA in Hot Springs. It was exciting and a little intimidating to hear the information presented and the discussion that ensued.  But overall it was a great experience and very informative on what it is like to perform a journal club in a healthcare setting such as a hospital.

On Friday I met with the staff at the Rapid City Regional Outpatient Pharmacy.  I observed many of the exciting new patient treatment options being performed in the outpatient pharmacy.  One of the most exciting parts of the day came when I was asked to go on a patient discharge and medication delivery by one of the lead pharmacy technicians.  While we were walking to the patient room it dawned on me that there was not a pharmacist coming with us.  When I asked who is going to do the discharge, she said “you are”!  It felt great to shift back into pharmacy student mode and deliver the medication consultation.  I have to give credit to the SDSU College of Pharmacy and Ken Main, my preceptor from Lewis Drug, for my ability to perform a complex and on-the-spot pain medication consultation with virtually no preparation.  While at RC Outpatient Pharmacy I was very grateful to have the opportunity to practice using their computer system and be very hands on and involved in the daily routine fill, dispensing, and consultation process. 

From Friday night at 7:00 until Saturday night at 9:00 I completed what has been one of my most exciting REHPS experiences thus far.  I was able to take call with Dr. Falkenburg in the ED.  Over a period of 26 hours, with a combined total of four hours of sleep, I observed Dr. Falkenburg see patients with a variety of very serious medical conditions ranging from sepsis to blunt force trauma.  Dr. Falkenburg has a great reputation among students for being an incredible preceptor and healthcare provider.  I can definitely confirm what other students have said and agree that her great mentoring and practicing reputation is well deserved.

For patient confidentiality reasons I will not go into the details of all the cases we saw. However there were some rare and interesting patient conditions that made my ED time an incredible experience.  Beyond the amazement at the wide range of cases, I was completely shocked at how well Dr. Falkenburg and the ED staff were able to take care of so many patients with calmness and professionalism.  I believe the type of teamwork that I saw was ideally suited to take place in a small community hospital because of the incredible interprofessional relationships and the closeness of the healthcare team.   I felt fortunate to have been able to work with such an amazing group of CNAs, nurses, radiology and laboratory technicians, environmental services, and doctor.  My experience in the ED could probably best be summarized by the following statement.. “you can study anticoagulant drug effects in school all you want and until you are blue in face.  But you will not learn as much about how they work and what they are capable of until you witness a patient coming into the emergency department at 01:00 hours with a hematoma from blunt force trauma”.

Week 4

I am just beginning the fourth and final week of my Custer REHPS Experience.  It is hard to believe that three weeks have gone by already.  Today I observed a Rapid City Regional Hospice nurse, Erin, make home care visits to three Custer Residents. Although we did not visit hospice patients, Erin explained the role of home health in the healthcare spectrum.  Of the three patients we visited, it was apparent that they were very content in their own home and the routine monthly visits were the perfect health check in. Erin also did a great job of explaining her responsibilities as a home health nurse and the excitement that comes as each day brings unexpected challenges and rewards.


On Tuesday Austin and I met with Michael Delano of Custer Regional Health (CRH) to discuss wellness in the workplace.  CRH is among the largest employment institutions in the Custer region and I was impressed to hear about all of the things that CRH does to promote wellness in the workplace.  CRH offers employees reduced cost gym memberships and a variety of wellness screenings.  A proposed expansion of the CRH facilities will also provide physical space for a dining area that would provide employees health food choices.  CRH also has the good fortune of being located directly adjacent to the George Mickelson path.  The path is a great resource for individuals interested in taking a walk over their lunch break. 

On Wednesday morning I met with Dr. Dan Custis and the staff of Destination Dentistry in Custer.  Dr. Custis was kind enough to let me observe a patient receiving an overlay.  I was surprised to hear Dr. Custis describe the use of the technologically advanced CEREC process in the small community of Custer.  With the CEREC process I watched Dr. Custis take complex images of the patient’s tooth, design an overlay using computer software, watch the overlay be milled out of porcelain in an office machine, and then be adhered to the patient’s existing tooth.  The entire process took less than an hour!  It was a great experience to hear Dr. Custis’s story and his history as he began practicing in this area over thirty years ago. It is apparent that Dr. Custis believes in staying current in dental procedures and has a genuine interest in how technology can help his patients.  Not surprisingly, some of his patients travel from hundreds of miles away to take advantage of Destination Dentistry’s excellent patient care and technology.

On Wednesday afternoon, I met with Dr. Nathan Wiederholt of Premier Family Eye Care.   Dr. Wiederholt was very thorough in his explanation of the techniques he uses to help his patients with their vision.  We discussed many of the new technologies that he employs in the clinic to detect pathological eye conditions.  One of the most interesting parts of spending time in the clinic was getting to see a very close up image of a retina from an individual with diabetic retinopathy.  I also enjoyed vising with Dr. Wiederholt about living in Custer and his experiences as a father of a young child here.

On Thursday morning Austin and I traveled with Department of Social Services social worker Laurie Morgan.  We made three house calls and conducted an approximately 15 minute interview with each individual. During the interviews, Laurie assessed general health, safety, and wellbeing.  After our interviews Laurie was kind enough to spend time with Austin and me discussing both the rewards and challenges of working in the social services department. Laurie explained that her caseload can range anywhere from 80 to 120! After spending time with Laurie this morning, I now have a much greater appreciation for the Department of Social Services and understand the importance of having the check-in house visits.

After visiting with Laurie, Austin and I were able to spend an hour with Bill Chamberlain of McColley’s Chapel in Custer.  Bill did a fantastic job of explaining how the chapel business operates and his history in the profession.  Despite having just received a call to go to Rapid City, Bill was kind enough to give us a tour of the chapel and explain how the entire process works.  Upon completion of our tour, Bill completely surprised Austin and me with a chance to play on his authentic 1980’s Rolling Stones Pinball machine, complete with Rolling Stones music and all!

Thursday afternoon Austin and I were able to spend five hours with the crew at Custer County Ambulance.  After two hours of discussing how Custer Ambulance operates, a call came in to transfer a patient from CRH ED to Rapid City Regional Health ED.  I will not go into the details for confidentiality reasons, but this was quite an exciting event and nicely illustrated the importance of having a quality emergency response team in a small community.   Austin and I were able to ride in the back of the ambulance with the patient and observe the paramedic stabilizing the patient.  During transport, the paramedic described the large number of medical treatments possible in the ambulance.  

For our final day Austin and I met with Ed from CRH facilities and maintenance.  With what may be considered a “backstage pass”, we observed the mechanical workings of the CRH Clinic, Wedgwood Assisted Living, and Custer Regional Senior Care.  Ed explained how each building has a unique heating and electrical system and he described some of the precautionary steps that are required for backup power in the CRH Hospital and Custer Senior Care.  It was interesting to see all of the machines and equipment that often operate behind the scenes to ensure that patients receive the best care possible.  Ed also explained some of the challenges he faces on a daily basis because of the age and overall wear on the CRH facilities.

It was both sad and exciting as Austin and I made our final goodbye rounds on our last day.  It was sad to have to say goodbye to the many individuals within the community and CRH that made the experience so rewarding.  I felt that I have grown close with some of the residents at Wedgwood and will miss the great meals, company, and card games!  It took a great deal of planning and efforts on the part of CRH Staff and I am forever grateful for the opportunity to spend a month learning there.  The final day was also a bit exciting however, as I felt charged and more excited about what my future role in rural healthcare may be.  I felt fortunate to have been exposed to such incredible health care providers and an incredible health care system at an early stage in my career.  I know that my experience with them will have a strong positive influence on the way that I practice in the future. 

Based on my REHPS experience in Custer, I observed many benefits to practicing in a rural setting.  For example, practicing in small community hospital and clinic allows interprofessional communication, effective transition of care, and thus provides patients with very high quality healthcare.  I realized that healthcare in a small community goes beyond simply providing medical treatment.  Healthcare in a small community is truly an important component of the wellness of the community and after visiting with so many different community health care settings during my REHPS experience, I have begun to get a grasp on just how important each component is.  The overall well-being that community members receive from these services goes beyond the immediate treatments they are receiving.  Each section is a part of a meshwork that strengthens the community members and I am now more excited about my future in rural because of my REHPS Experience.