Tanya Ochsner
First Week at Wagner
Sunday night, myself and Betsy Price (2 year PA student) arrived at the Wagner Community Memorial Hospital Avera, and were greeted by warm hospital staff, given a short tour, and shown to our rooms. Once we finished unpacking, we decided to find a grocery store to get some necessities, as the kitchen at the hospital recently switched to only serving meals to hospital patients.  Sadly, we missed out on the grocery stores by 3 minutes – due to early close at 6pm on Sundays, and ended up with a couple of delicious salads prepared by the local Subway.

After settling in Sunday night, we spent Monday and Tuesday becoming oriented with the Wagner Community Clinic Avera.  Because this week was the first week of summer for the Wagner school district, it was much slower than normal in the clinic, so we had a lot of time to get to know Lindsey Barthel, our CNP and coordinator, as well as her nurse, Connie.  Right off the bat, Connie and I learned that we have a mutual connection, as I graduated high school a year after her niece!

Wednesday, I spent time with a speech therapist and an occupational therapist. I was able to observe the speech therapist as she worked with a child she had seen last summer and was rescreening this week.  She told me that her job does not allow her much ability to work with children, so in working with this child, she was actually having to make a lot of in-session adaptations.  Immediately after the speech therapist, the child also met with the occupational therapist, who is from Wagner.  She also was completing a screen of the child and informed me that substantial progress had been made and that she was really impressed with all that had been learned.  I was really excited to have the opportunity to work with this child and provide my input as both the speech therapist and occupational therapist worked with the child.  For the rest of the day, I followed the two physical therapists at the hospital:  Joe and Brittany.  These two therapists are phenomenal, and have excellent rapport with their clients – I hope that I can do as well as they do when I begin practicing!  All day long both Joe and Brittany have clients back to back, and they are so knowledgeable and great at explaining to me and the patients exactly what they are doing and what they think the patient should be doing to continue to progress at an appropriate rate.

Thursday was a shorter day. I spent the morning in Radiology with Ronda, and learned from her what it is like to move to Wagner from another town that might be closer to a larger city.  She also told me about radiology and ultrasound technology and what her experience was like going to school and then going back to get education specifically on ultrasound technology.  There was a referral for an ultrasound to be done, but it was later cancelled, as the physician and patient changed their minds, so it was a pretty quiet morning in the radiology department.  After lunch on Thursday, Betsy and I met with Jane, who works with a domestic violence shelter based in Yankton. Jane told us about her work in Yankton and outreach programs that are provided by the shelter.  I really enjoyed talking to Jane about the various programs, and am very interested in the collaborative work she is doing in conjunction with the Yankton Police Department, Fire Department, and various health staff on working with victims of sexual violence.

The last day this week was Friday, and I spent the morning in cardiac rehab with Ashley, who told me all about the various machines that are used with cardiac and pulmonary rehab patients. I was able to shadow Ashley as she worked with a cardiac rehab patient who had undergone an open heart surgery and was currently working on recovery.  The patient was really interesting, fun to talk to, and seemed really motivated during the appointment.  After shadowing Ashley, I went down to James Drug for the rest of the morning where I shadowed and talked with Patty and Robin, who are a pharmacist and pharmacist technician, respectively.  Both ladies told me about how their system works with the hospital, explaining that they receive orders almost like an email system, and are then able to easily fill prescriptions for patients.  They also explained to me how James Drug and the drug store in Lake Andes were recently purchased by the same person. … Now, all of those prescriptions are filled through James Drug in Wagner, and each day at 4:30 pm, one of them in the pharmacy is in charge of bringing all of the prescriptions to the Lake Andes store, where they are distributed to the patients.  Patty commented that it can be hard sometimes to coordinate with patients whether they are going to pick up their prescription in Wagner or in Lake Andes.  For lunch, Betsy and I decided to try a local favorite:  Cake Lady, where the daily lunch special was Super Nachos.  We each had the lunch special and a scotcharoo bar.  If you are ever in Wagner, I highly recommend this place!  It’s only open for lunch, but the food is fantastic, and the desserts are mouthwatering!  Friday afternoon, I was back in the clinic with Connie and on call for the ER.  All in all, it was a pretty quiet and relaxing Friday afternoon.

I’ve had a great first week here in Wagner, and have already met so many professionals who I think exemplify what it takes to be successful in rural healthcare and how important interdisciplinary work is. Many of the health professionals I have met have expressed how helpful it would be for Wagner to have a clinical psychologist or mental health professional on staff on a regular basis, and have informed me that they will be looking to me for any input that I might have on the patients.  I am looking forward to all of the rewarding experiences that will be coming my way over the next three weeks, and I cannot wait to chip-in from the mental health perspective!

Week 2
Monday was a short day for me, as I travelled back to Wagner in the morning from a weekend away, so I spent the afternoon in the clinic with Lindsey and Connie. It was a fairly quiet afternoon, and we saw just a couple of patients who come into the clinic on a pretty regular basis. Connie informed me that the four month old we were supposed to see last week no-showed to the well-child check appointment again this morning, so there is still hope that I will be able to be a part of that appointment!  Toward the end of the day, Kristi, one of the other RN’s, mentioned that we should have a nacho bar for lunch tomorrow, and everyone is going to bring things for nachos, while Connie brings the ingredients for Shirley Temples (or Roy Rogers, which is the “boy version” according to Jordan). I’m very excited for that!

Tuesday morning was spent in the clinic again with Lindsey and Connie, and I had the opportunity to be a part of a yearly physical for an employee of the Army Corps of Engineers, who are continuously working on the Fort Randall Dam in Pickstown (which is just a 15 minute drive west from Wagner). These physicals are all-inclusive, and usually take about an hour to complete. They require vision tests, hearing tests, and labs in addition to everything you would expect from your regular yearly physical. The vision test was really cool, I thought. The clinic keeps a machine onsite that I think looks like something you would see in an optometrist’s office. It tests for colorblindness, depth perception, and peripheral vision abilities, just to name a few. Connie told me that she usually prefers to go with the “old version” of colorblind testing, which involves using a book for the test rather than the machine. She said that the book is easier for people to use and manipulate when they are being tested. The hearing test involves someone wearing older over-the-head style headphones, and raising the corresponding hand to which ear they hear the sound. I thought that this physical was very interesting to listen to, and spent a lot of the time thinking about how motivational interviewing, which is very important in clinical psychology, could be used to talk with clients, especially to get an idea of how things have been going over the past year, and really make sure that their mental health status is a part of their physical exam.

In the afternoon on Tuesday, I followed Amy, a home health nurse who goes around the area and visits with patients. She told me about the process of being a home health nurse, and I was able to help her with her assessment of one of the patients she saw this afternoon as well as work on the patient’s medication boxes for the next three weeks. Amy told me that for this particular patient they refill medications once a month at the pharmacy, but that the patient’s pill boxes have to be refilled every three weeks. This patient was on 17 different medications, which really wowed me. One thing that I noted was that the patient was on an antidepressant along with many other medications, yet did not seem to have any of the signs of depression that I am familiar with from my clinical training. When I asked Amy about this, she said that it was prescribed due to a change in a living situation. She also said that she didn’t think that it is needed anymore, but that getting prescriptions changed is difficult as this patient is also being served by the VA. Learning this from Amy was really informative to me, and also really showed me just how much small communities, such as Wagner could benefit from having a mental health professional on staff, even if part time.

I spent the day on Wednesday with Toni, who is the Director of Patient Care Services. She is in charge of a lot of the communication with social workers/social work that is done in the hospital for inpatients in regard to their plans after discharge from the hospital. Because of her new title, she is not as much involved with the actual planning of where the patient will go after discharge, so I again spent some time with Ashley, the nurse who I shadowed last week for cardiac rehab. Ashley walked me through the PASR, which is a form that has to be filled out with each patient who checks into the hospital. The assessment must be completed at least once during the patient’s stay so that hospital staff from all disciplines can be on the same page in regard to the patient’s needs and planning for when the patient leaves the hospital. This form is also supposed to be a part of an interdisciplinary meeting, but Ashley said that this is a slow process, and the hospital is working hard to find times when members of every discipline will be able to meet together to discuss the patients. Quarterly, a social worker for the state comes out to the hospital to check on the records of all patients and make sure that each patient has a PASR form filled out. What I learned from this experience is just how important it is to be able to perform multiple duties in rural hospitals. For example, as an RN, Ashley works with cardiac rehab patients, helps run machines for stress tests when the Cardiologist comes to the hospital on Thursdays, and also is in charge of the PASR forms and all of the work that happens with social workers.

After lunch, I spent more time with Toni. During the afternoon, a patient was to be discharged by ambulance to another hospital, so I almost had to leave to shadow someone else so that Toni could ride the ambulance with the patient; however, Ashley ended up going on the ambulance, so I was able to continue shadowing Toni. Later in the afternoon, Toni was able to connect me with Melissa, who is the mental health professional in Parkston. Melissa told me about how she got into work in rural mental health, and about her daily schedule. Although she is based out of Parkston, Melissa travels to Lake Andes one day a week, and Wagner as needed in addition to overseeing medication management for diabetic patients in the Lake Andes and Parkston areas. She told me about opportunities with the National Health Service Corps, especially with my interest in working in rural mental health, and this was very exciting for me!

Thursday was a very busy day in the clinic and hospital. Almost right away in the morning, there was an ER admit who was experiencing chest pain and shortness of breath, which Dr. Qazi said was due to fluid buildup in the lungs as a complication of cancer. After that, there was a full day of patients in the clinic and many other admits in the ER. One patient who came into the clinic was a very interesting case to me, as they had many symptoms of Panic Disorder as well as Generalized Anxiety Disorder in addition to the medical disorder they were diagnosed with. We were given a thorough background on the patient and then able to observe both Connie and Lindsey with the patient. I thought that it was really interesting to be able to observe the patient and develop some of my own conclusions about what might be going on in such a complex case. Later, Dr. Qazi saw a patient who is diagnosed as being in the beginning stages of Alzheimer’s, so Betsy and I were given the opportunity to perform a Mini Mental Status Exam on the patient, and it was really great to start working on some of the skills that I have learned as a first year clinical student!

Friday was a quiet day in the clinic, which seems to be a pretty common trend. We spent the day learning about a few of the clients that did come in, but all-in-all, it was a pretty relaxing day. For lunch, we decided to get patty melts at Valley Pump, one of the local gas stations. Because it was such a slow day in the clinic, our preceptor, Lindsey, told us that we didn’t need to hurry back from lunch. We decided to check out Jane on Main, a local boutique, where I found an oversize tee that fits my eating/exercise lifestyle! ;-) After visiting the boutique, we went to Cake Lady to try out some of the famous desserts! I had a rice krispie bar that was enough for two or three people to split, and it was delicious.

Week 3
Tuesday was a short day for me, as I had to meet with my assistantship advisor for the fall in the afternoon. Tuesday morning, we helped with a four-month-old well-child check. Connie and Betsy talked me through the ASQ (Ages and Stages Questionnaire) that is given to parents to fill out. The questionnaire is broken up by the age of the child at the visit, and lists some of the things that the child may be able to do by that point in time, and also will let providers know if the child seems to be developing at a “normal rate”. Lindsey told us about how this questionnaire is very beneficial to the clinic and hospital, not only for the information it provides, but also for insurance purposes.

Then, we were called into the hospital, and I was able to spend time with a patient who came in after a suicide attempt. I spent about an hour or so talking to the patient and getting to know them, the family history, and what really drove them to attempt suicide. It was rewarding to be able to use the skills that I spent a year working on, and know that I helped the doctor get to know the patient even just a little bit better. The patient noted anxiety, which resulted in shaking hands, so I was able to talk them through some third wave meditation breathing techniques to use when they are feeling nervous or anxious. I really took the opportunity to just spend time with the patient and help them to process the suicide attempt and the next steps. It was great to hear them tell me that a lot of what I told them was similar to what they were hearing from their therapist (sounds to me like I’m taking away the good stuff from my training!)

Wednesday, Betsy and I met up with Shannon and Alyssa who are in Platte for their REHPS rotation, and the four of us accompanied their host Jane up to the Grass Roots Hutterite colony, which is north of Platte. Once at the colony, we were greeted by Sandra, who invited us into her home for morning treats, which included caramels that were covered in dark chocolate and sea salt, Lindor truffles, Snickers bars, and many other sugary treats as well as coffee. Sandra oriented us to the Hutterite culture, and what daily life is like in the colony. She spoke fondly of her five children and husband. After answering our questions, we accompanied Sandra and her sister and mother to a shed, where we helped to debone 45-pound turkeys that had been butchered the night before. Being of very weak stomach, I was nervous about this activity, but actually found it to be much easier than I would have thought. Apparently I find humans much grosser than animals! :-) Deboning the birds only took about an hour from turkey breast to nugget-size. We reconvened at Sandra’s where we picked up hoes, gardening gloves, and knee pads to go out to the pea patch. Sandra told us that they hoe the gardens to prevent weeds from growing (a fun fact that I will need to try in my own garden), and we spent about an hour with at least 20 other women hoeing down the pea patch. This activity also lasted about an hour, which left just enough time to settle in, enjoy a glass of “Hud Wine” (which smells exactly like grape jelly!), and get cleaned up before lunch. Interestingly, lunch is held in a large kitchen/cafeteria building, and the women sit separate from the men. We enjoyed a lunch of cooked peas, cooked spinach, salad bar, homemade bread and strawberry jam, goose, and potato and egg soup. Lunch was absolutely delicious! Once we finished eating, we went to Sandra’s mother’s home for another dessert/snack time, during which I tried rhubarb cheesecake. It was very tasty. Sandra and her mother told us about the cooking and baking schedule. One group of the women bake one week, while another group cooks, and then they switch, and then they have four weeks off where they don’t have to get up really early to be in the kitchen. All of the women stressed how important the community is in the colony. If a woman is sick or has something to do that prevents her from being able to cook lunch that week in the kitchen, her family helps her out, and she returns the favor as soon as possible. Everyone in the community relies on one another for support and the safe running of the colony activities.

In the afternoon, we went for a tour of the truss plant where they manufacture wall, floor, and roof trusses, which is run by an outsider, Joe, who comes from California. In the 10 months since operations began at the plant, the workload has gone from Joe wondering how they will ever keep up to being almost a whole month ahead of schedule. Joe said that the Hutterite men work better and harder and have more attention to detail and doing things right than he has ever seen. Some of the men working on the trusses explained to us that this is because they know that the truss plant is their livelihood, and that they all are partial owners of the plant because it is owned by the colony. Their hard work and dedication is unlike anything that you could possibly find the outside workforce, according to Joe.

Thursday was another quiet day in the clinic. In the morning, we were able to visit with a patient who was participating in a pre-operational physical for surgery in Sioux Falls. This individual had recently been involved in a car accident which resulted in a concussion. Unfortunately, with concussions, the best cure is time. However, the patient is hopeful that the surgery will help with the headaches.

Friday morning started out slowly, but I was able to talk with a patient who had recently been experiencing some test anxiety and general anxiety symptoms while in class. Lindsey referred them to be tested in Yankton, so that we can know if this person qualifies for a learning disorder or perhaps some other diagnosis. If there is a formal diagnosis after this person completes testing, they will hopefully be able to qualify for aid at college, which will help them tremendously. It was really great listening to how healthcare providers approach psychological functioning and just how important the referral process is to the field of psychology. More and more, I am realizing just how important it is for rural health providers to be aware of mental health so that they can make the appropriate referrals for their patients.

Week 4
Wow, I cannot believe that this whole experience has gone by so fast! The days just fly by (especially this week), and I can hardly keep all of the days separate in my mind. Most of this week has been spent in the clinic, with a little action in the hospital/ER side of the building as well. I had the opportunity to meet with a couple of patients this week who had some interesting presentations of both medical and mental health issues. It has been really interesting and rewarding to be able to bounce ideas off of not only the providers and nurses in the clinic, but also with my partner, Betsy, about what we think might be going on with different clients. I have also learned a lot about different perspectives from different fields, and just how important it is to be able to work as a team and be aware of your readily available resources in a small community setting. Also, it is really interesting to see the perspectives of the patients who come through the clinic. Some of them, being from a small area, do not realize how difficult it can be to get into a specialist in either Sioux Falls or Sioux City, and that they are not able to walk-in like they might be in the Wagner clinic.

Another thing that really humbled me this week was to see the relationships that the providers and nurses have with the patients who come into the clinic. From other clinical staff to clinical staff families to just community members, it really does seem as though the providers know much more about their clientele than providers and nurses in bigger settings, such as Sioux Falls. Patients in smaller practices almost seem to expect their providers and nurses to remember them better and know a little bit about them when they enter the room, just like they expect to know a little about the provider or nurse before they enter. In our clinical program, we talk about dual roles, and what that looks like for mental health professionals in Vermillion, but I do not think that you can truly respect what that dynamic looks like until you experience it, like I have been able to over the past four weeks. I think that of everything that I have learned, being able to experience what those dual roles should look like, and how to remain a professional even when one of your neighbors might be your patient, is probably one of the most important.

My REHPS experience has really been great. Although the Wagner clinic is not a super busy one, I think that I really learned a lot during my month stay in the Wagner Community Memorial Hospital. I hope that anyone who might be interested in rural healthcare and learning what interdisciplinary work should look like in this setting will consider applying to be a REHPS student.