Kristin Rokusek on her time in Redfield
Day 1: We started our experience with tours and introductions to the healthcare facilities and the community of Redfield. Aly, our site coordinator, provided us a tour of Community Memorial Hospital, the Redfield Clinic, and Randall Pharmacy and introduced us to providers and staff. She then took us on a tour of the community of Redfield. We also received a tour of a local nursing home and sat down with the CEO of Community Memorial Hospital. Even though he had never planned to work in a rural community, he shared his love and pride for the facility and community. He explained to us that the facilities are owned by the community and run by the board of directors, yet managed by Avera, which allows them help with resources and services that they wouldn’t be able to obtain as a completely independent facility. I was also intrigued learning about the funding and finances of rural healthcare, which are substantially different that those of the larger acute care facilities I am accustom to.
Having been through Redfield a handful of times in my youth, it was fun to see parts of the community I didn’t know about and to compare the community now to how I remember it 10+ years ago. In my observation, Redfield has undergone some of the changes that many small communities have, loosing many businesses and services to more populated areas a reasonable drive away, but retaining some unique family businesses that contribute to the community’s character and charm.
Prior to my assignment in Redfield, I was unaware of the existence of the South Dakota Development Center on the outskirts of Redfield. I look forward to learning more about this facility and the services it provides to the state.
One other thing that surprised me was that the hospital has a protocol for trauma team activation. This was something I had only experienced in larger facilities. Hannah and I were lucky enough to see the activation and teamwork in action on our first day!
Day 2: Today we spent most of our time in the Redfield Clinic. I am impressed with the number of providers the community has. There are 3 MDs, 4 PAs and 1 CNP. The clinic is large enough for all of them, and while it wasn’t very busy in the morning, it did pick up in the afternoon. One observation I made was how the providers have good working relationships with the specialists in the area, particularly Aberdeen. While I am used to primary care providers reaching out to other specialists, it is usually in the same community. These providers can call to Aberdeen, ask for a certain specialist such as an orthopedist or podiatrist, get connected with them, and review a case within a relatively short amount of time. This allows the provider to develop a comprehensive plan of care and put the patient at ease. For example, after discussing with a specialist, one patient went directly up to Aberdeen to the clinic that day because the specialty provider was able to fit her in yet that afternoon. While this entailed some driving for the patient, I think she was relieved to be able to have answers and receive the care she needed without much delay.
We also got to see a telemed session. The facility has a room designated for telemed appointments and also has eICU services in their CCU rooms. While there is plenty of paperwork associated with the visit so that both the remote site and the specialty site have all of the patient’s information, the visit itself was relatively short. The most time consuming part was filling out and sending the paperwork to the specialty site so they could also register that patient for the visit. I think that having the ease of accessing the EMR in various locations is a huge bonus that makes these services possible. For the patients, it is nice that they can come to their local clinic and receive specialized consults which allows them to have testing and exams ordered and puts them on the right path for management/treatment.
Day 3: This morning we started out shadowing the nursing staff. This was right up my alley and I found myself helping with cares as appropriate. The nursing workload was similar to what I am used to but with differences because of the rural setting. Today they had 3 RNs for 9 patients. Two of the RNs had patient loads while the 3rd was assigned to cardiac rehab and ED. She helps out with the inpatients until she is needed in cardiac rehab or ED.
The ED has been relatively busy here. Today an ED patient came in at the same time that the first cardiac rehab patient was scheduled to start. In order to provide care, the Director of Nursing and the RN who works as the IT/clinical informatics expert came to help in both the ED and on the inpatient unit. Teamwork is a crucial part to providing care here. No nurse is designated to just inpatients, everyone is expected to help out. The providers too have varied workloads. Usually one MD and one PA/NP are on call for the day/night and then everyone else has clinic hours. When the ED or inpatient side get busy, everyone else picks up extra patients to help out those on call. For example, the MD on call today did inpatient rounds in the AM, saw a few ED patients through the day, saw a few clinic patients, and made two “house calls” at a nursing home in town. To allow him to do all of this, the three PAs in the clinic today covered the majority of the clinic patients. Once again, it’s all about teamwork! This included two of the PAs seeking the MD’s clinical expertise on a few patients today as well.
We also got to tour the South Dakota Development Center today. It is a fascinating facility with a long history! It serves individuals with intellectual and/or developmental disabilities with the goal of getting them back to communities closer to their families. They care for patients ranging from 12-85 and currently have about 120 individuals in their care. We toured the majority of the campus and got to see the dorms where the patients live. One of the patients graciously let us see her dorm and interestingly it reminded me of my college days in the dorms. The center has a huge activity building which includes common areas, a physical therapy department, and an indoor swimming pool. They also have a health services building with a PA, dentist, pharmacy, and lab on site.
Our visit with the director of the center shed some light on the history of the center. The original center was composed of a single large building made of Sioux Falls granite which housed both staff and patients at the center’s opening and it still stands today and is used for offices. The center ballooned from 45 patients at its opening to a maximum population of nearly 1200 patients in the mid-1900s. Both staff and patients used to live on campus and a tunnel system was built so that moving from building to building during inclement weather was possible. Due to regulations and improvements in care of individuals with intellectuals and developmental disabilities, the center cares for its population of about 120 individuals today.
Of course, they have staffing challenges just like many other care facilities, especially those providing services to this population. The staff that we saw interacting with the patients did an awesome job! We were also able to sit down with the behavioral therapists who explained to us the treatment plans of the patients and the lengthy processes for creating them. But, the lengthy process is necessary to ensure both patient and staff safety. I am really glad we were able to include this center in our experience!
Other Redfield experiences we have enjoyed have included various dining options and the drive-in movie theater! We got to watch Despicable Me 3; it was fun to see the kid’s excitement and I think it’s a great perk to have such a unique experience so close! The town has some of the conveniences of a larger community including two fast-food restaurants, a few sit-down restaurants/bars, multiple gas stations, a nice grocery store, and two retail department stores.
Over the weekend, Hannah and I enjoyed some rest and checked out Colorful Creations in Aberdeen, the pottery and canvas studio suggested by one of the nurses. On Sunday, we also celebrated National Ice Cream Day with Blizzards from the local Dairy Queen!
Day 1: Today we spent most of our time in the clinic. The majority of the patients I saw were geriatric. The American population is aging, so no matter rural or not, it is a necessity to be able to provide care for these patients. It was a great learning experience and refreshed my critical thinking skills.
One thing we discussed was how the providers deal with some of the limited services at the facility. For example, ultrasounds are only available twice a week. In these situations, care is focused on evaluating the pros and cons of sending the patient to Aberdeen emergently for testing vs waiting for the service in Redfield. Sometimes there are treatment options that may bridge the gaps, at other times, there are not. And there are patient preferences that must be considered in the plan of care as well. I admire the way these provides approach these situations, although I bet it takes a good amount of experience to be comfortable making those decisions.
We also got to sit in on another telemed visit today. I felt like this one was a little more interactive. It is really a neat thing to see as there is specialized equipment that can be used to allow the provider in the specialty practice to “assess” the patient from a distance.
In the evening, we enjoyed wing night at the Redfield Legion Hall. Apparently half of the town had the same idea because it was a busy place. The wings were good too!
Day 2: This morning we started with rounds with Dr. Wren. The hospital is still busy and census is pretty high, mostly swing bed patients. I’m still learning what qualifies individuals for swing bed care. Most of the patients have orthopedic injuries and are not able to care for themselves at home or need a little extra therapy after a hospital stay. Others are on long-term medication treatments that would make it hard to manage at home due to the frequency, the monitoring, or self-care issues.
We spent some time in the physical and occupational therapy departments today; they were really busy! As expected, many of the individuals they work with are those with orthopedic injury/repair. For example, one of the patients I got to work with had a knee replacement about two weeks ago and another was a younger gentleman who was recovering from surgery due to a shoulder injury. They also work with individuals with neurologic injuries, such as strokes. While I know a good amount about the anatomy and physiology of the body, it was really fun to observe and help with some of the sessions to understand how different exercises work different muscle groups and how small modifications can make a difference.
This afternoon we had a really sick patient Dr. Owens was trying to stabilize to transfer to another facility. Unfortunately, despite his best efforts, the patient didn’t want to cooperate and was continuing to deteriorate. At that time, Dr. Owens reached out to the family to tell them of his needs to transfer to a higher level of care and then utilized the eICU services to initiate that transfer. It was really nice because they made a few suggestions that helped both teams to better care for the patient. They also set up the flight for his transfer, which took a huge workload off of the nurses. While they didn’t use the features today, the eICU program is also available to help with nursing documentation if the nurse is busy providing care to the patient in a critical situation and with caring for the patient by having a doctor who can provide orders to optimize treatment. It is a wonderful service to have and I can see how it benefits both the patients and the staff!
Day 3: Today I spent some time in the Randall’s Pharmacy, the retail pharmacy attached to the Redfield Clinic. Hugh, the owner enlightened me in how pharmacy has changed in the 30+ years he has been practicing. The advent of electronic systems has been both a help and a hindrance. The pharmacy was a really busy place initially as they were catching up on all the orders they received overnight and taking in new inventory when it was delivered. They are lucky to have an automated medication dispenser for some of the most dispensed medications and that saves time and physical labor. It was also interesting to see the logs and check for controlled substances on the pharmacy side, I’m more used to the inpatient routine.
In the afternoon, I spent some time in cardiac rehab. Cardiac rehab occurs Monday, Wednesday, and Friday at the Redfield Community Memorial Hospital. This is a much-needed service that they are lucky to have. The sessions consist of heart monitoring and blood pressure measurement during monitored physical activity that is gradually increased with each session as tolerated by the patient. For example, my patient today spent time on both the treadmill and the Nu-Step machine and did a minute extra on each machine from her previous session and added some inclined on the treadmill. Thankfully she was able to handle it and her heart was too. In visiting with her, she stated she was far from that level of activity after her cardiac event so she was happy with her progress.
One thing I noticed is how they have to tailor care to their resources. An example I noticed during rounds the last few days is that pain control is managed different here. In the hospital I currently practice at, we use IV patient controlled analgesia (PCAs) frequently to allow the patient small doses of pain medication that they can control based on their pain frequency. Here they do not have that technology, mainly because it would be used infrequently and would be costly in small quantities. Therefore, they use more scheduled and as needed orders for pain control as well as pain patches. I guess it’s just a matter of becoming familiar with what you have.
Day 4: Today was a busy day. The hospital is still near full, mainly with swing bed patients, but there are still a few acute patients. We started off with rounds then went with Aly, PharmD. for her anticoagulation clinic. This is a great service for the patients who take coumadin to prevent clotting associated with certain conditions. It is a blood thinner that is most affected by changes in vitamin K level, so this time of year eating fresh garden greens seems to cause some problems. The clinic allows the patient to have a single person monitor their blood and change the dosage to find the most effective one. It also saves the providers a little on their workload.
We were fortunate to go to one of the nursing homes for some rounds before lunch as well. That is a busy place and there are all sorts of considerations when making decisions for the geriatric patient. When we got back, Dr. Owens helped conduct a stress test because the cardiologist who was supposed to come from Sioux Falls was grounded due to fog and then his flight ended up being canceled. Dr. Owens told us that he used to do stress test, but with the changes in billing and the interpretation that the cardiologist does, it works better to let the outreach clinic do them. The afternoon consisted mostly of clinic time and a family conference. In the evening, we enjoyed burger night at the American Legion. It was the place to be and I was so happy to have sweet potato fries, my favorite!
Day 5: This morning we started out the day in the laboratory. The phlebotomists and lab techs are responsible for both inpatient and outpatient lab draws. They can analyze many of the basic labs one would expect such as blood counts and chemistry panels. If the providers order something a little more complex, for example, an ammonia level, it needs to be sent to Aberdeen. A currier comes once a day except for weekends and holidays and takes all the samples to Aberdeen. To make this feasible, the lab techs need to prepare the specimens appropriately, for example some need to be frozen or some drawn in the late afternoon will not be picked up until the next day so they need to be preserved until then.
I spent the day with Dr. Owens, it was a mix of clinic, inpatient rounds, and nursing home rounds. Redfield is lucky to have providers with great family practice backgrounds who can serve in this capacity. We had a wide variety of patients today, from a young patient who had a wrist fracture, to an older patient who was weak and falling and we decided to stop the patient’s blood thinners. I got to pick Dr. Owens’ brain about this decision, the pros and cons. We also reached out to the state health department about a patient for a consultation on possible measles beings there is an outbreak in MN and the patient had recently traveled there. Thankfully the patient had been immunized so we got to look for other causes for the illness.
We also sent a swing bed patient to Aberdeen for a consult by the surgeon on call for a possible surgical complication. While this process involves the use of precious resources because the Redfield ambulance service must transport the patient up there, it is what the patient needed to ensure the patient got the best care. Hopefully it will be nothing major and the patient can come back to Redfield. Finally, I also got to watch Dr. Owens replace a plugged PEG tube for a nursing home patient; it was simpler than I thought. The silly thing is that if the CNP who normally cares for the patient was to do it, state practice guidelines require an x-ray to confirm placement, which would mean more cost for the patient and facility. But if an MD does it, his placement and confirmation by listening to the stomach doesn’t require any follow-up images. Like I said earlier, the community is lucky to have a robust group of care providers!
This last weekend we enjoyed a prime rib meal at Rooster’s, one of the restaurants in Redfield. Friday night was also exciting as some storms went through town. I was watching the radar, but we had a scare when the town sirens went off. Normally I would associate that sound with a tornado, but thankfully there was none, only high winds, which we found out later is also a trigger for the sirens. Thankfully there was only rain and no hail associated with this storm.
We enjoyed crazy days in Aberdeen on Saturday. Much like small towns, it’s becoming harder and harder to keep downtowns alive in cities as well. We also spent some time at the Railroad Depot Museum on Sunday. We were fortunate to receive a tour from a gentleman whose wife was instrumental in turning the historic depot into a museum. The history and memorabilia was fascinating; I love history, especially the history of our great state!
Day 1: This morning I spent time with Andi, the CNP, and we saw patients in the clinic and had two cardiac patients in the emergency department. They got the classic cardiac workup which meant that they had to stay with us at least 12 hours to make sure cardiac enzymes aren’t elevating, which indicates the need to seek care from a cardiologist. While ruling out a cardiac event is a necessity, the process uses resources like time and labor and is much different than the fast emergency department pace I’m used to. Where I currently work, the patients would either be admitted for monitoring or told to follow up with their primary care provider instead of receiving all-day emergency care. This has to do with the availability of specialized medicine nearby in Rapid City versus the distance and the need to rule out cardiac or other life threatening issues fully here.
In the afternoon, I spent the day in the clinic with Ron, one of the PAs. Most of his patient’s today were acute visits and all but two were orthopedic injuries. I was glad for that because this is one area I feel like I could use extra practice. I got to help him put on two casts as well; he is the cast and splinting go-to of the group. Overall, it was a great day and we ended it by enjoying wing night again at the Legion.
Day 2: Today we spent the day in home health. In the morning, I spent time with the nurses doing foot clinic. Approximately once a month they have a foot clinic and patients come in the have their feet soaked and inspected, their toenails trimmed, and callouses removed. This is a great service to have in the community as it becomes more and more difficult to care for your feet with increased age and decreased mobility. It is also important for those with diabetes or peripheral vascular disease because they are at risk for ulcers that could become difficult to heal or infected. Most patients come somewhere between every 2-4 months depending on need.
In the afternoon, I went on two home visits with one of the RNs from home health. Some of the services they provide include lab draws, vital signs monitoring, pill delivery and set-up, foot care, wound care, infusions, and wellness checks. While the two patients I saw were both older than 65, the home health department provides services across the lifespan. Sometimes they even go out to the nearby colonies to provide services. There are also homemakers who help with general tasks and personal care such as bathing, cleaning, and laundry. These are valuable services that allow people to stay in their homes and receive the care they need. For example, we did an ordered lab draw for a patient and that saved her a trip to the hospital lab, which was beneficial to her because she uses home oxygen and no longer drives, so it makes it hard to get around. This way doctor can monitor some lab levels without having to see her every time, and only if something needs to be changed does she have to go to the clinic or hospital.
Day 3: Today I spent the day in the clinic with Heidi, PA-C. We saw a wide range of patients. We saw a pre-school patient who needed a “school physical;” the important things to remember here are immunizations, lead screening, and screening for developmental delays. We also saw a few adult patients with acute complaints, which I was excited to delve into. Finally, we also had an ED patient today with a significant laceration. The patient was lucky because any deeper and it would have damaged some major structures. So, I observed some suturing; next time, hopefully I can get some practice!
Day 4: This morning I spent time in the Doland Clinic with Andi, CNP and Jen, RN. Doland is about 20 miles east of Redfield. Twice a week, providers are available in Doland – Monday afternoons and Thursday mornings. Doland is a much smaller community than Redfield, but there are many individuals who live on nearby farms or in Frankfort, a small community between Doland and Redfield. The majority of the population are elderly, so having decreased travel time is helpful. Not all of the conveniences available in Redfield are available in Doland, for example, the nursing staff is able to do lab draws and take them back to Redfield, but if an x-ray or other testing is needed, the patient still has to travel from Doland. Therefore, mostly follow-up visits are scheduled there, although there are some acute visits.
Over the lunch hour, Hannah and I presented a talk on successful aging at the Redfield Senior Center. We included topics like fall risk and prevention, personal hygiene and oral care, diet, depression risk and prevention, memory aides, and recommendations for enjoying life during the senior years. They were very receptive, asked questions, and enjoyed the presentation.
I spent the afternoon with home health. I went to a home visit east of Redfield and got to do some nail care, while the home health RN worked on refilling the patient’s medication for the week. The patient’s family brought up some concerns to the RN and when we got back to Redfield we followed up on those concerns with the provider and family. One realization I had while working with the Home Health nurses this afternoon, while we prepared for new admissions tomorrow, was the legalities and time involved in the Home health world. Depending on the patient’s insurance and who makes the referral, the paperwork, services, and reimbursement are different. Home health services can be covered by private insurance, VA, Medicare, Medicaid, social services, and a few other sources. This is one example where the wide variety of medical coverage options increases workload and can bring unnecessary challenges into care.
Day 5: Today was psychiatry day at the South Dakota Developmental Center (SDDC), and Hannah and I were thankful to be included. We got to see patients with the psychiatrist or psychiatric residents throughout the day. The team approach to care was integrated into these visits. Many of the patients have some sort of developmental delay, so the input of the behavior therapists and case managers is necessary to supplement the patient’s self-report. The psychiatrists focus on treatment management for these patients and this is mostly related to medication management. The day-to-day therapies the patients participate in, as well as the behaviors they struggle with, are shared to make decisions about care. It was fun to see some of the patients light up when asked about their “jobs” and their progress. This, of course, didn’t happen for every patient, as they have varying levels of cognitive development and attitudes related to treatment. I also got a good refresher on psychiatric medications as well!
This weekend I have to head back to Rapid City to complete a summer course. I am sad I won’t be able to stick around and enjoy a relaxing weekend in the Redfield area.
Day 1: I was happy to be back in Redfield today and excited to start the last week of the experience. I spent the morning seeing patients in the clinic with Dr. Wren. We had some patients that tested my critical thinking; Dr. Wren let me pick her brain and walked me through her thought process, which was very helpful. We also had some interesting discussions about critical access hospitals and rural health clinics and the billing and care regulations. Considering the recent political struggles related to healthcare in this country, it is becoming clear to me just how complex the regulations are. It is hard to wrap my head around all of it.
In the afternoon, Hannah and I spent time at the South Dakota Developmental Center. Today’s task was afternoon med pass. We got to experience shift change between the morning and afternoon shifts. Then we accompanied one of the medication aides on medication pass. We traveled to three different buildings. It appears to me, the most challenging part of the job is knowing how each patient takes his/her medications. It’s very important to have good relationships with the patients to make this easier. The teamwork in the different dormitories was also excellent so that medication pass went smoothly.
Day 2: I spent the day in the clinic with Dr. Owens today. Three were patients I had come in contact with sometime during my first three weeks here in Redfield, so it was fun to see how they were doing. Dr. Owens shared with me some of the nuances of medicine with the insurance regulations, basically, it can be really hard to do what it right for the patient at times because of all the hoops that either the patient, provider, or both have to jump through. I’m sad that this is the reality of healthcare, but hopefully we can look forward to a better future where care is truly patient-centered.
Day 3: Today, I worked with Andi, CNP again. Her patients are generally younger than Dr. Owens, so it was nice to switch it up. I got to refresh more clinical skills, including well child checks, so that was excellent practice. One thing I really like about the rural clinic is the true family practice aspect. While I have to brush up on some areas, I find it rewarding to be able to provide care across the lifespan. Family practice is not an easy place to work, but it is a place where providers can truly impact the patient’s health, from preventative medicine to referral when concerns or disease requires the input of a specialist. The key is knowing one’s resources and limitations; this is something I hope to achieve with more practice.
Day 4: I followed Mary for my last day in the clinic. The day had its ups and downs, it was busy in the morning, but slowed way down in the afternoon. At one point we had two patients in the emergency department for cardiac concerns, thankfully another PA was able to help out. Today was also our final presentation for the REHPS program. Cheri brought lunch for everyone and Hannah and I presented about our experience in Redfield.
Overall, I have come to see how important teamwork is in healthcare in a rural community. While SDDC and the Redfield Clinic/Community Memorial Hospital are two different entities, their teamwork and partnership provide for safe patient care. Within the clinic and hospital, teamwork enables the facilities to provide excellent patient care. Outpatient and outreach services are also integral to providing excellent patient care and focus on the team approach. Finally, there is a level of personal investment here that I haven’t always seen in the numerous healthcare settings I have been in throughout my career; personal investment brings heart into healthcare and that is exactly what healthcare needs these days.
Day 5: Our final morning in Redfield was spent with the psychiatrists at SDDC. It was much like last week, but the patients were new. There were different needs and plans of care to address as well as different family dynamics in some cases. I was also able to spend time with Renee, the director of nursing. She explained to me some of the changes in care they have made recently and those they want to make in the future. She also shared with me more in depth the work of nurses at SDDC. The nurse ensures that the patient’s care plan and actual care are patient-centered and holistic. This involves a significant amount of documentation as well as interdisciplinary communication to advocate for the patient and monitor the patient’s care. This was a really insightful conversation and reminded me that there is more out there than just acute care nursing.
I can’t believe four weeks has gone so fast! I am thankful that I got to spend this time in Redfield and get a first-hand experience into rural healthcare. This experience opened my eyes to the uniqueness and complexities of rural healthcare. I am grateful for all of the time providers and caregivers took to help me learn and experience what they do day in and day out. Rural healthcare is challenging, but rewarding and hopefully, in the near future, I can find my own little niche in rural SD.