From classroom to reality

Prior to heading to Moultrie, we spent three weeks in class learning about community and public health nursing, with a focus on the migrant farmworker population. We learned about many of the health concerns and conditions the farmworkers must face every day. We learned about the long hours they must work, the crowded and sometimes dilapidated housing barracks, the musculoskeletal issues, foot problems, exposures to pesticides, sun, and other brutal conditions.

However, seeing all the things we had learned about in the classroom out in the clinics, really came to light when seeing it in person. We saw in person some of how these farmworkers live everyday. Some of the sights were stunning. We learned about how the farmworkers sometimes live and sleep on old buses on a farm when there is no housing provided. It was shocking and heartbreaking to actually drive by those buses and see how they had been transformed into homes. One of our instructors explained that during some of the peak harvesting seasons, the camp barracks may be overfilled and force people to seek shelter in old, unused buses. She also explained the broken down, beat up building we passed on the way in was their laundry room. While sitting and taking blood pressures, a man asked me how I liked it in Moultrie. I told him it was nice being out in the country and away from the city. He then asked me what I thought about the smell. There was a little lake over towards the back of where we were set up. He explained that when the cooks are done at night, they take all the leftovers and garbage and dump it over there; thus the putrid smell we would sometimes get a whiff of. I felt it provided motivation to provide great care for these people who sometimes have so little.

At another camp, there were barracks covered with graffiti.

Covered in graffiti

Covered in graffiti

Barracks where they live

Barracks where they live

Bus that brings the farmworkers to the fields and back

Bus that brings the farmworkers to the fields and back

I asked Jose what does any of it mean. He explained that sometimes gangs of boys come and write their names. However, they do not come when the barracks are fuller, only when there are less people present.

 

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Moultrie in Photos

Nurse practitioners working with a farmworker

Nurse practitioners consulting with a farmworker

Nurse practitioners working with a farmworker

Nurse practitioner assessing a patient

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Sarah, pharmacy and nurse practitioner working with a patient

Sarah, pharmacy and nurse practitioner working with a patient

Tiffany charting blood pressure

Tiffany charting blood pressure

Winnie providing much need foot care while also assessing for any potential foot problems

Winnie providing much need foot care while also assessing for any potential foot problems

Dr. King and a nurse practitioner providing health care education to a patient

Dr. King and a nurse practitioner providing health care education to a patient

Katrina sampling blood for a blood glucose reading

Katrina sampling blood for a blood glucose reading

Fransico obtaining a blood pressure

Fransico obtaining a blood pressure

Rachel and Jess managing the height, weight, and BMI station

Rachel and Jess managing the height, weight, and BMI station

Nurse practitioner attending to a farmworker

Nurse practitioner attending to a farmworker

Photos courtesy of Domoneek McCoy!

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Moultrie Days 1-3

 

sunset at the camp

   sunset at the camp

After three weeks of classes I can’t believe we’ve finally made it to Moultrie and it’s already Wednesday! It seems like we’ve been going non-stop since we arrived, and I can tell we’re all going to be exhausted when we return home this weekend. In spite of the long days and hard work, it truly has been an incredibly rewarding experience so far.

Day 1

 We spent the morning at the elementary school setting up stations where the children could get their BMI and blood pressure checked, their vision and hearing assessed, their hemoglobin and blood glucose measured, and visit the nurse practitioner students as well as physical therapy students. We were all really excited to finally get started in Moultrie, and as we got to see the children walking through the halls with their teachers waving and saying hi to us it really sunk in that we were actually there. After lunch, which was generously provided by one of the local churches, we took a siesta break to rest up before heading out to the first night camp. Once we got everything set up near the barracks where this particular group of farmworkers was staying, we had to wait a little bit before they came out to see us because they wanted to shower and get cleaned up after a long day of working out in the fields. Although it was a long night and we had to deal with some unexpected challenges, I thought it was a great experience because I felt like I really got to connect with some of the men since I was working intake and I got to talk to them about where they came from and what health complaints they had.

 Day 2

 Today we got an early start at the school, which was a bit of struggle at first after a late night at the camp, but once we saw the children the fatigue was completely forgotten. Overall it was a great morning spent measuring the children’s blood pressure, but I quickly learned that measuring blood pressure on young children can be rather challenging at times since some 4 and 5 year olds have a hard time sitting still and being quiet. I really enjoyed it because it forced us to be patient and take a creative approach to helping them sit still and quietly. After another delicious lunch from a different local church we returned to the hotel for a siesta and then caravanned out to another camp in the evening. This camp was smaller than the first, so we weren’t expecting quite as many men to come through. We set up our stations close to the barracks again, and we all watched and waved as the men rode into the camp on buses. After cleaning up and waiting for the sun to sink below the horizon they finally began to trickle in, albeit slowly at first. I worked intake again and enjoyed it just as much as the night before because I got to talk with the men as well as some of the volunteer interpreters who were very familiar with the migrant farm workers and were hosting the Mexican consulate for the week to help the workers get the necessary visas and passports.

 Day 3

 We got started early again at the school this morning. I worked one of the vision screening stations, which was a lot of fun. We screened children of all ages for both visual acuity and color vision. I found it remarkable that some of the older children have gone through so many years of school with poor vision and no corrective lenses all because they move around and have missed out on regular vision screenings. Hopefully with the help of our referrals they’ll finally get the glasses they need. After another great lunch provided by another generous local church, we broke for our usual siesta and once again drove out to a different camp in the evening. Tonight’s camp was larger than previous ones, so we made quick work of setting up by the barracks and it wasn’t long before the men began to come in. I worked the foot care station this time, and it was by far the most rewarding job I’ve done since we’ve been here. Many of the men spend all day out in the fields where the ground is muddy and water-logged and ridden with pesticides, all of which soak through their shoes and socks causing a wide range of foot issues, but especially fungus from the moisture and contact dermatitis from pesticide exposure. Even the men who didn’t have specific foot complaints enjoyed coming because they got to sit back, relax, and get a little foot massage after a long day of work.

So far my time in Moultrie has been an incredible learning experience that I wouldn’t trade for anything. While working with the children in the school in the mornings and the adults in the camps at night I have already learned so much about the importance of problem-solving skills, thinking on your feet, creativity, and especially flexibility when providing care to an underserved community. I think the one thing that has surprised me the most is how patient the clients are in the night camps when, after working all day in the fields under the blistering sun and oppressive midsummer heat, they have to wait in line for their screenings and to see the nurse practitioner students and physical therapy students, and they do it all with bright smiles and gracious attitudes. It’s a humbling reminder of all that I have to be grateful for.

night camp

night camp

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First few days in Moultrie

First stop on the way to Moultrie: Dickey’s Peach Farm. Dickey’s farm store was a recommended stop on the way down. They have fantastic peach ice cream that is perfect for a driving break. They also have various other peach items such as cobbler mix, muffin mix, bread, and peach jams to name a few!

 

 

Dickey's Peach Farm

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Day 1

The first morning was spent getting ready to set up screenings at Cox elementary where the kids can see nurse practitioners, physical therapy, dental, and go through different screening stations managed by the the undergrad BSN students. Excitement filled the air as we all passed by the children that were in the hallways. Despite some of the conditions they may have at home, the children were clean, well-dressed, and full of energy. They waved and said hello as they watched us begin to set up.

 

Day 2

Night Camp

We watched eagerly as the farm workers returned in a school bus from the fields. The bus had arrived close to dark because they stayed out late, working long hours, to work as long as possible. When they arrived, they were able to head to the donation pile and pick out new clothes and shoes. Instead of going to intake, they returned to their barracks to shower and change their clothes. Instead of coming straight from the fields, sweaty and dirty, they pride in their appearance and took the time to shower so that they felt clean and presentable. The farm workers arrived to intake eager and ready to go through the screenings and see NPs and PTs for their health care problems.

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Farm workers spend a lot of time on their feet and often with wet shoes and socks. The foot care station was set up to be able to look at their feet and examine for foot conditions such as fungal infections (which is prominent among them), chemical burns, wounds, and blisters. Many of them had prunish skin on their feet from spending so much time in wet shoes and socks. This station also allowed the farm workers to have their feet massaged and exfoliated to provide some relaxation after a hard day of work while waiting to be seen by the nurse practitioners and PT. Here they were also able to learn about foot care and how to prevent from getting fungal infections. After, each person received a new set of flip flops so that they could wear them in the shower to reduce their chances of getting a fungal infection. The best parts from each day are the appreciation, enthusiasm, and thankful smiles from each farm worker seen at the clinic.

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Eleuthera Wrap-Up

sunset

nurses
The last few days of our trip comprised of a beach day and two more days at our clinics. After a glance at Trip Advisor, it is safe to say that we were able to hit most of the best beaches on the island, and our Monday holiday was no exception. Florida definitely won’t look as good after this trip!

Our last two days were clinic days. My clinic was not especially busy, but we did get to see what prenatal visits consist of on the island. Our clinic has a midwife, so she did these visits without the doctor, although the babies are all delivered in Nassau unless it is an emergency. We also got a chance to talk with our nurses, many of whom are from Nassau, about the differences in culture between the city and the outer islands, and some of the things that they like and don’t like about working on Eleuthera. It was a great two weeks, and we were definitely sad to leave the nurses who had become our friends.

This trip definitely fit the bill of “immersion learning”. We had a chance to see firsthand how the healthcare system worked. We were able to meet and talk to many local people, and we did this not just in the clinics, but out in the community. We provided teaching and screening at our health fairs, and hopefully at least got a few people thinking about how to better take care of themselves. We collected data that will be used to improve the diabetes education and focus on the island. This was a wonderful experience, and I think I speak for our whole group when I say we can’t wait to go back!

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D.R. Wrap-Up

Our final two days in San Francisco de Marcoris included Q.I. presentations about both programs we observed. The five of us who worked at the Hospital San Vicente de Paul, invited hospital administration, staff, and students to our presentation on the Kangaroo Care/Programa Caguro. Everyone did a wonderful job and the hospital team was very receptive to, and happy with, our observations over the two weeks. Later the same day, the second group presented to the Manhattan community and were also well received. No doubt we all learned a lot about a vastly different healthcare system than our own, and are so very grateful for our time in the D.R. Many of the people we met during our journey there will be faces remembered for the rest of our lives.

On the day before we flew back to the U.S., Dr. D gave a wonderful presentation on her research on Health and Spirituality, at the hospital. It was a big turn out! After grabbing our bags, we packed in to a minibus with fewer seats than people, and began a loooooooong, hot, squished journey to the capital, Santo Domingo. Many acres of rice fields, mountains, small towns, and farms later we arrived at the University, where we had a meeting with the new administrators about the purpose of our trip/projects.

Then piled back into the bus and drove around until we found our hostel for the night. Hostel Nomadas is a little slice of heaven in a beautiful city. We got out to do a bit of sightseeing, which included setting foot in the oldest cathedral in the New World. Amazing. Then the night ended with a lovely dinner on the rooftop of the hostel.

We all learned so much on this trip. And though it’s nice to be home, the experiences and people in the D.R. will be missed.

 

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Good-bye for now, West Virginia!

Today is our final day in Fayetteville, West Virginia. The past two days have been filled with putting the final touches on our group quality improvement project. We combined our data from our interviews with patients, providers and staff concerning the pulmonary rehab program into a written paper and power point presentation. We found that the majority of patients truly love and value pulmonary rehab and have greatly benefitted from it. With a decrease in their symptoms, patients can walk further, have more energy, and can do their favorite activities again. We hope with the collection of positive reviews and recommendations for improving recruitment and maintenance of the program that the two health centers are able to help many more of their patients.

photo 2 (2)

For our final night in our cozy cabin, we took a break from our project to reflect on our time here. We all greatly enjoyed getting to know this area, exploring the woods and the back country roads. We enjoyed getting to know a community and being able to help improve the health of that community in our own small way.  Many of us were surprised in how much history is present here, and in our own communities, and how often this history gets overlooked. The coal mining industry is ever present here. Before arriving, we took for granted where our energy came from and the lives of the people who brought it to us. By talking with patients and hearing their personal stories, we now know the effects of coal mining on this community and the nation. When the time is taken to listen to our patients, we are able to learn so much and are able to provide the holistic care we so hope to provide as nurses.

Prior to this experience, many of us were unsure of where we wanted to work in the future. By spending time in this rural community, we learned the value of rural health centers and their providers. Being immersed in the community, the providers we shadowed knew the patients’ entire families and their history. The patients trusted these providers more than we’ve ever seen in our previous urban clinical settings. These providers were like family to the patients and with this mutual caring, the providers and patients were able to work as a team to improve their health. The power of primary care was very evident in these clinics. This experience has convinced me that rural primary care is where I am meant to be, and I have a feeling some of my classmates also now know where they would like to work in the future.

As we say goodbye to the woods, the birds, and the river, we thank our preceptors and supervisors for this opportunity. Although we won’t be coming back to Atlanta with tans like our fellow classmates, we will come back with a deep appreciation for rural health care and will spread the word of the amazing things happening in the community and health centers in and surrounding Fayetteville. Thank you for a great two weeks!

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Wrapping up in St. Thomas, USVI!

Our last full day in St. Thomas was full of adventure! We started off with a visit to VITEMA – the Virgin Islands Territorial Emergency Management Agency, which was awesome!   We toured through their 9-1-1 dispatch area, emergency management training room (which was currently full of law enforcement officials preparing for active shooter situations), and viewed a few short tsunami videos in their main conference room. For those who may find themselves in tsunami zones in the future – signs to look out for include (1) a major earthquake (like really shaking, 7-8-9, etc.), (2) sudden significant/noticeable change in tide, and (3) a LOUD roar (way louder than jet engines) … This was an excellent experience – and we are thankful that Dr. Wright organized this opportunity before our departure!

VITEMA Bus

From Vitema, we headed to the downtown district. There were three big cruise ships in today which means all the shops are open. We had an extended lunch hour to eat and explore. It was especially fun poking around the straw markets!

Straw Market

Next, we were off to the FQHC. We first talked with a nurse at the clinic who manages the HIV screening program and learned about her efforts at the East End Medical Center and out in the community. She and her team are really doing great work to address the high HIV incidence rates (~30%) and empower women to be assertive and speak up for their sexual health. They even offer age-appropriate programs in schools (beginning with age 11) to inform adolescents, teens, and young adults across the islands.

Finally, it was time to time to deliver our final presentation! We discussed the Diabetes & Hypertension Registry, Ambulatory Care Survey, Innovative Health Fairs, and Teamwork & Workflow Observations.

STEEMC Final Presentation

(1) Diabetes & Hypertension Registry: This was the mega project! We officially demonstrated use of this tool to capture and report diabetes & hypertension data mandated for FQHC reporting. This document has many fancy features that we hope will not only help maintain FQHC funding but also improve chronic disease management in the clinic! (Many of their clients currently have uncontrolled diabetes & hypertension.) We also offered suggestions for implementation to promote utilization.

(2) Ambulatory Care Surveys: We collected a total of 115 surveys (completed by patients in the clinic) and compared data to last year’s findings. The major results – improved satisfaction related to “prompt return on calls” and “provider takes time with you” but decreased satisfaction related to several other items, including but not limited to: “time in waiting room,” “time waiting for results,” “collection of co-pay,” and “likelihood to refer friends and family.”

(3) Innovative Health Fairs: We screened a total of 141 employees at the three Innovative health fairs in three island locations: St. Thomas, St. Croix, and Tortola (BVI). Averages included: BP (140/82), non-fasting glucose (110.5), non-fasting cholesterol (201), BMI (31.6), and waist circumference (31.5 inches). Overall, we found this population is most affected by hypertension, elevated cholesterol and overweight/obesity.

(4) Teamwork & Work Flow: Finally, we shared our observations and anecdotes related to safety, efficiency, provider preferences, communication, and teamwork in the clinic. Specifics recommendations/emphasis included: consistent hand washing, the need for additional manual BP cuffs, implementations of daily huddles, and clarification of job descriptions and provider preferences.

Our presentation was very well received! We were complemented genuinely on our work and professionalism and were sure to express our gratitude to the wonderful team at St. Thomas East End Medical Center for welcoming us into their clinic and onto their team over these last two weeks.

We have really had a wonderful experience and are so thankful to Emory University, the Lillian Carter Center, and all of the St. Thomas organizations and community members that supported our service learning experience. We also owe a tremendous THANK YOU to Dr. Wright, our incredible faculty lead, and her wonderful family (Mr. Wright, Beka, and Connor!) for hosting us on St. Thomas and making this both an educational and highly enjoyable experience!

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Continuing quality improvement work in WV

 

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This week, we continue to shadow primary care providers in the clinics and work on our quality improvement project in the afternoons. We’ve begun interviews with patients, providers and staff in and out of the clinic. Today, two of us went on a home visit to interview a patient who is eligible for pulmonary rehab and is willing to go but is unable to afford it. He lost his insurance at the end of last month and is not eligible for Medicare at this time. Although West Virginia opted to extend Medicaid and despite the fact that these health clinics did a significant amount of outreach to patients about the Affordable Care Act, it seems that some patients did not sign up or were unable to pay the fees for the insurances offered to them through the exchanges. The patient we visited today stated that his provider mentioned “some Obamacare thing” to him but that he didn’t know anything about it. To me, this really illuminates how rural this area really is and how isolated these communities are.

Without insurance and with no job, the patient is not able to afford going to pulmonary rehab. (He is still able to see his medical provider as these are FQHCs and they cannot turn away people, and therefore offer a sliding scale for provider visits). In visiting him, we learned how great his need for rehab is. At this point, he said he can’t even trim his toe nails without getting out of breath. He spends most of the day napping, and rarely goes out. He is able to drive himself places such as the store or the clinic. He doesn’t have any family in the area anymore and he said he didn’t have anyone to help him around the house. He is a great example of someone who would benefit from this program. By slowly improving his lung function under the supervision of medical providers and by learning how to organize his daily activities in a way to avoid fatigue, he would be able to do so much more. Perhaps he could continue a favorite hobby of his or be more social by attending church or community events.

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We’ve also been calling patients and talking to providers in the clinic. We are talking to patients who have declined or refused to go to the rehab program and have discovered the multitude of reasons why patients are unable to attend. Lack of insurance, lack of transportation, lack of motivation, lack of social support are just a few of the examples causing people to not attend this program. By talking to providers, we’ve been able to learn about the education they are receiving about the new program and how they are “selling” it to patients.

As the week goes on, we plan to finish up the interviews and put together a presentation for the health clinics we are working at. With a formal write up and presentation, we hope to give them the tools and information necessary to improve the program so that more patients can benefit from it.

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Despite the hard work, we were able to squeeze in a little bit of fun this weekend. This area of West Virginia is great for outdoor enthusiasts and has some great whitewater rafting opportunities. Our classmate Lauren, who works as a whitewater raft guide in Tennessee, was able to set up a rafting trip with some local guides. We floated down the river past new and old coal mines, while trains on both sides of the river carried coal to the shipping center. We overcame our fears and jumped off a 12 ft cliff into the welcoming river. As a special treat, Lauren played some music for us on the guitar. The beautiful river, a beautiful voice, and a beautiful sunset made for a magical afternoon rafting trip.

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Hello Again from St. Thomas, USVI!

It’s hard to believe we have been on this beautiful island for 11 days already! We are still hard at work at the FQHC – building a diabetes and hypertension registry, conducting an ambulatory care survey, observing teamwork and work flow, and precepting with providers. As we prepare our presentation for Wednesday, we hope that the FQHC team will find our projects and results meaningful!

We have also made progress in our work with a local endocrinologist – learning about challenges experienced in a private primary care clinic and observing care provided in the local health department. We’ve really enjoyed the autonomy and hands-on patient care experience we have had in these settings.

In partnership with the FQHC and Innovative, we have also completed two additional health fairs in St. Croix and on Tortola in the British Virgin Islands. In total (including St. Thomas), we have now screened and educated over 160 island residents! This has been a great opportunity for us to finish up our Million Hearts (and then some) and interact members of the community. The ferry and plane rides to neighboring islands were fun too – Kristina and Ashley even got to co-pilot!

Off to St. Croix for the Innovative Health Fair

Innovative Health Fair on Tortola, BVI

We’ve also gotten our hands dirty with some more community service – a beach clean up!

Beach Clean Up!

Over the weekend, we also had a chance to explore the British Virgin Islands. Here’s just a sneak peek of our adventure!

The boat we chartered through the British Virgin Islands

Check out this lobster we found while snorkeling in the BVIs! Photo courtesy of Jenny K’s underwater camera :)

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