My time in West Virginia has been a defining moment in my life. I knew nothing of the “Hollers” where residents of Cabin Creek live. It is a very different part of the country that is most likely invisible to the rest of the United States unless you have “kin” from the area. This all changed when I saw the lyrics to the old song ”Sixteen tons”.
“…I owe my soul to the company store” is posted on a museum. I’d heard this song as a child, sang the lyrics, yet never knew what it meant . The impact that the coal industry has had on West Virginia and other coal mining states is a part of US history that I didn’t appreciate until now. The company stores only accepted currency from certain coal companies. They owned the homes and land of all coal miners, and could take everything once you couldn’t work anymore. In a sense, their souls were “owned by the company store”.
Thousands used the coal industry to make a living, while sacrificing their lives and lungs to support our mostly excessive needs for energy. Black Lung Disease alone has caused severe morbidity and mortality for coal miners to the point that there are special health plans for those with the disease.
Zane and I listened to the story of a disabled coal miner. He has COPD related to Black Lung Disease. When he came into the clinic, we weren’t sure that he would even be able to walk back to the room where we could listen to his story. “Weak”, “feeble”, “worthless”….some of the words that came from his mouth as he described his current state of health.
Surprisingly, he loved his work in the coal mines. He felt free, and loved the camaraderie he had with the other men. He was joyful describing some of the tasks he’d done over the years, but had to quit because of the dust. “It was everywhere, and so thick that you couldn’t see the man right in front of you”. It was a dangerous job, but he was able to provide for his family.
Since being put on disability, he hasn’t been able to get an adequate pension from the union. He has a strong support system, but was brought to tears because he saw himself as a burden. He’s had 8 hospitalizations over the past year due to exacerbations of COPD.
At the beginning of the session, he was was struggling to breathe, but what happened at the conclusion of his story left a deep impression on my heart.
He thanked Zane and I for listening to him. “It feels like a weight has been lifted from my chest. Sometimes it’s nice to talk to someone besides close family and friends. I feel like I could run around this room!”.
Holding back the tears, I thanked him for his time, and for sharing some of the barriers he’d had in his life. He left the room with his head and chest held high.
Neither Zane or I provided our coal miner any medications, didn’t make a care plan with complex nursing diagnoses. We just listened. He felt better leaving than when he came, and this defines what nursing can be for the populations we serve.
Jeff, Rachel, Zane and I have more oral histories this afternoon and hope to glean useful information for the providers of Cabin Creek Health System. We want them to hear some of the barriers their patients have for chronic disease maintenance and staying out of the hospital.
Thanks for reading!
Ashleigh @AshEliseMPH #RuralHealth
Greetings from beautiful St. Thomas! Where do I even begin? We have so much to share from the past 7 days, so we decided to do a photo blog so you could experience it with us!
As Holly mentioned in her previous post, the eight of us were split up for the first week (1/2 with Dr. Barzey, 1/2 at the FQHC). The lovely staff at the FQHC welcomed us with a sweet sign Annie, Rachel, Eyelle, and Kelly have been working hard to distribute ambulatory care surveys, creating educational materials for patients, shadowing the providers, and making the health center more patient friendly.
The other group worked with Dr. Barzey (the only endocrinologist on the island) to create a comprehensive booklet on diabetes education that she can give to her patients. We also had the chance to go out into the community and survey the locals about their nutrition and exercise choices.
Speaking of food choices, the most popular fruit on the island are mangos! They are sold on almost every street corner, and are some of the most delicious mangos we have ever tasted!
If you don’t believe me, ask Eyelle!
Both groups worked dilligently all week to meet their goals and deadlines. We have learned so much about the culture here on the island. It is amazing how differently islanders live, and how much they appreciate the small things that we often take for granted.
At the end of a long week, Dr. Wright invited us to have dinner at her and her husband’s beautiful ocean side home in St. Thomas.
Before we knew it, the weekend was here! We took a ferry (only $6, 10 mins) to the gorgeous island of St. John to enjoy our weekend off! Here are some pics of our trip:
The girls showing off their “Caribbean Hook Bracelets”
We had an amazing time in St. John and were sad to leave But also excited to start another week, and this time, all eight of us were reunited at the FQHC!
We’ve had an incredible week so far here in the Virgin Islands, and look forward to this week’s adventures!
The conclusion of our last post found us busy scheduling interviews with patients in hopes of further understanding – from a culturally sensitive perspective – what barriers exist to our patients’ care. Since then, after dividing up into teams of two, we have efficiently covered multiple counties in a relatively short amount of time and have collected several stories.
Purposefully, the technique of interviewing introduces neither scripted questioning nor new information, so that the stories gathered remain genuine and unbiased. The beauty of this process is that the story of the patient interviewed is revealed, layer by layer. The amount of suffering we have encountered has been tremendous, but it does not eclipse the equally surprising character and resilience of these West Virginians.
Each day we continue to attend multiple clinics, shadowing our preceptors in an attempt to understand primary care at its core. The pace varies, but one student seeing eight patients in the span of two hours is not uncommon for a Monday.
QUALITY IMPROVEMENT PROJECT STATUS: At this time, objective data analysis continues but is now (fortunately!) accompanied by a more human dimension as common, underlying themes are teased out of patient stories. We will report on findings soon as our presentation (presently underway) takes shape, so visit us often! ~ Jeff Lance
Christina Cummings and I had the opportunity to be in clinical at the hospital on Thursday under the guidance of two midwives from the University of Massachusetts. As mentioned in a previous post, there are multiple women in each room. We started out the clinical day in the post-partum room where we performed newborn assessments. Often, newborn assessments are not completed unless the newborn is in obvious distress. This can cause serious problems to be overlooked and not identified immediately. There were a few pre-nursing students that came with the midwives from the University of Massachusetts. Because Christina and I did newborn assessments in our maternity rotation, we were able to help teach the other students how to assess the babies.
After we did newborn assessments, we went into the room for women waiting for Caesareans. This provided Christina and me the opportunity to learn about antenatal care in an area of low resources. Unlike most places in the United States, electronic fetal monitoring does not occur. We were taught how to perform Leopold Maneuvers to figure out the position of the baby in the mother’s uterus. By doing Leopolds, we were able to estimate where the baby’s heart was and use a fetoscope to listen to the baby’s heart and take heart rate. It was so incredible to be able to hear the baby’s heart beat while still in utero, but it was even more amazing to watch the mother’s face when we let her listen. We were able to do this for a mother with twins also so it was informative to compare what the Leopold’s felt like for a multigestation pregnancy compared to just one baby.
From there, we moved into the early labor room. These women all were having vaginal births and were less than 7cm dilated. A few women were on Pitocin to augment the contractions to speed up the labor process but no pain medication was given. Christina and I provided labor support by fanning them to keep them cool, holding their hands, encouraging them to change positions, and rubbing their bellies during contractions. One lady had been there for several days and had not progressed in cervical dilation. Fear was etched across her face and she kept asking why the pitocin wasn’t working as she had been at 4-5cm for 8 hours. The doctors said that if she didn’t progress to 8cm by 3pm that day, they were going to section her. Therefore, food and water were withheld from the patient. However, this was not communicated to the patient and she was obviously frustrated and scared of what was going to happen to her. One of the midwives really advocated for this patient to have her pitocin turned up because there was really no need for a section. We found out the next day that the doctors listened to the midwife and once her pitocin was turned up, she delivered vaginally 3 hours later. This experience speaks volumes about the role of the nurse in patient advocacy. Because this midwife acted as the patient’s advocate, the patient was able to deliver in a way that was healthiest for both her as well as her baby and in the way that she wanted to.
While we were there, one of the other ladies broke her water and after a vaginal exam was performed to check how dilated she was (no privacy), she was taken into the closed off area of the maternity floor to deliver. Christina and I went with her and in less than half an hour later and after Christina excitedly yelled “Empuje, Empuje!” many times, she delivered a beautiful baby boy. Christina stayed with the mom as she delivered the placenta and I went with the pediatrician and the baby. The babies are not washed but are just dried with a towel. One of the practices that the DR doctors do is stick an NG tube down the baby’s trachea because they believe that it helps to suction the fluid out of the lungs. However, there is no evidence to this practice and actually can hurt the baby. No footprints were taken but weight and measurements were. After all of this was done, the pediatrician handed me a diaper, a baby cap, socks, onesie, and a blanket, and mittens for their hands. I dressed the baby, swaddled him in the blanket, and then gave him to his mother
No words can describe the beauty of pregnancy. How incredible it is that two people can create another being that grows and develops inside of its mother. It fascinates me that the baby knows how and when to be born and the process by which it transitions from intrauterine life to life outside the uterus. Watching all of this unfold at clinical was breathtaking and it was beyond an honor to share in this moment with the mother and the baby, whom was named Jahle (spelling unknown). I felt undeserving of the privilege to dress the baby for the first time and to hand the baby to his mom and was unable to do so without beaming with tears in my eyes. Yes, birth is messy and laborous, but it is nothing short of absolutely miraculous.
We’ve now been in Eleuthera for almost a week, but let us go back to last Saturday at 12:00 PM when our adventure truly began. Eight eager students, one extremely brave instructor, and over twenty suitcases met at the airport to board our flight down to Nassau. After an unknown mechanical glitch kept us on the edge of our seats for two hours, we deplaned only to reboard the plane a mere 600 seconds later. Not to stray from the luxurious norm of us ABSN’ers, we were met by a friendly Bahamian taxi driver who somehow managed to squeeze all 9 of us plus luggage into his lavish van (we will spare you the details, but be on the lookout for us in next month’s issue of Ripley’s Believe or not).
Although Constance booked us a room at a casino resort, we focused on celebrating Amanda’s birthday, soaking up as much AC as we could, and resting up for our 4 AM wake up call (who thought a 5:30 AM flight was a good idea? we’ll never know). A quick 45 minute flight later brought us to our final destination – the family island of Eleuthera. Our “home away from home” for the next 14 days.
After catching up on zzzzz’s, Monday morning arrived, and we hit the ground running. Students were paired and dropped at 4 different clinics across the island. Rock Sound and Tarpum Bay clinics in the south, and Governor’s Harbour and Hatchet Bay clinics in the north. These clinics have provided us with a snapshot of the people, culture, and the function of healthcare on the island.
We have witnessed the nurse take on the role of doctor, pharmacist, social worker, secretary, psychiatrist, and friend to all who walk through her door. Here in these community clinics, incredibly personable care (always with a smile) is provided with fewer commodities than we are afforded in our skills lab. The nurse’s ingenuity and passion for her craft and native people mitigates for the lack of resources seen across the land. Throughout the past week, we’ve witnessed first-hand their desire to educate and motivate patients to tackle their non-communicable diseases such as hypertension and diabetes.
But we must mention, it is not all work.. Thursday we took a field trip to The Island School, which is a sustainable, eco-friendly, and research driven boarding school (for details refer here http://www.islandschool.org/). After learning all about permaculture, aquaponics, and marine conservation initiatives, we set out on a winding, unpaved road to Mrs. Rose’s for a delicious, family-style traditional Bahamian lunch.
Following lunch, we spent the afternoon swimming along the beautiful pink sand beaches on the Atlantic Ocean until a massive storm sent us running for home.
We wrapped up the night with an evening filled with karaoke and fellowship with the Tarpum Bay locals (all footage of karaoke will be destroyed upon leaving the island.. sorry folks! But whether she claims it or not, Dr. Coburn can “sang” my friends).
Please stay tuned for updates as we continue our experience immersed in Bahamian culture.
So long for now,
Mary Chandler & Elisabeth
Before I begin writing about our experiences in Dominican Republic, I want to say that although I will try to capture the experiences of all of us in the group, what I write will inevitably be reflections of my own experience and my perceptions.
After a 3 hour plane ride and a 2 hour bus ride from Santo Domingo to San Francisco de Macoris, we arrived at the homes of our hosts Tuesday evening. Two students are staying at one home and the other 6 and the faculty leader is staying at another.
The bus ride allowed us to see the country as we traveled from one of the two biggest cities in the country through mountainous rural areas into a different city. San Francisco de Macoris is the third largest city in the country. Motorcycles, taxis, “carditas”, and mopeds speed rapidly along the street and appear not to abide by any sort of traffic regulations. Traffic accidents, including those involving pedestrians, are common and a major reason for emergency admissions into the hospital. The city is noisy with dogs barking and the traffic and trash litters the street. We are able to walk to the hospital in about 25 minutes and receive far too many cat calls from the Dominican men.
Yesterday (Wednesday), all of us went to Hospital de San Vincente de Paul for an orientation. The hospital is at the end of a street off the main street. We met and spoke briefly with the hospital director as well as with the director of nursing. Much of what was said went over my head due to my inadequate Spanish and the Dominican accent. Those who are fluent in Spanish are having difficulty understanding at times due to the accent and different idioms.
We then went to see the Kangaroo Program that the hospital has. The Kangaroo Program was created to help premature babies with temperature regulation. Because babies, especially those born prematurely, are unable to regulate their temperature effectively, they can lose heat quickly. Thus, it is critical that babies are kept warm. In a lower resource area like Dominican Republic, isolettes are limited. Kangaroo care uses the heat of the mother’s body to warm the baby by keeping the baby skin to skin with the mother. In order for babies to be in the kangaroo program, they must be stable. In the United States, viability of a premature infant is about 23 weeks gestation. In the United States, viability is at 28 weeks. This reflects a great disparity in the technology and care between the United States and the Dominican Republic as the vast majority of the 28-weekers in the United States survive.
After spending time seeing the Kangaroo Program, we went to the maternity floor. There are six different rooms that the women are in, with about 8 beds per room. There is no air conditioning in the rooms and the ceilings have water dripping from them.
Once the women reach 4 cm in dilation, they are moved to Sala de Cinco, which is the room for active labor. Once they progress to 7cm, they are taken back to a delivery bed where they deliver.
There is also a surgical room for caesarean sections. Something that struck me about maternal care was the fact that 50% of births in Hospital de San Vincente de Paul are elective C-sections and 90% of births in private hospitals are C-sections. Because C-sections carry more risks than a vaginal delivery, I am curious if maternal mortality would decrease if C-sections were performed more sparingly. The women receive no medication for labor pain and are often there for days or even weeks because they are admitted to the hospital under false diagnosis of “active labor.” I met a lady today who had been there for 2 weeks and still is yet to deliver. Approximately 1/3 of all births are to teenagers so there is a Sala de Adolescente (Adolescent Room). Once the babies are born, the mothers return to one of the 6 rooms on the floor and the babies stay in the room with the mom. They do not have beds for the babies so the babies are in the beds with the mom. There is a unit in which they put babies that need some extra care. In this unit, there are baby cribs and a few isolettes. It was incredibly simple compared to a NICU in the United States and personally reminded me more of the set up of the newborn equipment in a normal delivery room.
In addition to seeing the maternity floor, we were able to see a dialysis center that was completed donated by a famous Dominican baseball player whose name I do not know, and we walked through the pediatric floor and the ambulatory clinic (outpatient). The outpatient clinic has multiple specialties, but is not open all day every day like the OB/GYN and pediatrics floors are.
This tour allowed us to have a taste of what the healthcare system looks like in Dominican Republic as well as see the facilities and resources available before we begin our project.
What do you get when 8 ABSNs, 6 MSNs, and 1 instructor are packed into a cabin meant for half that amount? The answer is new cabin. We were hardly settled before we began our days in West Virginia, filled with tours of the different hollows/valleys or “hollers” as the residents of Cabin Creek say. These are the areas typically near creeks, where people are able to build communities. We also learned about the impact the coal mining industry and mountain top removal sites have had on this community.
The main clinic in the Cabin Creek community was initially established to support coal miners with Black Lung Disease and their families. Many patients
in both the Cabin Creek Health System and New River Health System, where students are placed, have generations of families that have lived in these communities their whole lives. This is a valuable characteristic for rural West Virginia, because our approach for tackling our quality improvement project relies on oral histories.
The administrative and medical staff have tasked the ABSN “SWAT Team” with discovering the story of patients that have had over 2 hospital admissions over the past 12 months.
The admitting conditions are related to Chronic Obstructive Pulmonary Disease, Chronic Heart Failure, Hypertension, Diabetes Mellitus, and others, which are typically managed in the primary care setting.
What are the barriers these patients face with managing their conditions? Statistics can only tell us so much, and we want to take a culturally sensitive approach. We will do this by hearing their stories. We are busy reviewing charts and have interviews set up after clinic/shadow time with our preceptors in the morning.
I will keep you posted. Please visit my twitter account @AshEliseMPH for real time updates with #RuralHealth as the hash tag.
As a requirement for our Public Health Nursing course, BSN students who participate on the Farmworker Family Health Program conduct a “community assessment” on one of the four counties where Moultrie area farmworkers live and work. In groups of five, we set out in groups to discover what resources are available in the county, how health services are accessed, whether or not transportation is available, etc. to determine what the barriers to healthcare might be.
Yesterday my team was able to meet with two women who work for the Southern Pine Migrant Education Program. We spoke at length with the woman who runs a migrant summer camp for school-aged children of farmworkers and a Regional Recruiter — a woman who finds and meets with migrant families when they first arrive to assess the educational needs of their children. By default, she also ends up assessing many of the family’s other needs, including any health problems they may have.
We went with these women into the trailer neighborhoods where migrant workers live and were able to speak to a man who once worked as a migrant farmer, but now works in construction. He had overcome a major hardship when he first arrived in the US (“Gracia de dios,” he repeated many times) — his daughter had a severe vision problem and he was referred to a big hospital in Atlanta where services were provided to her for free. Since then, he said, his family had experienced few health problems in the 13 years they’d lived in the US. We spoke with him for the better part of an hour, explaining that we hoped to learn more about the community and possibly offer ideas for improving healthcare services to farmworkers. Then he and his son let us feed maiz to the two pet sheep he kept penned up in the yard beside his mobile home.
We also visited with a woman who had the day off of work from the packing sheds. Her trailer home was small but impeccably clean, especially considering that she was caring for eight children under the age of seven — a rotation worked out by the women at the packing sheds to reduce childcare costs. I made a mental note to remind myself of this woman’s workload the next time I complain about having too much homework on the weekend. She told us many interesting things about the health of the children in the community: there are a lot of allergies and asthma, and they tend to get worse at times when the parents’ hours in the fields are longer, or just after major pesticide sprays take place. She also noted that colds and viruses are hard to keep under control in the children, because everyone lives in close quarters. At the same time, she was forthcoming about her opinions on high diabetes rates within the population. “We have plenty of grocery stores and access to fruits and vegetables,” she said in Spanish. “It’s just la cultura — the culture — to eat few vegetables and more starch.”
Perhaps the best thing about my experience speaking to these two members of the immigrant community was the opportunity it gave me to confront my own stereotypes and biases. The gentleman we spoke with was exactly that — a gentle, kind man who loved his family and was grateful for all that he has been able to achieve in the US. I suppose I expected more machismo and weariness of outsiders on his part. The woman was so well-spoken and aware of her situation in life — clearly, as she cares for the children of the neighborhood, she considers how things like dietary choices and pesticide exposure pose a threat to their development. I had to kick myself for thinking that just because she doesn’t speak English well (though she is taking classes) and has a lot of diapers to change, she wouldn’t think of things in a complex way. It’s hard to put into words the feeling I had visiting these two families’ homes, but it changed the way I think about migrant farmers.
I think when we provide service to vulnerable populations, we run the risk of creating a hierarchy or caste system — we are the knowledgeable healthcare providers, and they are the sad, downtrodden people who need our help. The migrant farmworkers I have encountered on this trip are not lesser beings. They don’t need my pity and they certainly don’t need a bunch of kids from an affluent school in the city to teach them how to take care of themselves. Really, all they need is access to quality healthcare. Which they don’t have, because they are undocumented workers. In the future, I hope to do more as a nurse to advocate for access to insurance and services for underserved populations. But it was enough for the day to simply understand that the best way to find out what services people need is to ask them — in person.
Leave Atlanta at 2:30PM; arrive in St. Thomas at 9:15PM. That was the plan, anyway. After sitting at the gate (on the plane) for over an hour and a half, the plane’s radio was repaired and we were ready! Just after the announcement to “prepare for takeoff,” we were informed that the radio was broken (again!) and we would be leaving the next morning. After riding on the Miami airport train to two different customer service desks and waiting an additional 2 hours, we received hotel and meal vouchers. We stayed in Miami overnight and departed the next day for St. Thomas. More quality time with my classmates!
It was all worth it when we arrived at St. Thomas and were met with breath taking views, cool breezes, and an afternoon at the beach!
As with most places, there is a big difference in the tourist area and what the locals call home. For the first week of this experience, one group will be working with the Federally Qualified Health Center. They have been shadowing providers and seeing patients along with developing a patient satisfaction survey. My group has been tasked with working on educational materials for the only endocrinologist on the island, Dr. Barzey. She is a passionate clinician who has taught us so much about island culture and the unique challenges she faces as a provider here. She took us to local restaurants and food trucks as we survey the locals and observe what they eat and how they perceive their own health. We are on a mission to develop quality, culturally relevant information about nutrition and activity to help fight the obesity on St. Thomas.
Christina and I look forward to blogging more about our experiences with Dr. Barzey and the FQHC as we learn more about the culture here and how to help these clinics improve the quality of patient care.