Thursday, September 27, 2007

Prescribing a Squirt Gun

REFLECTING ON: Community health rotation placement and treating patients in their homes...

For my Community Health clinical rotation, I’ve been assigned to work at a nursing agency that provides in-home care to patients that have been discharged from the primary hospital. Grace is the nurse that I have been assigned to work with. She’s Puerto Rican and mainly of African descent. Spanish-speaking patients do a double take when she switches fluidly English to Spanish. She’s subtle like that—holds her cards close and lets the patient reveal him/herself. I could take a lesson. Silence is sometimes the best diagnostic tool.

We visited three patients: one foot amputee, one renal failure with dementia, and one pressure wound. They had names too, but HIPAA wouldn’t like me revealing them. The foot amputee patient didn’t take to “patient education too well. We encouraged him to elevate his foot, which he explained he couldn’t do because it made him uncomfortable. I decided to play the “dumb student” and ask Grace why a patient should elevate his foot in order to heal an infected wound. Of course I already knew, but I just thought a conversation between professionals might be less irritating to the recalcitrant foot amputee. We’ll see.

I was excited to observe wound care because, although I practiced on latex models in skills lab, my clinical placement on the oncology unit didn’t have much opportunity to manage wounds. If the low-platelet, neutropenic leukemia patients had a wound, they were usually sent to the ICU. I like skills and technical stuff, so I’m juiced that my community placement opens the opportunity to work in people’s homes as well as practice new clinical skills.

The second patient we met was a 94 y.o. Brazilian woman with acute renal failure, diabetes, and slight dementia. She lives with her 84 y.o. sister and an obviously unstable dog. The dog is named “Sister” until they realized she was a he, necessitating a name change to “Brother”. Sometimes they still call Brother “Sister” due to his being neutered.

I consulted the patient’s vitals, lab values and history. I listened to the concerned cousin that provided 8 hour/day care to both her family members. In addition to monitoring her weight, liquid/food intake, diet, blood pressure and bathroom habits, I determined that the dog was a primary concern. While I was there, the dog attacked every family member at least once, Grace twice and nipped my hand until it bled. When it jumped on our patient, it went right for her slowly healing IV wound, which had become infiltrated during a recent hospital visit. Grace and I will be prescribing a squirt gun to deal with the dog. I mean, this woman isn’t exactly a quick healer.

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