I'm long overdue for another clinic post. It's been a busy week.
There was, of course, the obligatory rectal exam. I was looking for intestinal bleeding in an elderly man who had recently lost a lot of weight. Small amounts of blood in the stool is one of the most sensitive test for colon cancer. So get those colonoscopies every ten years. It beats the hell out of a med student poking around up there. He turned out fine, by the way.
Another patient that sticks out in my head was an elderly woman who was here for a diabetes check up. As you probably know, getting a person with diabetes to change the habits that gave them diabetes in the first place is one of the hardest tasks in medicine. I'd even go so far as to say that it's harder than brain surgery. Granted, I'm biased, but I'm pretty serious about that.
This particular patient was in her 70s, and she was getting tired of all the medications that we were giving her. She was taking about 6 or 7 drugs to keep her diabetes and high blood pressure at bay. It's easy to write her off and label her as "non-compliant", but we had a really nice chat about what goes on in her life after she leaves the clinic. First of all, her children seem very supportive, but they had to move off the reservation to find good jobs (very common). And as friendly as her neighbors are, most of them are elders who are also struggling just to take care of themselves. So here we have a woman in her mid 70s living alone and getting endless piles of mail and forms to fill out. Some forms are heath care related, some aren't. She can barely read what's on the paper ("They just keep using smaller and smaller print on these things"), and when she can make out what it says, she barely understands what they're asking. We can't really expect her to know the difference between glipizide and glyburide. Hell, I can barely remember, and I go to school for this.
Her memory is also fading. That's not helped by the diabetes, but it does make it harder for her to remember the medications that she uses to treat it. The pill bottles are hard to open, and the pills are the size of golf balls. She says that every few weeks, she just throws in the towel and says that she's just going to let her body take it's natural course. You really can't blame her.
Now, as you know, the medications that we're giving her aren't for the sake of passing out pills. They'll protect her memory and vision, and they'll prevent even more serious complications. They may not make her live longer, but they will help her enjoy the years that she has left. Of course, if they're a hassle to take, and if she doesn't connect real benefits to why she's taking them, she's going to dump them down the drain. With all this going on, writing her off as "non-compliant" is almost malpractice.
At this point, I was ready to go to her home and sort through her pill bottles one by one. But then the doctor that I was working with reminded me that we actually have people who can do that! One of the nicest perks to a system as unified as the Indian Health Service is that we can provide services that may not fit into the usual doctor/hospital/nurse/insurance company model. One of those services is public health nursing. These are fully licensed nurses that drive around the reservation in an off-road jeep and provide services in patients' own homes. They can provide wound management, home safety checks, school vaccinations, newborn exams, and other services that don't really require patients to come into the clinic. From a public health standpoint, it's a wonderful service that has a clear benefit for the community. And from a cost-efficiency standpoint, it's also a no-brainer. If people can't come in to the clinic, they let small problems become big problems (which are obviously more expensive to treat). And for quick check ups, it's far more efficient to send out one nurse than it is to mobilize the entire clinic apparatus, including doctors, nurses, registration clerks, medical assistants, etc.
Public Health Nursing is another clear advantage of an all-in-one health system like IHS. For the rest of us, the same type of program is much harder to achieve. When a person gets discharged from the hospital, who sends the nurse out? The hospital? The primary care doc? These questions get a lot easier to answer when multiple health care players are all under the same umbrella.
But before I go off on too much of a tangent, I'll round out the post with a couple of the more unique cases out here. The first was an elderly woman who had a chronic cough. She mentioned that her husband worked at the uranium mine for many years, and she asked if that could play any role in her illness. Yep, uranium. There's a working uranium mine on the Navajo reservation (which seems wrong on so many levels), and quite a few of the tribe members either work there or know people who do.
The last case is a 17 year old boy who had a pretty bad laceration on his hand. He got kicked by a horse. I don't see a lot of that in Tucson.
