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Amy: A Mobile Experience
OVERVIEW
Amy’s interview takes place in a frontier community clinic, after a long workday and long after the clinic staff have gone home. As is typical, she is alone in the clinic trying to finish up her work, returning patients’ phone calls, checking lab results, and charting.
Amy is now the sole provider at the clinic, but this was not always the case. Amy had originally been hired to work on the mobile van. A few years earlier the clinic merged with a larger health care organization. Prior to the merge, the clinic had employed a part-time nurse practitioner (NP) to work on their mobile van. The mobile clinic had provided health care to a small community (basically a gas station/mini-mart and a post office) 20 miles away, but this service was terminated after the merge.
An opportunity to work on the mobile van came at a time when Amy and her husband were considering purchasing a home in the community. They had been vacationing in the area for more than 10 years and felt it was time to buy a second home. The part-time employment income would offset the cost of a second home and also allow her to spend more time in a community that she loved:
I liked the idea of going out on the mobile clinic and taking care of the rural poor because that was the way I perceived the NP role. It was to take care of all people of all ages and financial statuses, and to take care of the rural poor.
Prior to enrolling in an NP program, Amy had been a surgical clinical nurse specialist (CNS) and assisted surgeons in the operating room:
I built up the Medicare program for surgical assisting and because of the crossover with medical practice, the hospital wouldn’t allow me to do it while I was on duty as an RN. I had to take the extra step of clocking out and being independent when I was in that role. Some of the surgeons also wanted me to work in their offices but as a CNS I couldn’t get prescriptive authority, so I needed to get an NP license. The carrot for the NP role was the independent piece that the NP role was supposed to be an autonomous and independent role for nurses.
Prior to entering into frontier practice, Amy’s emergency care experiences were limited. Besides her CNS experience in the operating room, she had telemetry and cardiac catheter lab experience. She honed her suturing skills by assisting with surgical cases and eventually taught a suturing class for NP students.
CONCEPTS
The concept of the frontier NP as an expert generalist and multitasker was discussed in the literature review. Amy’s prior experiences proved helpful when faced with situations that involved this concept:
I was on the mobile clinic and a man came in who was having an MI [myocardial infarction]. When he walked onto the van he had no blood pressure, he had no chest pain. So you do the EKG and you see that he’s having an MI and you call for a helicopter. The problem with the little town we were parked in was they didn’t have an ambulance, they had a rescue truck. So it’s either put him on the back of a flat-bed rescue truck, or drive him to the landing zone in the mobile van. So, I’ve got a patient in the back of the van, I’m holding onto him while the driver is driving. I had the IV in him, I had him all packaged and ready to go. So, you have to be able to multitask. You have to start an IV, put him on oxygen, and give medications without the help of backup, you’re doing it all yourself.
Sometimes, a receiving trauma center can make assumptions about the level of care that can reasonably be provided in a frontier setting without delaying transport of a critically injured patient:
The river was extraordinarily high one year and a tourist jumped into the river for a swim, hit his head on a rock and nearly de-scalped himself. He was hemorrhaging by the time the volunteers were called and the ambulance got him to the clinic, he was losing his blood pressure. I didn’t even have time to give him local anesthesia, I had to say, “I’m sorry sir, but if I don’t do this you may die.” I managed to slow down the bleeding by rapidly closing the wound with staples before he was flown to the trauma center (120 miles away). I called the trauma center a couple hours later to see how he was doing, “Oh, that guy’s doing great. We’re getting ready to send him home.” I asked if they had explored his wound and they replied no. So I said, I think you better because there could be pebbles in his head, all I did was close his wound because he was bleeding to death!
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