5 Ann: A Grow-Your-Own Story Ann wears the hats of clinic administrator and health care provider. She is an example of the grow-your-own concept: I grew up out here, in the northwest, and my father was ill so I decided I wanted to become a nurse and had no idea that was going to be a challenge at all. I became a BSN [bachelor of nursing science] and I had grand ideas that I was going to become an ICU [intensive care unit] nurse and travel the world. I came home for Thanksgiving and met a man who I later married . . . so guess where I started my first practice? There were no physician offices, clinics, or hospitals to work at; therefore, Ann had to find creative ways to use her new nursing skills: I became an EMT [emergency medical technician], I taught childbirth classes, and did anything I thought was related to nursing. I did it, promoted it and used those hours to renew my RN license. It was the late 1970s and people were beginning to hear about the nurse practitioner (NP) role. Ann and a group of community members tried to recruit an NP to their community, but found a PA (physician assistant) to take the job instead: He practiced for 2 years to meet the requirements of the National Health Service Corp loan repayment program, then he left. We then tried to merge with other agencies (100–150 miles in any direction) and one of them sent a visiting doctor. . . . We’d have someone here for a while, then the politics would change and he or she would leave. As a result of unreliable and interrupted access to health care in her community, Ann went back to school and got her NP certification. She started a community clinic on a shoestring budget, and had little or no money for equipment: We didn’t have personal protective equipment that looked like what they had in the hospital, but we had farm safety goggles, and we had raingear. Ann had been one of the few nurses in her community. There had never been an established medical office; therefore, no one in the community had ever been trained to work in one: You have no staff to recruit, if there are RNs out here, they’re out here for some purpose other than health care or they want a wage, which is something to this day that I can’t offer. So we hire bar maids and grocery clerks and train them to our needs. Additionally, there were no funds to hire ancillary staff even if there were qualified people available: . . . so you have to wear many hats. You’re the housekeeper, carpenter, the plumber, the repairman, because there’s nobody to call in. We’re getting more and more people and now I actually have people I can call to work on the plumbing, it’s a wonderfully federal-funded thing, but I still do a lot of things here. Eventually, the community became a taxing district which provided tax revenue to help fund access to stable health care. Through community efforts and grant funds, a medical clinic came into being. A review of literature indicates that one of the main differences between rural nursing and frontier nursing is the number and acuity level of emergency patients that are seen. When asked to relate a story that paints a picture of what it’s like to be a frontier NP, Ann thought this over for a while and then responded with a story involving emergency care: This guy came in, he had been out . . . and he came in with part of his face peeled off, literally peeled from mid-eye to ear. He came to the clinic and refused to go on, didn’t have money, didn’t have transportation, didn’t have a good car, maybe didn’t have a license, I didn’t know. So I made him sign his life away (consent to treatment, and refusal to seek a higher level of care), and I said, okay, I’ll try to put you back together but you have to know, this is beyond anything that I think I’m capable of doing. So 6 hours, several bathroom breaks, Vicodin for him and Advil for me (due to bending over for so long), I had him back together. He looks pretty good, he has function, he talks, and he’s satisfied. When asked if her NP program provided education on emergency care skills, Ann relays a story that also includes the concept of the art of frontier NP practice: No. No, it’s all learned on the job. And trauma is so different for each person. For example, the other day we had a child that had been cut by . . . it was a deep cut, it had probably nicked an artery, and there was lots of blood involved. We probably could have sewn him up but he was so shocky, so traumatized, and the adults were so traumatized by the whole affair that it was not in our best interest or the client’s best interest to sew him up. So, when do you sew up a face and when do you refer a little cut? It’s an art. Working with trauma victims often involves working with local emergency medical services (EMS) systems. When asked about managing trauma victims, Ann explained some of the inner workings of the EMS system in her community: I depend on the EMS, I wouldn’t live here, and I couldn’t survive, if I didn’t have EMS because I cannot sustain a life here. My IV bags out-date, I’m lucky to have two IV bags and once I’m done with those two then there’s hell to pay, so if I really need lots of volume I’m not going to last very long. I can’t carry ACLS [advanced cardiac life support] drugs because they’re too expensive, they out-date too fast. So I rely on EMS for drugs. When asked about the availability of an all-volunteer EMS system, Ann provides this example: It’s all volunteer and so much of the time there is no response. It’s summer they’re gone, they’re vacationing, they’re harvesting, they’re just not available, so we go the next community, 30 miles away and they’re also harvesting and farming. That community has two EMT 2s (their scope is higher than EMTs), one worked for the government, but the government office closed so we don’t even have that resource. So then we can call on the next community down (70 miles away) or we can call in an air ambulance if they’re available, which has a 20- to 30-minute estimated time of arrival, but you need fire department and other personnel to land them. Last weekend, someone, who has renal failure and congestive heart failure, he’s very ill, he called 911 because he was vomiting after his last chemo therapy and “he’s going downhill rapidly” according to the call. It happened to be on my day off but somehow I got involved anyway. There were no EMTs to respond so after about an hour a couple of first-responders got to the scene, assessed the patient, decided he didn’t need an air ambulance and he came to the clinic.
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