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Lori: A Career Choice
OVERVIEW
Lori left frontier nurse practitioner (NP) practice several years ago due to unforeseen family issues. She spent a total of 17 years in frontier NP practice; two of these were during her NP training. Lori was working as an acute care medical–surgical nurse in a rural hospital prior to applying to an NP program. She had planned on pursuing a master’s degree in nursing education but was unsure if she wanted to leave direct patient care. While working at the hospital, “I met a nurse who lived in a frontier community about an hour away. She worked part time at the hospital and part time as a home-health nurse for a rural health clinic in her frontier community.” Lori was intrigued with this notion of a frontier practice and eventually learned that the clinic director was an NP. “I drove up to meet this frontier NP and was amazed at the variety of patients and problems that were seen there and the complexity of care that the remote clinic offered. Right then and there I made the choice to apply to NP school.”
The clinic director agreed to precept Lori and she spent the majority of her 2-year training program at the frontier clinic. She was hired 2 weeks after graduation: “My preceptor, and now clinic partner, left for his yearly vacation two weeks after I was hired. I was on my own with a summertime population that was easily 10 times that of the year round population.” Lori and her partner split 24/7 call, but with her colleague on vacation she covered call five out of seven nights with a locum tenens physician covering the weekends. This went on for a month: “It was kind of trial by fire; my clinic RN would come to me and say, ‘the waiting room is getting pretty full,’ while I was rummaging through texts trying to get my diagnosis and treatment plan correct.” Even though she had a rough start, “I loved every minute of frontier practice. I loved taking care of people of all ages; I loved the wide range of problems, from well-care to emergent care.” Lori states that one of the biggest benefits of frontier practice is really getting to know your patients and their families: “Case management is a big issue now a days, for us it was just the way things were done. We knew the patients, their families, and what their resources were. This was very helpful when you’re dealing with a complex medical issue.”
CONCEPTS
Lori took call as a routine aspect of her NP practice. A review of the literature indicates that being on call can cause personal challenges for a frontier NP:
. . . yes, it’s a challenge. In the summer you can be up half the night but still have to show up on time in the morning prepared for whatever comes through the front door. Since there were only two of us to cover a call schedule we over-lapped just one day per week. If the waiting room was still full at 5 o’clock, there was no point in going home because if you were the one on call that night, you’d just be right back. We provided medical coverage for the jail and on the weekend you could almost guarantee a call out at 2 a.m. to draw blood for a potential DUI [driving under the influence].
This last statement brought up the concept of role diffusion:
You do everything because there’s no one else to do it. The jail does not have a nurse to draw blood in the middle of the night, there’s not enough inmates to justify that expense. The county doesn’t always have a coroner on duty either. I’ve had to pronounce kayakers and rafters on the side of the road after they’ve been pulled from the river. If you’re on call during the weekend and the snow is covering the walkway to the clinic, you go shovel it. If someone needs blood drawn, you’re a phlebotomist; if they need an x-ray, you’re the x-ray technician. I’ve even helped the sheriff’s department in determining if skeletal remains were human or animal. I was shown the skeletal remains of a foot once and I honestly couldn’t determine if it was human, or more likely, bear. I called a local retired vet and he explained that there was only a slight difference in lengths of one toe. I was able to determine that it was, in fact, a bear’s skeleton. Also, there is no local veterinarian but we do have a traveling vet who comes to town a couple of times a month. That’s not much of a help the rest of the time. We have a lot of mining claims up here and people will leave rat bait out over the winter. Sure enough, first time they visit the claim in the summer they usually have a dog with them. Invariably the dog eats the rat bait. I’ve injected several dogs with vitamin K over the years. I’ve also treated dogs for rattlesnake bites with steroids to decrease the swelling . . . but that’s one of the things I love about frontier practice, it’s always different and you learn so much as a result.
In the literature review, Connor (2002) stated that knowledge of referral specialists is very helpful. Lori had mentioned use of a retired vet as a resource, so I asked if she used this type of informal referral source regularly:
Since we don’t have any specialists up here it’s really helpful to know who you can call. I remember one summer when a group of school kids went up to one of the local lakes on a swim trip. The following week I started to see kids in the clinic with an atypical rash. They appeared to have all been exposed to something at the lake. I finally called the county health director (he doesn’t live in our county but he’s in an adjacent county) and he told me it was probably just swimmer’s itch. I spoke with one of the old-timers about it and he said, “Yes, everybody knows to stay away from that lake right after the duck migration or you get a rash.” Chalk one up for local knowledge, I could have saved a lot of time by just asking him first [chuckles]. It was also good to know the ER [emergency room] physicians at the local hospital [a rural hospital 55 miles away]. They are a good resource if you’re unsure about something, like maybe a minor EKG abnormality that you’re not sure you should send. Also, if you build a good rapport with them they develop trust in your judgment. For example, if you have a trauma but you think the local hospital can handle it, they are more likely to accept the transfer based on your judgment. This is important for patients because if you send them to a trauma hospital and they’re discharged later that day, their family has to drive an additional 1 to 2 hours to pick them up. Some of my patients just didn’t have the resources to cover that kind of travel.
The provision of emergency medical and trauma care has been noted to be one of the biggest differences between rural and frontier nursing. I asked Lori about her experiences with this:
The first time I met with the clinic director to discuss precepting at his clinic he told me I needed some ER experience. I was just finishing my BSN program at the time [Lori had been an RN for 8 years] and still hadn’t chosen an area of concentration for my advanced nursing course. So before I started the NP program I used the opportunity to work in a fairly busy ER for a semester. Certifications in ACLS [advanced cardiac life support] and PALS [pediatric advanced life support] were required to work at the clinic and I eventually got my MICN [mobile intensive care nurse] certification that allowed me to direct the volunteer ambulance crew. The locals only had BLS [basic life support] certifications, which meant the clinic NPs were the most qualified people to provide emergency and trauma care. That didn’t mean I was comfortable with it, I never did get comfortable, but when someone’s in trouble and you’re the only one who has the knowledge to help, you do the best you can.
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