7 Pam: The Traveler Pam lives in a community that is 80% Native American. There is a reservation 14 miles from her community with a small hospital and ambulance service. However, if you are not Native American, it is difficult to avail yourself of their services. Pam came to the frontier by way of marriage. She grew up in a metropolitan area but always wanted to live in a rural setting: I love looking at the wildlife, I love watching the seasons change, I love waving to the farmers when they’re planting or harvesting their crops, I don’t know, I just love it. I also love rural health. People in rural America will help you. I have lived in other places and it’s not the same as when you live in rural areas, it’s just, people trust each other. . . . For the past year, Pam has worked as a nurse practitioner (NP) in a physician-owned clinic in her frontier community. Prior to this, Pam had traveled out of her community to work in other frontier settings. Travel meant being on call, which usually entailed being away from home for several days at a time: You can’t sleep because you’re not in your own bed. So you’re lying there and you think, I’ve got to get to sleep! Finally, you fall asleep around 2:30 in the morning and at 3 o’clock somebody calls, it’s the ER [emergency room], you’ve got 20 minutes to get there, maximum. So you try to look like a person when you roll out of your motel room. Of course, it’s totally cold out so your car’s half frozen. I tell you, I finally got a car starter. Before that I would have to go out there and crank it over and hope it would start. So then you’d make it to the hospital or the clinic, you’d get out of your car, and you’re frozen [chuckle]. Pam’s sense of humor is evident as she continues: And then, you get there and this little boy had an earache. You examine the child and tell the parent what to do and you smile [laughter] and that’s all that you can do, then you start the whole cycle over again. Okay, now the car’s kind of warmed up, you go back to the hotel room, after you dictate, of course. You go back to the hotel and you can’t sleep and when you do get sleep, it’s time to go to work, and you realize you forgot to eat the day before so you’re really hungry! For a while Pam had worked in a frontier community approximately 110 miles west of her home. She worked for a clinic that was attached to a critical access hospital (CAH) and a skilled nursing facility. This required an extended daily commute (along with some weekend call), which could be dangerous in harsh weather: “You have to be prepared, but I loved it, absolutely loved it.” The concept of limited resources and support in frontier settings is evident in the literature. The CAH was a satellite facility of a larger health care organization. One aspect of working within that system was the amount of support Pam had. For example, if Pam were called to the ER for a medical emergency, she had physician backup by telephone: “They’d talk you right through it. They were just there for you, all the time.” Even with telephone support, there are issues when dealing with trauma patients, particularly managing multiple trauma patients when you’re alone: It’s a nightmare. The patient’s family doesn’t understand why the other patient might be more important than their family member, or whatever. And it’s hard to have enough supplies on hand because they cost so much. People don’t understand things like that. Pam received support in other areas as well: I’m not comfortable with x-rays and so, they sent me down to . . . and I spent some time with the radiologist. Out here the x-ray can be a very valuable tool but they have actually cut x-ray services in most of the clinics where I used to work. The hospitals make more money if you have to send the patients all the way over there.
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