2018 Week 2: Healthcare and Health Policy
Wow, Week 2 went by so quickly! We were all recovering from the excitement that was the Pride parade and festival for the first few days (we won Best Group!!), but things were back to normal by the end of the week. We were busy preparing safe sex kits and outreaching for National HIV Testing Day next week, and we also had a farewell party for a case manager who had been at Chase Brexton for the last 10 years.
During my shifts, I had the opportunity to observe rapid HIV testing. This 15 minute test involves a finger prick and the blood sample is placed on a paper strip resembling a pregnancy test. A thin line in either the antigen or antibody box indicates that a patient is a preliminary positive for HIV, and the patient is sent to the lab to assess the viral load of the HIV infection. The patient is also asked a series of questions about their demographics, any drug use, and past sexual behaviors.
Although the methodology of the test and the questionnaire is standardized, I realized how important it was for the tester to be able to read the body language of the patients. Some patients came into the appointment light-heartedly, while others were so nervous that they were quiet the entire time. I saw patients who declined medication that would protect them from getting HIV because they trusted that their partner was taking their medication. And I saw patients who were apprehensive at first, but then realized that their sexual behaviors were risky and decided to start medication, all in the span of 15 minutes. Each test that I observed was so different because the testers modified the way they spoke to make the patients more comfortable.
Although I haven’t been able to perform the rapid HIV tests, I feel a lot more comfortable interacting with patients, whether that is exchanging stories or laughing about a funny experience. Our goal is to educate, support and help people stay safe, but it is also about building connections with the people of Baltimore.
Like I mentioned in last week’s blog, I really have taken to framing my work, my feelings, and my experiences the same way that I like to frame harm reduction–meeting people where they’re at, but not leaving them there.
On Saturday, I facilitated an opioid overdose training mostly on my own, and I was incredibly nervous. I was entering into a community that was not my own, and I didn’t want to seem as though I was speaking like I knew the realities that people were experiencing day to day. How can I educate and also still be learning and listening?
Meeting people where they’re at:
While I was there to educate about harm reduction and teach people how to administer naloxone, I used their questions as a means of understanding where to take my facilitation. Allowing people’s questions to guide my emphasis was challenging for me as a facilitator, but overall very rewarding. We talked a lot about the potential harms of calling emergency services, connections of overdose and police presence, racial injustice behind responses to substance use, and about how pharmacies don’t always follow the laws on the books to distribute naloxone. Because we focused on these issues more centrally, I hope that I was able to connect better to my audience. Maintaining a person-centered and community-centered approach hopefully meant that everyone attending took what they needed from the training and got their questions answered.
Not leaving them there:
There were some parts of the presentation that at first received pushback, but with the proper framing were accepted and understood. For example, when I first started talking about the syringes that we give out in our kits, some people attending were understandably hesitant about needles. They didn’t like the idea of injecting someone with a drug. Comments from other people attending, like the church’s pastor, shifted the focus to the ability to save lives, support their fellow community members, and keep people alive and safe for the future. The shift from the smaller details to the bigger picture made a huge difference in the tone of the room, as well as the receptiveness of the audience. By the end of the training, I had given out 31 naloxone kits to about 20 people, and many people thanked me for such an informative presentation.
This week, I attended a Public Naloxone training by Baltimore Harm Reduction Coalition. It was a wonderful, informative presentation co-led by Reah Vasilakopoulos, another CIIP intern from our health-centered group. One of the most interesting and unexpected parts of the training was the post-session conversation concerning whether or not to call 911. As a governmentally certified organization to provide naloxone training, the Baltimore Harm Reduction Coalition is required to state that the second recommended step for responding to an overdose scenario is to call 911. The first caveat given about that step was that when you call, you should only describe the conditions of the person that you’re attempting to help—you don’t need to tell the 911 call representative that you suspect the person is experiencing a drug overdose. If you say the word overdose, then that call will be flagged for not only emergency personnel to respond, but also the Baltimore Police. Only once the medical first responders arrive should you tell them that the person may be experiencing a drug overdose. But it doesn’t always happen that way. One audience member was describing their personal experiences calling 911. Even if they didn’t state anything about drugs or an overdose, the Baltimore Police arrived before any medical personnel. In the context of harm reduction, responding to an overdose scenario by calling 911 might be doing more harm than good for the people involved. We discussed a revised general protocol for naloxone use: after ascertaining that the person is unable to regain consciousness by shouting, checking for breathing, and administering a sternum rub, the next step should be to give the person naloxone. Within 30 seconds, the person should usually show signs of waking up. If they do not, another dose should be given. If the person is not experiencing an opioid overdose, delivering naloxone will not help but it also won’t cause any harm to that person. If they wake up, then calling 911 may not be necessary but they should be continually monitored. If, however, they do not wake up, it’s then likely best to call 911 and to alert any other individuals present that you are doing so. People who would not want to be present when police arrive could then leave the scene. I thought a lot about this conversation afterwards. Rather than being a protective entity, the police are now on the same level of the substances that they strive to control—both are possible harms to the Baltimore Community.
This week at Shepherd’s Clinic certainly brought its challenges. Our office manager left this week, so their responsibilities have been shifted to the patient care coordinator and the clinical care coordinator. I have been helping both coordinators catch up on the unfinished work left by the office manager. My transportation situation will also be changing. Another intern at the clinic was placed there by a program similar to CIIP at Washington and Lee University. She has a car and had been giving me rides to and from the clinic each day. Her program is moving her placement, so she will no longer be working at Shepherd’s Clinic. For the rest of my internship, I plan on taking the shuttle from Mason Hall to the JH @ Eastern campus each morning. While I have met some challenges, I have also been getting more familiar with the culture at the clinic. I know a majority of the staff by their first names now, and I even learned how to use the drip coffee maker (which I have come to learn is one of Shepherd’s most important assets). I have also gotten more experience using the clinic’s scheduling software, scanning and labeling documents (I was nicknamed a “scanning machine” at one point), and talking to patients and other clinics over the phone. I probably spend around 45-60 minutes speaking to patients or physicians/physician offices on the phone each day. I am now even more confident than I was last week answering the phone and dealing with patient requests. However, it is still somewhat difficult when I have to tell patients that the next available appointment is not for quite some time. It’s also frustrating when patients don’t show up for appointments or arrive late, since someone else could have benefitted from that appointment. I’ve been getting better with dealing with patients that don’t follow clinic policies, and I’m excited for next week to begin and to continue learning.
Earlier this week, nurse “Mother” Theresa asked me to pause triaging to help her with a patient. A mother had brought her toddler to get him a new prescription for his rare syndrome, and Theresa needed help taking his vitals. Taking children’s blood pressure is always a challenge, the arm band restricting their movement and requiring them to stay seated for almost a minute. Yes, an entire 60 seconds. It is however worth acknowledging that this was more of a challenge to him than to us, unable to communicate, or understand our role and why we were holding him to a chair.
Never able to speak, he was able to listen, and smile the sweetest smile when he was able to focus his gaze on my silly faces. After giving up on eating the Black Panther stickers I put on him and covering my glasses with drool, he finally decided to trust me and let us listen to his medical history. His mother had gone out of her way to bring him to the States, hopking to get better specialty care for her boy and the drugs they had been unable to find in their country of origin. Yet finding the drugs at a local pharmacy wouldn’t relieve her for long, their foreign prescription declined, and our primary care clinic unable to confirm his diagnostic.
Fortunately, he met the requirements to be covered by Hopkins’s TAP program, which provides specialty care for patients living in 10 surrounding zipcodes. It was then my joy to do their paperwork and schedule them for a Pediatric Neurology appointment later in the week. The scheduler on the other end of the line was less enthusiastic. “We need an accredited neurologist’s note for such a rare diagnosis.” Our entire staff was livid. “It was mailed from his country weeks ago and has still not arrived,” I explained, “the kid is having seizures, can’t he be seen for at least that? Have your department give him a new diagnosis?” They didn’t budge. I didn’t understand.
Interning at Esperanza has allowed me to learn some of the different steps that primary care encompasses, many of which I don’t understand. Our TAP coordinator took over his case and changed his referral to exclude his rare syndrome, calling on another day to talk to another scheduler. She explained how misunderstanding the process is sometimes really just understanding its flaws, and being part of every step allowed us to play it right. It posed again the question of whether I want to change it from within, or outside.
It’s a remarkable feeling to forget that you’re in a city; to be so completely surrounded by nature that the sounds and smells of East Baltimore melt away. Although I was raised in the country surrounded by agricultural and dairy producers, I never imagined that I could find the same peace that comes from harvesting produce on a hot sunny day in the middle of noisy Baltimore.
I am so grateful for the opportunity to work with the incredible crew at Boone Street. Although each person brings unique talents and experiences to the farm, everyone works equally to plant and harvest. Almost immediately on my first day, I felt incredibly comfortable and accepted by my fellow workers on the farm, and although the work is grueling at times, it is also highly rewarding.
Some of the staff jokes that I’ve made it my summer mission to turn one of the other workers Jace, who is quiet and reserved, into a chatter box through my incessant questions about his personal life and through numerous selfies. Interestingly, this silly quest is oddly representative of my experiences at Boone Street so far. Just like Jace, the various farm properties are unassuming and overgrown, yet inside reveal incredible thought and complexity. Similarly, Jace’s quiet humor echoes the open community that Boone Street strives to create.
This coming week we are welcoming three Youth Workers to the crew, which I am equally anxious and excited about. I have been tasked with assisting in the management of the young workers which slightly scares me as I feel like I’m still slowly learning the ropes. However, I have had great experiences working with youth in the past, and I can’t wait to meet our newest members!Tags: 2018, Baltimore Harm Reduction Coalition, Boone Street Farm, Charm City Care Connection, Chase Brexton POWER Project, CIIP, CIIP 2018, Esperanza Center, Shepherd's Clinic, Week 2