Pandemic Story – Part II


Let me begin this second post by noting that anyone over the age of 65 who lives in California has been told to shelter in place. On Wednesday (three weeks ago), I went down to do some legal stuff for my 92-year old stepmother, who just moved into assisted living. Between 10:00, when I arrived, and 1:30, shortly before I left, the facility locked down and now will not allow any visitors except family and only if the patient is dying.

The two feet of snow we got Tuesday made things even more difficult for the patients of our clinic – not only locked down but snowed in. At our clinic, we just got approval to start seeing patients in what we are calling televisits. We will get our usual fee from MediCal for a telephone visit as long as there is supporting documentation of the same sort we use for a face-to-face visit. So far Medicare hasn’t agreed to televisit payment, but we’re operating on the premise they will follow suit. That means a lot of fleet-footed revising of our usual visit process. For example, we complete various assessment forms, weigh and measure patients, take blood pressure, pulse etc. Can’t do that with televisits. We use medical assistants as scribes to document all the findings from a visit and any orders for things like medications, X-rays and so forth. I’m thinking we’ll put the providers in their offices with the scribe, close the door to minimize distractions and have them turn on the phone microphone so both scribe and provider can hear what the patient says. Certain visits won’t lend themselves to televisits – hard to do a pelvic and pap, or perform vision and hearing tests for a well-child. We’re still figuring those out – may wind up doing a lot more home visits.

RNs in California can perform certain tasks under what is called a standardized procedure – a document that has been formally approved by the medical director and administrative staff. The SP expands the scope of practice for an RN and allows us to order in-house lab tests or refill prescriptions as long as the patient meets certain criteria. The way our procedure is currently written, if the patient has not had a visit within a certain interval, or hasn’t gotten lab or screening (like a mammogram) done, we can only refill for 30 days. We rammed through an overnight change in the policy (the process usually takes a couple of months) to allow us to renew for 90 days even if the criteria aren’t met. This will be in effect for the duration of the pandemic. The effect is to decrease patients coming through the doors in a potentially infectious situation and cut down on trips to the pharmacy.

From the televisit standpoint, the timing couldn’t have been better. The two feet of snow we got Tuesday shut us down and snowed in a lot of our patients. So today in huddle (first day open since the snowstorm) we developed plans to call, beginning with the older people and the ones of any age we know are most vulnerable. We want to see who needs medication refills and/or food, find out whether they have adequate heat and check on those who are dependent on oxygen. The planning was interrupted by the news that the county backhoe clearing the road into the clinic had broken our water main (which was admittedly invisible under the great berm of snow that had already been piled up). To add insult to injury, the backhoe then drove over the water line from the water main to the clinic.

So the minute huddle was over, we sent staff to the Dollar General across the street to buy enough water for staff to drink and so we could flush toilets, while we started calling off the scheduled patients. And since we were closed, we had to notify various agencies, like state licensing. We can’t reopen until we have water – probably (we hope) Monday. Even then, we’ll have to shut off water valves in the exam rooms because we can’t use the water for anything except flushing toilets until we finish testing for coliform bacteria – think E. coli – which means staff can only use hand sanitizer rather than washing their hands between patients. My second RN made it in to work today (she had been snowed in since last Friday). I was delighted to see her, as it meant I could deal with multiple snow/water/coronavirus/procedure issues instead of taking triage calls and doing prescription refills.

My back office supervisor and right hand woman came in walking very oddly because the previous day she, her husband, sons and two of her cousins had been shoveling snow off the walks and away from the walls to prevent melting snow from causing a flood inside the clinic (as happened to us in February 2019). Our HR/compliance person (who is also our resident disaster prep expert) is out with pneumonia, and I’m her disaster back-up. Then the RN who usually relieves me sent an email from her IPhone that she was in the emergency room of a local hospital with chest pain and dizziness.

I finally managed to eat breakfast about 1100. I ate my lunch after I got home around 6. Our staff pulled off a tremendous amount of work despite our trials and tribulations. As I told them in huddle; “I said we’d let you know when it was time to panic. Well, here’s the deal – we aren’t going to panic. Our patients need us.” I was so proud of them.

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Pandemic Story – Part I


I started keeping a journal on the pandemic story a few weeks ago. This is the first part of at least three. As I described it to our CEO a few weeks ago, “I feel like I’m standing in snow up past my knees, seeing the avalanche coming and not able to do anything about it.”

I’m not looking forward to what I expect will happen in the small mountain community where I live and the nearby slightly larger community where I am the nurse manager of a federally qualified health center (FQHC). For those of you who aren’t familiar with the acronym, FQHCs were created back in the 60s to serve the most vulnerable populations across the US. We have over 40% seniors in our population, many patients who have multiple medical problems and many others who have mental health issues as well. And Ma Nature is apparently not very happy with us because she just dumped over a foot of snow and we had to close the clinic for today and maybe tomorrow.

We’re trying to figure out how to help our elders shelter in place now that they are snowbound as well as homebound. We’re running longer hours at the food closet, but these people can’t get to us now. Transportation is always an issue in our area – we don’t have buses, taxis, trains or any sort of public system. We need to make sure our patients have meds, food, heat – the logistics boggle the mind. We have people who live in cabins without heat and even a few in tents – at 3,500 feet in elevation. At least one family I know hauls their water from a stream in buckets.

Luckily I have always been of the “be prepared” mindset and had been monitoring the situation as soon as China started talking about the coronavirus, so I was able to get the conversation going early (to the point, I’m sure, some folks wished I would shut up about it, already!). I got the triage nurses checking for possible COVID-19 symptoms early, we revised our triage tool to make sure we answered all the right questions and every morning – and now sometimes at noon – the whole clinic huddles for updates, changes and planning. We stocked up on extra medications for our dispensing closet and made sure the oxygen tanks are all full. Everybody is doing extra cleaning before, during and after the workday.

It’s a constant struggle. Do you insist staff wear masks all the time and use up valuable personal protective equipment (PPE)? If not, how do we protect ourselves and our patients? How can we do telehealth or phone calls instead of face-to-face visits and how do we get paid? Like most FQHCs, we run on a very tight budget. Like hospitals, we are closely regulated – if we don’t color within the lines, they can shut us down. But difficult as our situation is, I can just barely imagine what it’s like in acute care – it’s more than 15 years since I was a director of nursing.

People are a big part of this pandemic story. While I am extremely thankful not to be working in acute care any more, my heart goes out to the hundreds of nurses I’ve precepted and mentored in my 50+ years of nursing. There’s a pain in my heart to know we’re going to lose some of them. Every time I talk to a patient, I have a tiny voice in the back of my mind: “Some won’t survive – will it be you I mourn?” On the other hand, I’m one of the oldest staff members, so maybe it’s me they’ll be mourning. It’s the hand we’re dealt – gotta play it with fingers crossed.

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Garlic – Herbal Workhorse


Sprouting garlic, covered with wire to keep cats out of the bed.

Garlic, in my opinion, doesn’t get nearly the respect it deserves. While pretty much everything that grows on the face of the earth has some sort of constituent that is useful to humans, I think garlic is pretty much at the top of the list. It’s easy to grow, it stores well on the shelf, it comes in different flavors/varieties and even if you have to buy it at the store, it’s inexpensive.

The Basics

A member of the allium family, garlic contains several volatile oils: allin, allinase and allicin. When crushed, allinase (an enzyme) converts allin to allicin. In addition, this onion relative is high in various sulfur compounds. It’s the combination of the volatile oils and the sulfur compounds that give garlic both its pungent odor and its medicinal properties. Organically-grown cloves are much higher in these constituents than conventionally-grown cloves. Garlic is also a source of selenium and vitamins A,B,C and E.
Allium sativum is an immune stimulant and antioxidant. It has anti-inflammatory effects and is directly antibacterial, antiviral and anti-fungal. It can also have anticoagulant effects, as some folks who take medicines like Coumadin have found out the hard way. There are some studies that show garlic can help lower blood sugar. However, others show no effect, so the jury’s still out on this one. Not to mention that it really enhances the taste of a wide variety of foods. The only disadvantage to cooking the humble clove is that it is much less effective medicinally.
Garlic was one of the ingredients in the infection remedy found in Bald’s Leechbook. Pasteur was the one who proved garlic’s antibacterial effects. In 1858, Pasteur placed cloves in Petri dishes of bacteria. Each clove subsequently developed a clear ring around it where the bacteria had died. In both WWI and WWII, doctors applied garlic to soldier’s wounds to prevent infection. Unlike antibiotics, this herbal “antibiotic” does not seem to produce resistant organisms. It can also be used for ringworm (although I think tea tree oil works faster and better), vaginal yeast infections, urinary tract infections and respiratory infections.

Garlic is an important ingredient in Fire Cider.

Medicinal Preparations

You want fresh, uncooked, crushed cloves. Organically grown are preferred. You can also buy powder and granules or capsules, but they are not as effective.

  • Fresh Garlic Juice
    Juice only enough cloves to produce ¼-1 teaspoon juice. Mix with raw honey or fruit juice to taste. Take every four to six hours.
  • Garlic Tea
    Boil four cups of water (rain, spring or filtered water is preferable) and cool slightly. Add four to five cloves of finely chopped or crushed garlic, some fresh lemon juice and raw, unprocessed honey to taste. Drink three or four cups daily, either warm or cold. Heat just a little; do not bring it to a boil. Good for internal bacterial, viral and fungal infections.
  • Garlic Tincture
    Chop enough garlic to make one cupful. Pour into a mason jar. Add 2 cups vodka or grain alcohol (or vinegar) and screw the lid on. Write the date on the jar. Shake the jar daily for 2 weeks. After 2 weeks, strain out the chopped cloves and store the tincture in brown or cobalt glass bottles. Store in a cool dark place. Use five drops, four times daily.
  • Honey Garlic Syrup
    Crush a clove and place on a tablespoon. Pour raw, unprocessed honey onto the spoon. Swallow a spoonful of honey garlic syrup every four to six hours. Good for internal bacterial, viral and fungal infections.
  • Useful Applications

    For topical treatment of wound infections, use any of the above. Wash the area well with soap and water as soon as possible after the injury. Apply the garlic remedy and cover with a sterile dressing. Reapply dressing and remedy once or twice a day.
    For ringworm, apply fresh chopped garlic under a dressing for one or two hours a day. Repeat daily for two weeks. Or use garlic tincture – apply and leave on under the dressing until the next day. Continue the treatment for at least one week after the skin looks clear.
    Apply a fresh slice of garlic to a wart and cover with a band-aid. A little olive oil on the skin around the wart can prevent irritation.
    Peel a clove of garlic, wrap in gauze and place it in the vagina like a tampon to clear a vaginal yeast infection. Leave in eight to 12 hours before removing; repeat the following day.
    Warm a mixture of garlic oil with mullein oil; put a few drops in the ear canal for ear infections. You can put a cotton ball over the ear and tape in place to prevent the oil from running out.
    Then there are the garden uses. For example, plant it among your roses to help keep down aphids or make your own bug spray with garlic and hot peppers.
    Let’s hear it for the humble clove.

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