No One Cares Alone

Sarah McConnell [00:00:03] From Virginia Humanities, this is with good reason.

Heather Wicks [00:00:07] He is our wild child. He has a twin and he has an older brother who's five.

Sarah McConnell [00:00:15] That's Heather Wicks. Early in 2018. She had twin boys, Sammy and Alex. Sammy is the one she calls her wild child.

Heather Wicks [00:00:25] And he thinks that he's as big as the five year old. He wrestles. He runs around. He's absolutely fearless. And we always say that he lives like someone who's gone through something because he's just absolutely fearless.

Sarah McConnell [00:00:40] And while Sammy is now a vibrant, healthy toddler. Soon after he was born, Heather noticed something wasn't right.

Heather Wicks [00:00:47] He had always had breathing issues, like from the moment he was born, he always would breathe really fast and he would be breathing normally. And then all of a sudden he would start breathing very rapidly.

Sarah McConnell [00:01:00] I'm Sara McConnell. Today on With Good Reason. The groundbreaking surgery that saved Sammy's life. And later, burnout affects around 50 percent of health care workers. We'll hear from a doctor who's doing something about it.

Mark Greenawald [00:01:15] If the crisis comes because the crisis doesn't come at a convenient time. Right. Is there somebody you could call it 2:00 a.m. and say, I need your help? And they would be there right away.

Sarah McConnell [00:01:25] But first, that strange breathing that Heather Wicks noticed in her son, Sammy. It turns out he needed heart surgery. His mitral valve wasn't working properly. Heather says she was relieved to finally have a diagnosis, but the thought of her newborn boy undergoing major heart surgery was almost unbearable.

Heather Wicks [00:01:46] The pain was so great that sadness isn't enough to describe it. And I guess when I think of the word grief, it just seems bigger to me than just being sad or scared. And, you know, because it is something, a condition that he'll live with forever, there'll be things that he can't do. You know, it's still you still kind of grieve a version of something that you've lost or you have to, like, prepare yourself for a different future.

Sarah McConnell [00:02:14] Sammy needed valve replacement surgery. The problem is most valves are made for adults and much too large for infants. So Sammy's doctors came up with a unique idea that would try to build a valve that could actually grow with the baby.

Heather Wicks [00:02:31] So that's what they liked about it. It wasn't just a one size. They can expand it and lengthen it as his heart grows. So instead of having to replace the actual valve like multiple times in his life, they can just expand this one as his heart grows.

Sarah McConnell [00:02:51] But the heart surgery was a huge risk. And Sammy was the smallest person ever to undergo the procedure. The surgery took hours, hours that must have felt like days for Heather and her husband. And while it was successful, the recovery process was taxing.

Heather Wicks [00:03:08] And he had to be woken up, you know, every two to three hours for a different drug. And so we were waking him up through the night for that kind of stuff. And that went on for months. He wasn't off everything completely until a year after his surgery.

Sarah McConnell [00:03:26] Now, a few years removed from surgery, Sammy's made a full recovery. Every three to four months his cardiologist checks to see how his valve is doing. But so far, so good. And Heather couldn't be more proud of Sammy. Her wild child.

Heather Wicks [00:03:40] We're just in awe in how he recovered. I mean, he he came out of the hospital tiny. And then within a couple of months, he had gained like two or three pounds on his twin. And he's still bigger than his twin. And we're just constantly amazed at how strong he is and how strong willed he is and how brave he is. I still get scared and anxious about him. He's like on my mind every day. You know, when he falls off something because he's being wild, you know, we worry about it staying in place and things like that. But I think it is amazing how well he's doing.

Sarah McConnell [00:04:23] The man behind Sammy's groundbreaking surgery is Dr. Mark Roeser, pediatric surgeon at the University of Virginia. He says they had two options replace or repair his mitral valve. And when it became clear repairing the valve would be impossible. Dr. Roeser and a team of doctors worked together to build a replacement that could grow with Sammy as he aged. Mark, how old was baby Sammy when you first saw it?

Mark Roeser [00:04:53] Baby Sammy was actually about two months old. He is a twin and he had not grown at all. So he was still like three point one kilogram. So, you know, a little over six pounds, still kind of his birth weight, where his brother, you know, basically almost already doubled in size.

Sarah McConnell [00:05:09] Wow. It must have been so obvious to his parents that something was wrong early on.

Mark Roeser [00:05:13] Yeah. And it's interesting, you know, because for those who have kids out there, you know, your first kid and you don't really know what to do and you know, you feed them, you just think everything's going well. So a lot of times we'll have parents who will show up a couple weeks later and their kid is, you know, small. Well, he doesn't eat well. He's kind of scrawny, but they're not too concerned because, you know, it's your first kid. But since Sammy was a twin, it was obvious to the parents, you know, right away that something was abnormal and he was not progressing as well as his brothers. You know, he always had something to compare him to.

Sarah McConnell [00:05:44] But I bet even you had never seen such a stark comparison.

Mark Roeser [00:05:48] Yeah, it was it was a huge I mean, they're both in the room and you can see them together and you're like, wow, that makes him look even sicker, which is the sad thing, because then you have a normal, healthy, you know, baby looks just like them to compare it to. And he was very skinny, very pale and just very unhealthy looking.

Sarah McConnell [00:06:06] Most babies this is happening to, the problem with the heart is usually what?

Mark Roeser [00:06:11] They'll have a hole in the heart. Most common thing and a lot of times they'll come in with coughing and they'll become sickly children, always coughing. And the reason why their coughing is because when the blood is leaving the heart, it goes to the path of least resistance, which is to the lungs. And the lungs will kind of get too much fluid around them. His problem was that the blood was coming back out of his left heart and it was going back into his lungs and his left atrium. So instead of circling around, just kind of getting built up and he was not able to grow because his body was using so much energy because was so inefficient. We can't really make tissue, but we can rearrange things that God is kind of formed these kids with. And he was lacking a lot of tissue on this leaflet. So the mitral valve is kind of like two parachutes that come together and meet in the middle. And the top parachute was on the smaller side and the bottom parachute had not developed at all. So there is just a big opening there and at this age for these children what we want to do is repair that valve and then repair that valve so he can get bigger before we have to replace it. Because if you think about putting something inside of a baby, it can't really grow with the baby very well. So we have the oversize it's like buying shoes for your kids, you always buy them a size up, because the next thing you know, they've already outgrown it. So if we could fix it, we wanted to, but we're unable to fix it, giving how it looked on the echo. So when I talk to other people about their thoughts on replacing it.

Sarah McConnell [00:07:35] What were some of the things they thought of? It's so interesting to have a fly on the wall view of what a conference like that is like.

Mark Roeser [00:07:42] Yeah. So for replacement, there's kind of two options for this age group. And one is a 50 millimeter valve. It's a mechanical valve. So that valve you have to give blood thinner for. And also that valve would have been too big for him. And then whenever you have a small baby and you have to give them blood thinners, the way that blood thinners work is it inhibits your liver from making normal enzymes. But since the baby's growing and the liver is changing, it's hard to keep that in the level you want it. So it's a lot of sticks. And then since, you know, babies may spit up after they eat the medicine or they, you know, start off on breast milk, but then going to change to normal foods, all those levels changes affects the liver. So it's hard to keep a baby anticoagulated and if that blood is not thin enough. And that can get clot on the valve and that can lead to strokes and other issues later in life. And then again, that valve is not going to grow with that child. So eventually outgrow it and they'll need another operation for it.

Sarah McConnell [00:08:38] That's fascinating. What were some of the interesting alternative ideas that people had?

Mark Roeser [00:08:45] So there's a valve that was approved in 2010, and it's from a bull, it's the jugular vein out of a bull. This guy in France, von Hoffer, was working on this and he found out that a bull actually has a valve in its jugular vein. So the vein from bulls neck. If you think about humans, we don't really have big veins, but a bulls of large animal and it has all these chambers. So there's these veins in the neck. So they actually take these 800 kilogram bulls. They'll take the van other neck and I'll process them. And they'll sew them on basically a Chinese finger trap. As you stretch it out, it gets thinner and as you scrunched up, it kind of gets thicker and wider. And the idea was that we would use that valve for Sammy. Boston Children's had previously done this on some larger kids in 2012 and had good success. And they actually, the nice thing about doing what I do is everybody wants people to know what works because everybody runs in these problems and there's not a ton of kids the same size that need mitral valves. So they wrote about their experience and how they did it. When we use their knowledge to actually take a vow, that's for adults. And then in the oh, are we actually cut that valve down and resew it for Sammy specifically.

Sarah McConnell [00:09:59] To the piece of a cow neck vein, Could I have slipped my pinky finger in there?

Mark Roeser [00:10:04] Yeah. Yeah. So it actually, you know, it's very pliable. So it can be bigger than you think your small inner pinky, depending on how you stretch it like that. So there's a Chinese finger trap around it, which is this metal matrix. You can put a balloon in it and blow it up. And the interior diameter gets larger, but the stent then gets shorter and that's how it works. They shrink them down and put it through your leg, into your heart, and they blow it up with a balloon and adults. And that will you be new pulmonary valve. And that's what it was designed to be used for, for adult pulmonary valves, for tiny surgery like this.

Sarah McConnell [00:10:38] Do you have to have a huge magnifying glass on top of what you ordinarily would do?

Mark Roeser [00:10:44] Yeah. So you have these little, you wear these little glasses and they have microscopes inside them and the microscopes are three and a half times. So they're actually, you know, if you think about jewelers. They're called loops that jewelers wear. And we call them the same thing. They're called loops and jewelers can be two and a half to three and a half. And we wear three and a halfs during cardiac surgery.

Sarah McConnell [00:11:03] What was the hardest part of this?

Mark Roeser [00:11:05] The stent is too big for his heart. So we had to cut the stent on the back table and resew it and angle it in order so that whenever his heart contracted, blood could go through a giant "V" we cut in the stent and out his aorta. So we have to put something in his heart that will let blood in his heart, but not block any blood from coming out of his heart.

Sarah McConnell [00:11:30] How long did it take?

Mark Roeser [00:11:30] The operation self took about three hours. It took us about 45 minutes to make the valve before we even started. So we already had the valve made. We had Dr. Hainstock was in the room with us and we got all the teachers in and we kind of parachuted into place. So we have sutures in it. We pulled the sutures down the valve kind of slides down. And then Dr. Hainstock takes a balloon and blows it up. And then we tie everything down and close up the heart and let the heart start beating again and see if it works or not.

Sarah McConnell [00:12:01] How how long before you knew it it worked?

Mark Roeser [00:12:04] Right away. The heart started beating, which is good you can give them heart block where you can hurt the electoral conduction of the heart. And since this was the smallest kid that's ever had this, we were concerned about that. But we took the clamp off. Blood comes in the heart and pushes the medication that's keeping the heart from beating out. And the heart started beating in a normal way. So that was a great sign. And then we actually have an echo probe down the child's mouth so we can look at the heart in real time. And everything on that echo look good.

Sarah McConnell [00:12:32] Even though it was a great success immediately. Inevitably, with these things, there are worries in the days that follow. What were yours with, Sammy?

Mark Roeser [00:12:41] Yeah, a little bit of an irregular heartbeat that we had to address with some medication. And then whenever we do these operations, we actually leave a hole. So that way we can go back in the catheter lab instead of having to open up his chest. You can put a wire across that hole in his heart and you can put a balloon back inside this valve. And as he grows, Dr. Hainstock can go in and use a balloon to dilate the valve and have the valve grow with him, if you will.

Sarah McConnell [00:13:07] It's interesting that you had heart surgery when you were very little, right?

Mark Roeser [00:13:11] Yeah, when I was about two years old, I had a heart surgery done in Texas, which was successful. I'll at some point time need another operation on my valve. I had a very good surgeon that he used his finger to dilate my pulmonary valve, which at that time was what I needed. And it's lasted 38 years but at some point in time that valve will not work as well as it should. And I need to have it replaced.

Sarah McConnell [00:13:35] How will you know when?

Mark Roeser [00:13:37] You go to the doctor every year. But I usually only go before my wife makes me, which is usually before we have or a child or some other major life event. But I'm pretty active and I make sure that if I have any sort issues, I'll go. But I'll probably need it in about 15 years out I'd imagine.

Sarah McConnell [00:13:58] Dr. Mark Roeser is a pediatric surgeon at the University of Virginia.

Sarah McConnell [00:14:06] Coming up next, burnout with doctors. We've all probably felt burn out in one form or another, but it's especially prevalent in the medical field. In fact, about 50 percent of health care workers experience burnout. Dr. Mark Greenawald of Virginia Tech is a family medicine practitioner at Carillion Clinic Family Medicine. Early in his career, one of his patients tragically died while giving birth. And for years, he felt alone, carrying his pain of depression and burnout. That's why he's created a buddy system he calls Peer RX Med. So others in the field don't have to deal with their depression and burnout alone.

Sarah McConnell [00:14:53] Mark, tell me about physician burnout. What do you mean by burnout? What does that encompass and is it prevalent among doctors?

Mark Greenawald [00:15:02] So if you can imagine just having nothing left. Like, I just emotionally, I have nothing more to give. Here I am called to take care of other human beings and their suffering. And I just don't care anymore. I don't. I don't even want to be here anymore. I don't want to be here with them. Or sometimes it manifests as what we call meaninglessness. Or the idea that all this good work that we are able to do in health care doesn't matter, doesn't make a difference, doesn't mean anything.

Sarah McConnell [00:15:35] Why would doctors especially experience meaninglessness, or cynicism? You would think that it would be full of the opposite of those things.

Mark Greenawald [00:15:44] Yeah. And so, burnout, when I think about burnout, often we use the term burnout in a much more familiar way. Man, I had a hard night. I'm kind of burned out. That's not that's not what we're talking about here. We're talking about something that accumulates over time. And so physicians are constantly in that space of fielding or being part of other people's needs and suffering. People come and they bring that to them. And then the person leaves and the physician, then they wipe that clean and they're supposed to go and do that all over again. And the emotional toll that that takes over time, if they don't have a place to process that emotion just starts to wear them out from the inside.

Sarah McConnell [00:16:24] It's crazy because most of us think doctors and others in the medical field are feeling fulfilled, that they have a purpose driven life and they're financially secure. All these things. And yet. You say in spite of that, this is very prevalent among doctors.

Mark Greenawald [00:16:43] The statistics run on burn out are are humbling and alarming. Some national studies have shown upwards to 50 percent of physicians at any one point in time are experiencing this phenomenon called burnout. And that doesn't even take into account other forms of distress that they may be experiencing or things in health care. And this is something that people have talked a lot more about now with the COVID pandemic is something called moral distress or moral injury. So the idea that I can't or don't feel that I'm able to provide the kind of care both that I aspire to and that I think this person deserves. So some examples that have come up, let's just use the example of people who are admitted to the hospital who are positive for the coronavirus, who aren't allowed to have any visitors. And we know that having visitors is part of the healing process. And so I face this dilemma of I think the best thing for you to do would be to have visitors and of course, that would be a terrible thing right now because of so many things we don't know about this virus or things that have happened in some of the the early hot zones, which is I want to help care for you, but I don't have the proper equipment to do so, whether it be because we don't have ventilators or I don't have the proper personal protective equipment to be able to do those things. And so what happens then is it that violates my moral integrity or moral principles and we experiencing something called moral injury.

Sarah McConnell [00:18:09] Tell me about your own experience even when you were a medical student. You went through a kind of grief and emotional distress that was very alarming to you.

Mark Greenawald [00:18:20] Yes. When I was so when I was a medical student, I had what may be called medical students disease, which is that I was starting to associate some of the symptoms I was learning about with my own experience. Then when I was in practice, at that point in my career, I was taking care of pregnant women, doing obstetrics as part of my practice. And I had a woman who died in labor. And the result of that was was a year of incredible distress that resulted in many things likely. I was experiencing a lot of anxiety, likely some depression, certainly some PTSD type symptoms, as well as symptoms of burnout. But at that point in time, I wasn't able to put a name on it and chose to because of my own socialization and indoctrination. I think that many, many in health care experience didn't reach out for help. And so I tried to travel that journey alone, having had a patient who died literally in front of me and labor, which is something that, again, that it's just awful. A young woman and then her baby was neurologically devastated because of the event. And I tried to process all that on my own.

Sarah McConnell [00:19:44] Were you blamed for it?

Mark Greenawald [00:19:47] So certainly I was questioned. Nobody ever came right out and said, you messed up. You did this. But there was a lot of a lot of subtle innuendos. Boy, you know, if he had done this a little bit differently, maybe that outcome would have been different. And so I was left with my own blame. And so all those emotions just bottled up inside.

Sarah McConnell [00:20:13] Was there sort of a breaking point for you that unleashed all that?

Mark Greenawald [00:20:17] Yeah. There was. So I walked around literally for a year. There was not a day that I didn't go through most of the day with a lump in my throat. And then literally one day my wife and I were going on a trip to celebrate our anniversary. And I got pulled over for the only speeding ticket of my life. And as the policeman walked away. Nothing. Nothing unusual. There was no there nothing that happened in the interaction that would have been at all disturbing. I just broke down weeping. And my wife, the first when she first looked at me, she just she had no idea what was going on. And she'd just said, look, it's just a speeding ticket. It's not a big deal. And then and then she realized, oh, wait a minute. That's not why you're crying at all. And then just in that moment, just for whatever reason, it had to come out. And so she looked at me and basically said, you need help and we need to get you help. And I said, no, I don't. I'm fine. I just need to cry this off. And she's in her wisdom, fortunately said, no, you need help and we need to get you some help. So I ended up seeing a therapist and she was an angel. And, you know, I'd like to tell people, you know, while, I never, for me, and this isn't the case for all my colleagues who go through this. I never thought about ending my life. And some of them do, sadly. She saved my life because what she did is she gave my life back to me.

Sarah McConnell [00:21:44] When you say you went around for a year with a lump in your throat, that's a very powerful thing to hear.

Mark Greenawald [00:21:53] I was off. Yeah, it was it was even thinking about it now. I'm even talking to you right now, I'm getting a little tearful thinking about it, that you're thinking now like, why did you do that? Because that was a year we had a young family at that point in time. And I think, you know, I wasn't there for them. I couldn't have been there emotionally because I had nothing emotionally. And that's a year that you never get back.

Sarah McConnell [00:22:23] So all these decades later, you've done something that's been in the back of your mind for a long time. And that is create a program to try to address this and others. I mean, if half of the doctors are experiencing some form of this, that's huge.

Mark Greenawald [00:22:39] Yeah, so. So I've been carrying around a program in my my head for over a decade and thinking what would it what could have been different for me that would have changed that outcome even way back then. And what I realized was part of what I felt during that time was incredibly alone. I didn't have anybody who said, wait a minute, Mark. You just had this horrific thing happen to you. And you're telling me everything's OK. I'm not buying it. And so so the program that I created is basically it's called Peer RX Med or Peer RX for short. And the the tag line is no one cares alone. And the premise is very simple, the premise really is based on my experience when I was a boy with YMCA camp. And when you went to a YMCA camp and went swimming, you always had a body in the water and at periodic intervals. The lifeguard would blow the whistle and say, buddy check, and you went to the side of the pool and you grabbed your buddies hand and you held it up and the lifeguard made sure everybody's OK. And then you could go swim again. And so I thought, well, what's the equivalent of that in health care? And the equivalent of that would be that everyone who practiced medicine has a buddy, somebody who they've invited into their professional life to say, I'm not taken. Everything's fine for an answer because there's no way any of us can go through all that we go through and say everything's fine. And so every week I send out a nudge and an encouragement. So the judge says, time to check in with your buddy. And the encouragement gives them some some trigger questions. So when they connected with her body, they might ask or share the answers to those trigger questions as a way to get to know each other better. So that if a crisis comes or often in health care, more or more realistically, when a crisis comes, they already have somebody who they trust, who they can go to and talk about it with.

Sarah McConnell [00:24:42] Do you have a buddy?

Mark Greenawald [00:24:44] I do. He's been a saving grace for me. We have we we actually have been colleagues and friends for a very long time. But, yeah, we have an agreement that we will we will call each other on things. So it's it's a I mean, it's a beautiful relationship and that we give feedback to each other all the time. We both happened to be in leadership roles in our organization and we're able to just say, I know you well enough to know this is not you right now. What's really going on? The thing that the thing that's so important to me, Sarah, is if the crisis comes because the crisis doesn't come at a convenient time. Right? The crisis often comes at 2 a.m. when you wake up and all of a sudden the voice in your head starts telling you stories or you're creating the story about whatever happened. Is there somebody you know you could call who is not your spouse, if you have a spouse or your partner, because sometimes we we don't want to or we won't burden them. Is there somebody you could call it 2:00 a.m. and say, I need your help? And they would be there right away.

Sarah McConnell [00:25:44] That's a tall order for most of us. Right? What I mean is I'd be willing to be that 2:00 a.m. person, but most of us are too shy to think there's somebody out there that can be our 2:00 a.m., right?

Mark Greenawald [00:25:56] Yeah. And yet we of course, we all need that person because we none of us know when we're gonna get that call. Right. You know, and that that call could be something happened to someone in our family where that call could be the doctor's office saying, hey, you know, I need to talk to you about that test that we did today. You know, none of us know that. But we know in life those things are going to happen when I think back. And I think what would have happened if, you know, one month into that, somebody had said, okay, you know, it's been a month now and you're just acting like everything's normal, like nothing ever happened. Let's talk like, how would that trajectory have been different? And I don't I can't I can't say that I know what that would have been, but I want to believe that I would have said, uncle. You're right. This is this is crazy. Let's talk. Here's what I'm struggling with right now.

Sarah McConnell [00:26:51] So who can sign up for Peer RX? Just certified doctors?

Mark Greenawald [00:26:56] The original vision was physicians. And now actually the division as as it has evolved is it's anybody really in the health care is who it's targeted to. So I have now, when we did the pilot, we had psychologists, nurses and nurse practitioners, physicians assistants, health care administrators. We had resident physicians. We have medical students. So. So it's really anybody who's traveling in the health care journey is who I'm targeting. Really, the only criteria is have a buddy. And we want to help you.

Sarah McConnell [00:27:34] Mark, this has been wonderful. Thank you for talking with me on With Good Reason.

Mark Greenawald [00:27:38] Thank you, Sarah.

Sarah McConnell [00:27:42] Dr. Mark Greenawald at Virginia Tech is a family medicine provider at Carillion Clinic Family Medicine. For more about his buddy system, go to PeerRXMed.com. This is With Good Reason. We'll be right back.

SFX [00:27:57] Music: "Club Felix" Blue Dot Sessions

Sarah McConnell [00:28:05] Welcome back to With Good Reason.

Sarah McConnell [00:28:06] At Virginia Humanities, when the pandemic struck, states issued stay at home orders to limit the spread of the virus. But it also put many women at risk, isolated at home with abusive partners. And it caused such a spike in domestic violence that the United Nations chief called for peace at home.

SFX: UN Chief [00:28:30] I recently called for an immediate global cease fire to focus on our shared struggle to overcome the pandemic. I appealed for an end to violence everywhere now. But violence is not confined to the battlefields. For many women and girls, this threat looms largest, where they should be safest in their own homes. And so I make a new appeal today for peace at home and in homes around the world.

Sarah McConnell [00:28:56] Jhumka Gupta is a public health professor at George Mason University. She says the rise in domestic violence, while unfortunate, was predictable. Jhumka, you studied domestic violence around the world. How common is it? Is it worse in some cultures than others?

Jhumka Gupta [00:29:17] Yes, the domestic violence is pervasive and multi country studies have shown that throughout the globe, it's actually one in three women experience sexual or physical, intimate partner violence. At some point in her lifetime, often growing up in a home where there was violence that can place a woman at risk for experiencing violence as an adult. And there are many factors at the individual level not having autonomy over financial decisions, not having her own income. But I think what's also a very large driver is the way people think outside of the home, in the family, for instance, how accepting is a community about violence against women, about gender equity and women's rates? How willing are they to tolerate mistreatment of women and girls?

Sarah McConnell [00:30:19] Give me an example that sort of makes that real for me. When you talk about how a whole family or extended family that has certain views on how women can be treated can make a very hopeless situation for a woman or girl.

Jhumka Gupta [00:30:35] I think an example of that is, you know, if a woman is experiencing violence in her relationship and she tries to confide in her friends about it and the friends may say, yes, that's an awful thing, but that happens or that's an awful thing. But, you know, think about your kids or or will it bring shame to the family? If people know that this is a family where there's violence happening, domestic violence is a very stigmatized thing that happens. No one wants to actually be known as the family that is experiencing domestic violence.

Sarah McConnell [00:31:19] Given how many years you've looked at trends in domestic violence, could you have imagined that the pandemic would worsen domestic violence?

Jhumka Gupta [00:31:30] Yeah, that's a really interesting question, because, you know, I think it was back in late March, early April was when major news agencies were running stories about this shadow pandemic of domestic violence. And a lot of us were just talking about it like, what are women going to do? How are agencies going to reach out to women? We were actually quite pleased to see that there was so much attention paid to domestic violence from the get go, because generally it's an afterthought. And, you know, for myself and when I talk to my colleagues who also do research in this area or actually provide services in this area, I mean, it certainly wasn't surprising because, number one, you know, we know how common violence against women is globally. And we also know from experiences in disaster settings, whether it's after war or widespread political conflict. Violence against women did increase in the aftermath. So it was quite predictable.

Sarah McConnell [00:32:46] What did you mean? That we wondered how these organizations could reach out to and help women who had suffered domestic abuse at home? What did you understand about how that would be made harder by the pandemic?

Jhumka Gupta [00:32:59] Sure. So we know from research in other settings that have been impacted by war or natural disasters, that these types of occurrences can increase vulnerability to violence against women in a number of ways. Number one is economic stressors, financial stress in the home, whether it's job loss or fear of job loss, can be a trigger for violence against women in the house. So what you had is you had stay at home orders which were absolutely necessary to control the pandemic. At the same time, women were essentially cut off from family and friends who could have been sources of support. And then we know that women's safety tends to get triaged in emergency settings. And, you know, I have a story about that from my work in Haiti back in 2004. The country was going through a very difficult time with widespread violence that ultimately resulted in a coup. But I was running a women's health program in rural Haiti. And as a hospital, we were making plans, basically contingency plans soon. How do we make sure our patients can continue to get their diabetes medications or other types of medications when everything is shut down? But at the same time, a woman showed up to the hospital with near fatal stab wounds, and they weren't necessarily because of the violence that was happening in the country for political reasons, but they were inflicted by her husband. And when the surgeons were done stitching her up, there was no emergency planning about where she could go from this very real health threat she faced, which was domestic violence. And so I share with you that story because, you know, women's safety gets triaged. You know, we're worried about the very public types of violence in the public types of emergencies, but not this private violence.

Sarah McConnell [00:35:25] I understand that you have been working on a telehealth resource this summer. What are the pros and cons? Are you learning about the effectiveness of telehealth for domestic violence?

Jhumka Gupta [00:35:37] Yeah. I mean, we are very much in a learning phase. So I can tell you a little bit about the project. One thing that we were interested in is whether it's actually feasible to ask women about their safety at home in the context of COVID delivered via telehealth. And the appeal to that is that, again, know the healthcare worker can be in a position to help by providing resources and connect. And they're often the only ones outside of the family that can actually do that, given the isolation. At the same time, you need to be concerned about safety. So when you're doing these types of domestic violence related conversations in a health care setting, in person, if the partner is there, you can use strategies such as asking for a urine sample to get the woman away from her partner and have that conversation in private and telehealth. You can't really do that. So we're trying to think about ways that in the midst of all the risk. Is there any way at all to do this safely? Can we provide resources via text, via the chat function? Or can we do codewords or hand signals during the telehealth visit that lets us know that this woman needs help? And one thing that's really come up is this idea that the women don't necessarily want to be routinely screened about, you know, are you experiencing violence, yes or no. But just really working in the conversation about violence against women in the context of COVID. So you go through your safety assessments about COVID and then bringing up, you know you know, some women in your community are also feeling unsafe. So if that happens, these are some things that can be done. And that way it's making it routine and normalized. And even if that particular woman is not experiencing violence, it might be something that she can share with others.

Sarah McConnell [00:37:54] If somebody's listening to this is experiencing violence and feels trapped. What advice do you have?

Jhumka Gupta [00:38:02] First of all, I would say that, you know, you're definitely not alone. And it can definitely feel isolating. But the most important thing is that there is help available. There's the National Domestic Violence Hotline that can be called or can also be reached via text. So I would definitely encourage to reach out for help. And they can connect somebody who needs help to even more local resources and also resources that might be available in various languages other than English as well.

Sarah McConnell [00:38:43] Well, Jumka, thank you for talking with me on With Good Reason.

Jhumka Gupta [00:38:47] Thank you so much for having me.

Sarah McConnell [00:38:54] Jhumka Gupta is a professor of public health at George Mason University. The National Domestic Violence Hotline is 1-800-799-7233.

Sarah McConnell [00:39:09] Long waitlists and physician shortages are problems around the country, but in rural areas, it's often even worse. Erica Metlzer Sawin is a nursing professor at James Madison University. She runs a program called UPCARE. It places registered nurses and doctors offices serving rural communities. Erika. Tell me about your program to get RNs, registered nurses, into rural areas that really don't have them, in particular, Page County, which is adjacent to yours.

Erica Metlzer Sawin [00:39:42] Right. So it's a really interesting county. It's kind of tucked in between two interstates, but it doesn't have interstate access through it. It's surrounded by mountains. So it's very rural. It has a lower than state average poverty level. It has a lot of older adults and a lot of kids. It's well known because it has a big tourist attraction, which is Luray Caverns. But one of the issues that people have dealt with is that there were some factories that had been in Page County for a long time. I believe they were timber related and a I believe a clothing manufacturer, a company. But then they closed about 20 years ago and that really impacted the community.

Sarah McConnell [00:40:25] If you lived there instead of where you are in Harrisonburg, Virginia, what would health care be like for you? Just for the normal things like seeing the doctor, going to an obstetrician, what would the limitations be there compared to what you experience in a larger city?

Erica Metlzer Sawin [00:40:43] Well, Page County is technically a medically underserved area and a health professional shortage area. And so if I had to get counseling for something, I would have a problem because they don't have a lot of counselors in the area for mental health. If I was pregnant, I would have a problem because they don't have obstetric care in the counties. I would have to drive over the mountains or out of the county, probably about 45 minutes to get to see a nurse, midwife or an obstetrician. I would have good access to some rural health clinics, thanks to five federally designated rural health clinics that are in Page County. And I would be able to go to a small hospital with 25 beds. That is Valley Health Page Memorial Hospital.

Sarah McConnell [00:41:29] What are registered nurses and what difference would they make compared to the technicians that are staffing the clinics, for instance?

Erica Metlzer Sawin [00:41:36] So the way I look at it is when you go to the doctor's office, usually you kind of walk in and you have a problem. You get taken back to the office. Usually a medical assistant or maybe a practical nurse will take your vital signs and say what's going on? And you'll tell them. And then a medical provider will come in and do that visit. You won't necessarily see a registered nurse in the course of that visit. So let's say I have something like diabetes and I'm newly diagnosed with diabetes. So I come into that same scenario, talk to my doctor and she or he says, you know, your your levels are high. Let's talk about some diet and exercise, like maybe eat less sugar or eat less carbs, try to exercise a little more, you know, maybe gives you a medication and out the door you go. How about all that area in between where I'm thinking as I leave that office? Okay, I'm gonna have a problem getting to the doctor to get follow up care on this, because I live a distance away and I'm having trouble driving. I don't understand that medication that she just explained to me a little bit, but I was too scared because I was thinking about that diagnosis, you know, to really process that medication that I now need. I don't actually know what a carbohydrate is or what glucose is. So how do I actually change my diet? Because I don't understand those words. And that's where the registered nurse can come into play. They can really be part of a team that works in that system to help patients really manage their chronic diseases.

Sarah McConnell [00:43:11] Let's say, is it pricey to get a RN to stay in a rural area? Registered nurses have more education. They command higher salaries. Right?

Erica Metlzer Sawin [00:43:20] Yeah. That's been one of the reasons why a lot of doctors offices can't or won't hire registered nurses because they do cost more. And when you're looking at a pretty classic model of care, like I just described, where, you know, you come in, you have this problem, you see the doctor, you get a prescription and then you go home. It's hard to see how registered nurses can can fit into that. But if you can think about the doctor's office and that whole primary care system as a system that is actually really hurting and stressed out and kind of broken and you're kind of thinking, what do my patients really need? Then you can think about ways that registered nurses can can help your patients stay healthier or get healthier. Or whatnot.

Sarah McConnell [00:44:08] So what is your grant allowing you to do? Is it hiring the two RNs? Is it training up a new generation in the nursing school to go into the rural areas? Just why?

Erica Metlzer Sawin [00:44:19] Yes. So the grant focus is to actually restructure primary care. And what it looks like in the United States, because right now, registered nurses don't typically work in primary care, which means that we don't actually teach about primary care very much. I teach community health and I've taught it for over 10 years. But we never have students go into primary care because legally students need to work with a registered nurse and there haven't been registered nurses for them to work with in primary care settings. So maybe they go with a home health nurse where they go to a health department or something. But meanwhile, there's this whole area of care, which is, I believe, as a community health professor, the most important place where care happens, which is where people come from home to a doctor's office to talk about how to get healthier and stay healthier. And registered nurses really haven't been there. So that's why the grant even came about in the first place, was to try to find ways to increase nurse education.

Sarah McConnell [00:45:27] So registered nurses are primarily in hospital settings?

Erica Metlzer Sawin [00:45:30] Well, you know, historically, they have not typically been in hospital settings. They've been in both the community and hospital settings. Most of our graduates go to work at the hospital, but within about five years, many registered nurses are not working in the hospital. They're working in other parts of of the health care system. So maybe home care or hospice care or in the health department or somewhere like that, but not typically primary care. So one of the things that the grant actually helped us to do is to examine what registered nurses can actually do in primary care and help measure. How does this actually affect patients? How does their work help patients out? And is it cost effective for clinics?

Sarah McConnell [00:46:17] Do you think these are ends can be at all helpful with coronavirus?

Erica Metlzer Sawin [00:46:21] Absolutely. The RNs are really good at. I think patient education and really, I think decreasing anxiety about corona virus and helping people to preventing getting corona virus from happening. I think moving into the fall, they're going to be really helpful to providers, especially with telehealth visits. They can conduct visits themselves. Hopefully they can do some home visits if needed. One of the things that grant is going to be able to purchase is some equipment that nurses can take out with them on home visits, which should hopefully be able to prevent some patients who are really high risk from having to actually go into the clinic. I know patients that there have been concerns about are, for instance, older people, premature babies, that kind of thing. So we just got some Cares Act funding that will enable us to purchase things like, you know, scales for their preemie babies so that the nurses can help parents to weigh their babies and report back on progress. Hopefully, some monitors, like if a patient has high blood pressure, they can take their blood pressure at home and then talk to the nurse about it. So I'm really hopeful that the nurses can help with a lot of management of chronic diseases, because I know that's one of the things that we've been hearing about lately is, you know, through coronavirus, we shifted completely as a country to worrying about, you know, hospital based care. I think largely, you know, do we have enough ventilators? What are that in hospital staff going to be doing? You know, do they have enough gowns and and n95s, et cetera? But in the meantime, out in the doctors' offices, there are also major questions about prevention of COVID screening for COVID and all of the people. And there are over 150 million people in the country who have a chronic disease of some sort. All those people who normally are going in regularly for checkups didn't really go in for a little while. So there's going to be a lot of people who are going to have to kind of play catch up. And I think the nurses will be really helpful to help them, you know, stay healthier, get back on track.

Sarah McConnell [00:48:30] It's just so amazing how much all of us have had to retool suddenly with the advent of Coronavirus. Right?

Erica Metlzer Sawin [00:48:38] Oh, yeah, absolutely. So one of the things that happened to you was the students didn't come back after spring break. So our nurses in Page County kept on working away. But in the meantime, we actually have another primary care site in Harrisonburg City, which is the suitcase clinic. That is a clinic on wheels that operates at different homeless shelters in the area. So we have an agency that provides a low barrier shelter for homeless people, which means. You can basically, if you're an adult, you can come to that shelter and stay if there's enough space and that had been operating out of different churches every week and it rotated sites weekly. And then when coronavirus hit, of course, church stopped. And we had the edict, you know, you can't have, what, more than 10 people in an enclosed space at a time. And of course, the homeless shelter is 50 residents, their clients on any given night. So we didn't have a space anymore. So one of the things we did at James Madison is we were able to open a shelter in one of our gymnasiums at Godwyn Hall. And the students were able to come and help the registered nurses screen clients at the door for COVID and if they were having any kind of COVID symptoms, we were able to get in right away and help them get tested and get care. Also, people who had a lot of risks, especially people who were older or people who had illnesses, they were able to get housed in motels. And sometimes the registered nurses and one of the physician's assistants would go from hotel room to hotel room and just check in with people. So that was one of the things we had to be really flexible with, really quickly making sure that it was going to be safe for all the clients. We did have a few positive cases, but they it was contained and people emerged from those hospitalizations and are healthy again. So I'm really relieved about that. Ironically, when the state open things up a little bit more, the shelter closed. This is not a shelter that normally is a twelve months a year shelter. And so it was deemed that people did not have to be housed anymore in that temporary shelter. So sadly, now I worry a lot about our homeless clients who don't have a place to go in the city of Harrisonburg at this point. And still, because things are still a little bit closed, there's still not a lot of places to go during the daytime.

Sarah McConnell [00:51:13] Erica Metlzer Sawin is a professor of nursing at James Madison University. With Good Reason is produced in Charlottesville by Virginia Humanities, which acknowledges the Monacan nation, the original people of the land and waters of her home in Charlottesville, Virginia. Our production team is Allison Quantz, Matt Darroch, Lauren Francis and Jamal Milner. Aiden Carroll is our intern. Some of the music is by Blue Dot Sessions. For the podcast, go to WithGoodReasonRadio.org. I'm Sara McConnell. Thanks for listening.