Providence VA Medical Center, Rhode Island
An Outpatient Clinic with an Inpatient Feel
For the longest time, John Joseph only used the VA healthcare system for his medications. He never thought about transferring all of his care to the VA. He never felt he needed to.
Things changed, however, about four years ago when he began having pain and cramping in his legs. His outside providers conducted a procedure called arteriography, which uses dyes to help identify whether an artery is restricting the flow of blood to the legs. This procedure is not without risk. In Mr. Joseph’s case, the dyes affected his kidney functioning. He began seeing a nephrologist in the community and was paying for shots of Procrit every two weeks. The costs were piling up, so his Primary Care Provider (PCP) suggested he meet with a VA nephrologist. Not long after, Mr. Joseph met with Staff Nephrologist Dr. Andrew Cohen to discuss his condition and the possibility of transferring his care to the VA.
“I made an immediate connection with Dr. Cohen,” Mr. Joseph recalls. “Dr. Cohen asked me if I wanted to think about it (transferring my care to the VA)…but I told him I don’t need to think it over.” Mr. Joseph transferred his care to the VA right away. After discussing treatment options, both he and Dr. Cohen realized that he would have to begin dialysis. Dr. Cohen introduced him to the Dialysis team where he met with one of the nurses, Beth Upham, who gave him lots of information to read about dialysis. By the time he had surgery six months later to have the fistula placed into his arm, he felt he knew a bit more about what he was about to undergo.
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Our kidneys are powerful and critically important organs that filter waste products from the blood and remove the waste that the body produces throughout the day. When these waste products are not removed adequately, they build up in the body. An elevation of waste products, as measured in the blood, is called “azotemia.” When waste products accumulate, they cause a sick feeling throughout the body called “uremia.” When this happens, the most common treatment option is to go on dialysis. Dialysis helps the body by performing the functions of failed kidneys, allowing most dialysis patients to live productive and active lives even though their kidneys no longer function adequately.
Dialysis is often a frightening experience. Attitudes fluctuate. Sleep patterns are often interrupted (one patient in a wheelchair has to get up at 4 a.m. to get here from the Rhode Island Veterans Home). Self-control is taken away by the disease. “Most patients feel that coming to dialysis is like a part-time job: three days per week for up to four hours,” says Donna Berube, Nurse Manager on the Dialysis Unit.
Additionally, patients undergoing dialysis must submit to a very restrictive diet. “Diets need to be restrictive,” says Dietitian Shannon Gorski, “because the kidneys normally help flush out waste, but dialysis patients lose that function.” Patients are limited to one liter of fluid per day (32 ounces). Diets should be high in protein and low in potassium (that means limited oranges, bananas, cantaloupe, and tomatoes), phosphorous, and sodium. “Despite the need for protein,” says Shannon, “patients often lose taste for meat. When this happens, we supplement the diet with protein bars or protein powder; it’s important that dialysis patient have protein at every meal.”
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Lorraine Perry has worked in Dialysis since 1979, first working in an outpatient facility for 25 years before transferring to the VA 8 years ago. Lorraine believes that the VA offers a better system of care than most outside dialysis facilities can provide. “In the community, it’s one nurse for four patients; at the VA, there one-to-one care. We can follow patients within the hospital. We can develop close relationships with patients and their families. Nurses are very lucky to be able to get to know their patients this way.” Lorraine feels very fortunate to work here and with the Dialysis team. She sees the impact that the VA’s interdisciplinary team approach to care has on the patients and their families. “It’s very important that they work with a dietitian and social worker,” she adds. “We collaborate and share ideas about how to provide the best care possible.”
Sarah Stevenson is the Social Worker for the Dialysis Unit. She enjoys working with the patients despite the chronic nature of the disease. Her focus is on helping the patients sustain a quality of life. “Our Clinic is an outpatient clinic with an inpatient feel,” says Sarah. “Here we provide a close-knit setting that becomes like a second family.” Sarah acknowledges there can be a high rate of burnout in this setting, so she and the leadership make a point of making time so they can regroup and connect with each other. “We have a team environment and if someone is stressed out, we talk about it. Everyone here is always willing to help so we not only take care of the patients we also take care of each other.” What she and the rest of the staff find comforting is that even though it is difficult to see the patients go through the stages of kidney disease, by being at the VA they get to stay in touch with people who are like extended family. “If a patient is hospitalized, we can simply walk upstairs (to the inpatient wards) to check in on them. Working in the community, the dialysis staff usually does not have that option.”
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Mr. Joseph served in the Army during World War II where he taught instrument repair on the scopes that guided the cannons. Upon his release from the Army, he worked for what is now Fleet Bank as a financial advisor until he retired. Now 82, Mr. Joseph enjoys spending time with his family. He has three daughters: one who lives with him, and two who visit him every day. He has one granddaughter who is “beautiful and getting married next year.” He notes that he lost his wife, Judy, 25 years ago to cancer. “It was a great loss,” he sighs, but then he smiles as he remembers how much fun they used to have. “We laughed all the time.” Mr. Joseph’s philosophy about life is simple. “I refuse to let anything spoil my day.” While he is in for treatment, he watches TV or reads the newspaper. “I do the crossword puzzle first to help keep my mind active.”
When asked to share his thoughts about the care he receives in the Dialysis Unit, Mr. Joseph nods: “There is no place in the world better suited or that provides better care. Nothing falls through the cracks. They have a great system here.” He has nothing but praise for his care team here at the Providence VAMC. “Dialysis patients say that the fistula is their lifeline, but I believe that these nurses are my lifeline, and I could not be more grateful. They go out of their way to help the patients. I would be lost without them.” Mr. Joseph feels the same way about Dr. Cohen. “Dr. Cohen is right on the ball. He works well with the nurses. If there is a problem and the nurses call him, he comes right away…The whole staff is committed to improving my lifestyle.”
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Nurse Beth stops by as we are wrapping up our interview. He smiles as she asks him if he’s going to wear his red socks and shirt when his picture is taken to go along with this story. “Only if you wear your red pants!” He laughs. He then tells me that Beth has an outfit to celebrate every holiday. “She surprises me sometimes. On September 17 she asked me: ‘Do you know what today is?’ I said no. She replied, ‘It’s half-way to St. Patrick’s Day.’” He and Beth start to laugh. I smile as I walk out of the unit, taking that image and this story with me.