CHAPTER XIV
The Tuberculosis Dispensary—Equipment—Medicines—Hours—Consideration of Patients—Function of the Dispensary—The Physician’s Service—The Physician’s Qualifications—The Physician and the Patient—Duties of the Nurse—Tuberculin Classes—The Nurse in Home and Dispensary—The Nurse as an Asset to the Community.
The Tuberculosis Dispensary. No community can make definite progress against tuberculosis until it establishes a place where suspicious patients may be sent for examination and diagnosis. Unless this disease be promptly and definitely recognized, it is impossible to give advice, or take authoritative action concerning the treatment of the patient and his family. If in connection with the dispensary there was also a corps of municipal physicians, who could visit the patients in their homes, and examine all suspects called to their attention, diagnoses could be obtained even more promptly. As it is now, considerable interval often elapses between the time when the patient is advised to go to a dispensary and the time when he follows this advice. The existence of a corps of visiting physicians would prevent such delays. The patient would be allowed a reasonable time in which to present himself, at the expiration of which period he would be sought out by the officer of the municipality. This prompt recognition of tuberculosis would save the community from an enormous amount of exposure. The time may yet come when Departments of Health will see the wisdom of such measures.
Until that time, the special dispensary represents the only means of obtaining a diagnosis; it is the only place where patients may freely be sent, and where an expert and frank opinion may be had. Such a dispensary may be established in connection with the general dispensary of a hospital, or by the local Health Department, or it may be supported by the same group of people or association which supports the special nurse. In Baltimore, we have had dispensaries of all three kinds, and the nurses have worked in connection with each one, on exactly the same terms.
Equipment. The great tuberculosis dispensaries run in connection with the large hospitals and medical schools are usually very completely and elaborately equipped. They contain large waiting rooms, examining rooms, special rooms for the giving of tuberculin, for X-ray examinations, for throat examinations, for laboratory work, and so forth. All these are needed in teaching centres, where it is necessary to collect certain scientific data. But for the purpose of making an ordinary physical examination a simpler equipment will do equally well.
In Baltimore there are several small municipal dispensaries, all under the control of, and managed by, the Department of Health. They are situated in different parts of the city, readily accessible to the patients of different localities. Each dispensary consists of two or three rooms, which are in the same building which houses the Federated Charities, and other social agencies. This arrangement has several advantages, from the point of view of both economy and co-operation. To have rented similar rooms in another building or in a private house would have meant a much greater outlay of money, to say nothing of the opposition encountered in obtaining the use of these rooms for dispensary purposes.
The furnishings of these little municipal dispensaries are extremely simple, but they lack nothing of comfort and convenience. The outer or waiting room contains two or three dozen chairs, or benches to accommodate an equal number of people. A corner of this room is screened off for the nurse’s table, where she keeps her charts and records, and writes the patients’ histories. A couple of filing cabinets, a medicine closet, and a pair of scales complete the outfit.
Waiting Room in Municipal Dispensary
The inner, or examining room, is also simple and inexpensively furnished. It is divided into several compartments by means of gas piping, each compartment being large enough to hold a revolving stool and a wicker lounge. Unbleached muslin curtains hang from these gas-pipe rods, making several little cubicles in which the patients are examined. It is thus possible for the doctor to examine a patient in one cubicle, while another patient undresses in the adjoining one—an arrangement which saves considerable time. Sheets, towels, and blankets complete the necessary furnishings, which may be cheap or costly according to the means available. The doctor’s table stands in one corner of this examining room.
This is not necessarily the last word as to what tuberculosis dispensaries should be, but we have found the ones described practical. No tuberculin tests are given here, and all sputum examinations are made at the Health Department laboratory.
Medicines. A supply of simple drugs is kept in the medicine closet. This includes a few of the standard tonics, such as iron, quinine and strychnia, nux vomica, gentian and alkali, and so forth; there are also cough syrups, and heroin, codeine, cascara, etc. The tonics are usually bought in large quantities, in gallon jugs, and in her leisure moments the nurse pours them into four- or six-ounce bottles. If these bottles are filled by the druggist, the expense is somewhat greater. This medicine is given free of charge, although now and then a patient may wish to make a small payment of ten cents or so. In themselves, these drugs cannot be said to constitute treatment, yet it has been found advisable to dispense them. Patients are so accustomed to being dosed, that they have no faith in an institution which does not prescribe for them. It is above all things necessary to make these dispensaries popular, so that patients will freely seek them, and recommend them to their friends. Only through wide publicity and extensive patronage can they become effective factors in the fight against tuberculosis.
Examining Room in Municipal Dispensary, showing the room divided into cubicles, by means of gas-piping
Hours. The hours at which a dispensary is open will depend somewhat upon its location, also upon whether or not the physician’s services are volunteered; in the latter case, it will depend upon the time he is able to give to it. If it is open in the morning, the workingman cannot attend without losing a whole day from his work, nor are these hours convenient for schoolchildren, or for the busy housewife who does most of her work before noon. If the dispensary is open in the afternoon, all three classes of patients may be accommodated; the workingman will lose half, not an entire day, while women and children can attend with no inconvenience at all. Afternoon hours, say from two till five, not only permit patients to be examined by daylight instead of artificial light, but the doctor will be further aided in his diagnosis by the presence or absence of that characteristic symptom, an afternoon temperature. Night clinics are necessary in certain localities, when they may be patronized by men and women, employed during the day, who would otherwise be unable to come to them.[[6]]
[6]. Night clinics are in existence in New York, Hartford, Boston, Chicago, and other cities, and are well attended.
Consideration for Patients. The first consideration of the dispensary should be the comfort and welfare of the patients. We have known many dispensaries where the first consideration was the experience of the students or physicians, the patient being regarded merely as good clinical material. In dispensaries connected with medical schools, which are essentially used for teaching purposes, this condition is unfortunately necessary, yet we cannot believe that it is necessary to the extent to which it is sometimes carried. We have often known of “interesting” cases being held up for hours, in order that they might be examined by certain men, or groups of students; moreover, this detention, prolonged examination, and exposure often took place when the patient was very weak, when he lost his job through the delay, or when a husband’s dinner, a nursing baby, or a houseful of children made such detention intolerable. Patients often refuse to return to a large dispensary on the ground that “they keep you all day, everyone in the place examines you, and you get so tired and sick you have to stay in bed for a week afterward.” This lack of consideration—failure to look upon the patient as a human being—is what tends to make dispensaries unpopular. We have known patients to come straight from such an experience and deliver themselves into the hands of a quack. However necessary it may be to use certain dispensaries as teaching centres, the tuberculosis campaign demands clinics of another kind. If the tuberculosis dispensary is to be a factor in the fight against this disease, it cannot afford to be a training school as well—it should be in charge of men already trained.
Function of the Dispensary. It follows, then, that the function of the municipal dispensary is of necessity different from that established for teaching purposes. The larger dispensary serves a double purpose, the little dispensary serves but one; it is an examining station for making diagnoses. Here the patient should come as informally as he would to a doctor’s office, and here he should be able to consult experienced men. We feel that the informality of these little clinics constitutes their strong point. The patients are not afraid of them, and their great advantage lies in their social rather than their scientific value. They are merely places where a communicable disease may be discovered at the earliest possible moment.
The Physician’s Service. If a community decides to establish a dispensary, the first step must be to secure the services of a physician. At first this may be voluntary, and many doctors will gladly offer an hour or two of their time, once or twice a week. Should there be great pressure of work, it may be possible to find several men willing to offer their time. But however willingly and freely offered—for most physicians are generous in response to calls of this sort—it must be remembered that, after all, this service is gratuitous. The busy physician will often be obliged to side-track his dispensary obligations, in favour of urgent private calls. This is only to be expected, yet too many such side-trackings are bad for the dispensary. The patients lose confidence in it; it is discouraging for a roomful of sick people to find no one to receive them.
Experience teaches us to look askance at all volunteer work, no matter how generously or sincerely offered. Under certain conditions it may have to be accepted, but whenever possible, the physician in charge of the dispensary should be paid. It is fairer to him, and fairer to the patients.
The Health Department of Baltimore has three special tuberculosis dispensaries, each open twice a week, for two hours at a time. The physician in charge is paid a good salary, and as a result, the regularity of his attendance is in sharp contrast to that in certain other dispensaries, where the work is done by well meaning but overworked men who volunteer their services. Tuberculosis is a disease that cannot be overcome by volunteer work or economical methods.
The Physician’s Qualifications. The success of the dispensary depends upon the ability and character of the physician in charge. He should be able to make a diagnosis by means of auscultation and percussion, without hesitating to commit himself until a sputum examination reveals the bacilli.[[7]] For if finding the bacilli is to be the sole test by which tuberculosis may be recognized, it would be possible for the nurse to obtain specimens of sputum from her patients and submit them to the laboratory direct—thus doing away with the doctor and proving the dispensary superfluous.
[7]. See Chapter IX., page [109].
Nor is this all. The physician must have a strong social sense, and be able to inspire his patients with confidence. In no other work does the personal character play so large a part, and this applies to the doctor as well as to the nurse. One of our patients, enthusiastic in her praise of one of the dispensary men, summed this up with homely accuracy: “He couldn’t have been nicer to me if I’d paid him fifty cents in his office.”
The Physician and the Patient. After the patient has been examined, the doctor carefully explains to him the nature of his disease, and the precautions necessary. Since these directions must often be brief and hurried, he will further add that he is sending a nurse to the patient’s home, to act under his orders, and see that certain directions are carried out. In this manner, the doctor prepares the way for the nurse’s visit, and gives her an authority which greatly facilitates her work. With this assistance, it is far easier to gain the patient’s confidence than if it has been forgotten or withheld. The orders concerning the patient are then given to the nurse, and if these include admission to an institution, it is her duty to arrange all the necessary details, and so relieve the physician of much time-consuming work.
Duties of the Nurse. If a community has a special dispensary as well as a special nurse, the nurse’s duties are twofold, and should include not only the home supervision of the patients, but attendance at the dispensary as well. She is the connecting link between the two. In this way, her intimate knowledge of home conditions is placed at the physician’s disposal, who is then able to give sounder advice and deal more intelligently with his patients if he has some knowledge of their environment.
The nurse’s presence at the dispensary is often a considerable assistance in persuading patients to come. Patients are often frightened and shy, and dread the unknown, consequently it is better if the nurse can give them the comforting assurance that she will be on hand to welcome them. From her knowledge of their home conditions, she also knows which cases can afford to wait, and which should be taken out of turn and given immediate attention. It is thus possible to deal with them in a personal and intelligent manner. Since at present the control of tuberculosis lies largely with the patients themselves, and depends almost wholly upon their good-will and co-operation, it is necessary to establish this co-operation as firmly as possible.
The duties of the nurse consist in taking the history of the patient; taking his weight and temperature, and preparing him for physical examination. If the patient is a woman, she must be present while this examination is made. She also gives such drugs as may have been prescribed. On his arrival, each patient receives a paper napkin to hold over his mouth during coughing attacks, and to use for expectoration. A special receptacle should be provided for these soiled napkins, and they should afterwards be burned. The nurse should come to the dispensary half an hour before it opens, in order to put it in readiness,—to take out the charts and histories, attend to the drugs, place towels and sheets in the examining rooms, and so forth. Whenever the clinic becomes large enough to require it, it will become necessary to place the clerical work in charge of a clerk.
In these informal clinics considerable trouble is often caused by patients who arrive just before closing time, and expect to be examined. It is unwise to encourage this sort of tardiness, and a time limit should be set and strictly adhered to. All patients arriving after a specified hour should be directed to come another day, except such patients as are recognized by the nurse as worthy of exception from this rule. The most frequent offenders are not the patients who come from a distance, but those who live just around the corner. Unless punctuality be insisted upon, there will be endless overtime work for both doctor and nurse.
Tuberculin Classes. At some of the large dispensaries, selected cases are formed into what are called Tuberculin Classes, and given special treatment. These patients are very carefully chosen, both from a financial as well as a physical standpoint, and intensive work, of a curative rather than a preventive nature, is put upon them. The treatment is carried out in their homes, where as nearly as possible sanatorium conditions are attained. Unruliness, or failure to comply with the regulations, means being dropped from the class. These patients live on a carefully planned routine, carried out under close supervision of both doctor and nurse. They report to the dispensary at certain intervals, once a week or so, and there tuberculin is administered, weights taken, and examinations made. Each patient keeps a little book containing a daily record of his doings, including the number of hours spent in the open-air, food—kind and amount, exercise, temperature, cough, and other symptoms. This book is presented at each visit to the dispensary, and the nurse also inspects it when she visits his home. These class patients often do extremely well, and excellent results are often obtained. Like all work of a curative nature, however,—in which the subjects are carefully selected and as carefully rejected,—it deals with so few people that it makes no real impression on the situation. The tuberculosis problem is, what can be done for a thousand patients, not for twenty. It is always possible to select a handful of cases and maintain them indefinitely at a high level of health, by a considerable outlay of money, energy, and time—an expenditure from which the community as a whole derives little benefit.
To establish a tuberculin class is purely a physician’s affair, and all directions in regard to it come from the doctor himself.
The Nurse in Home and Dispensary. When the staff is large and there are several nurses, it may seem advisable, upon first consideration, to assign one nurse solely to dispensary duty, and leave the others to work in the homes. It is a better plan, however, to let all the nurses combine service of both kinds, as the single nurse in the small community must do. The intimate connection between home and dispensary should never be broken—it is much too valuable. Moreover, as far as the nurse herself is concerned, the monotony of dispensary work becomes extremely wearing, and it is well to vary it with duty in the home. It is a regrettable fact that a nurse confined to mere mechanical routine, is apt to lose that fine understanding and sympathy which she needs in her work, and which is always lost whenever human beings become merely “cases.”
In Baltimore this service is arranged in the following manner: There are three Municipal Dispensaries, and one other clinic, managed on the same lines, although not connected with the Health Department. These are situated at the boundary lines of two or more adjoining districts, and are thus accessible to the patients as well as the nurses of the adjacent areas. All four clinics are served by certain nurses of the Health Department, who are on duty on alternate days or alternate weeks, as the case may be. Thus, the nurse from any one district is on dispensary duty for two afternoons a week, every other week. This deprives the home of her services to only a very slight extent—a deprivation which is counter-balanced by her increased opportunities for effective work. We should never advocate any greater curtailment of home work, however, since the home, or centre of infection, is always the chief point of attack.
From another standpoint it is well that the nurses combine both kinds of service. Through sickness or other reasons, it may become necessary to substitute one nurse for another, and it is an advantage to have nurses trained and able to relieve each other when necessary.
The Nurse as an Asset to the Community. We have hitherto considered the nurse as a public health nurse, or servant of the entire community. Whether supported by public or private funds, whether connected with the Health Department or a private association, we have considered her as ready to answer all calls made upon her. We have regarded her as at the service of all physicians, dispensaries, institutions, social workers, and laymen, ready to respond to all calls without hesitation or discrimination. Her unattachment to any claims but those of the community as a whole gives her this broad field.
If, however, her work be limited to the patients of any one institution, association, or sect, she is no longer an asset to the community. For example, if she is employed by a certain dispensary to visit its patients only, her work is circumscribed. Her usefulness will be restricted—her service will be valuable to the physicians of such an institution, and she will collect data for their records, but her duties will be localized for the good of the dispensary, rather than for society as a whole. The same would be true if she be employed by a St. Vincent de Paul Society to care for Catholic consumptives, or by a Jewish organization to follow up Jewish patients—any arrangement through which she visits one patient in a block, but refuses the case next door, means a narrow field of service. She then becomes the nurse of an institution, or a sect, rather than a public health nurse. The object of her work is not the welfare of the community, but the welfare of certain individual patients. Incidentally, her work may benefit the community, but it falls far short of its possibilities. It must be supplemented by new agencies, with the consequent duplication and waste of effort that this always involves.
Our experience in Baltimore will illustrate this point. In 1904, when tuberculosis nursing was first organized, two nurses were placed in the field. One was attached to the dispensary, of the Johns Hopkins Hospital, the other placed in charge of the Visiting Nurse Association. Between them the city was divided into halves, one nurse working in the eastern, the other in the western portion of the town. The dispensary nurse visited only patients who had been to the dispensary. The nurse of the Visiting Nurse Association visited not only dispensary cases, but all patients reported from whatever source. Thus, in East Baltimore, if two consumptives lived in the same tenement, one a dispensary case and the other under no supervision at all, only one of these two was visited. In West Baltimore, both patients were cared for on equal terms. At the end of a year, another nurse was added to the Visiting Nurse Association staff, but not to the dispensary. The city was then redivided, this time into thirds, and again the patients were cared for under the same conditions. The dispensary nurse served the Johns Hopkins Dispensary; the Visiting Nurses served the dispensary and the community as well. Finally, in 1910, the tuberculosis work of the Visiting Nurse Association was taken over by the city, thus creating a new municipal department, the Tuberculosis Division of the City Health Department. At that time the dispensary nurse gave up visiting in the homes of the patients, and confined herself entirely to routine dispensary duties. This left all visiting work to the Health Department nurses, who were as punctilious in making reports to the dispensary as was the dispensary nurse herself. By this arrangement, the Phipps, in common with every other dispensary in the city, has had a large staff of nurses placed at its disposal. Both the dispensaries and the community gain through this co-operation.