A blond woman with a red bandanna knotted at her throat bounded up the stairs of a low-rent apartment building. Stomping the snow off her boots, she knocked at a door and announced herself: "It's Joy!"
Joy Buehler is a traveling nurse who sees patients in Siskiyou County, in the extreme north of California. But to the young woman in the apartment awaiting a prenatal checkup, Buehler is the equivalent of a doctor.
Buehler, 35, set her bag of instruments on the living room floor. The tenant had left the oven door open for warmth and the apartment was overheated. The 21-year-old patient was listless. Her attention drifted from Buehler to the soap opera characters on the television.
"What have you been eating?" Buehler asked the patient.
"Mostly beans and canned fruit," she answered.
Buehler's exams include the basics--checking the mother's blood pressure and inspecting her ankles for swelling--but she also asks about the family's living conditions. This patient said that her husband, a migrant worker, was employed sewing sacks in a potato plant in nearby Macdoel, but his income barely covered food and shelter for himself, his pregnant wife and infant daughter.
In the past, when Buehler worked in a hospital, it was not her place to assess a patient's life style, nor to make recommendations for care. Whenever a judgment had to be made, a doctor was the one to make it.
Country nurses like Buehler have achieved some of the status city nurses are striving for.
"As a rural health nurse, I don't feel dismissed. I feel people do value my opinion," said Buehler, who has put 200,000 miles on her '67 Volvo station wagon, traveling much of the distance on dirt roads, sometimes in blizzards.
According to Sandra Stuart-Siddal, coordinator of the Rural Clinical Nurse Placement Center at California State University, Chico, residents of small towns may have quite a different image of nurses than city folks.
Stuart-Siddal said she once accompanied the local nurse practitioner (a nurse specially trained to do many of the basic procedures usually performed by doctors in urban areas) into the local diner in Chester, near Mt. Lassen. Each lumberjack and truck driver at the counter swiveled on his stool and acknowledged in his own way that someone important had entered the restaurant, she said.
These men may have grown up with the same nurse stereotypes as city people, Stuart-Siddal explained, but they had seen their own nurse save lives, heal the sick--do all the things doctors are honored for.
With a plentiful supply of doctors at hand, urban nurses rarely get the chance to test their limits. The Nurse Practice Act is a rather vaguely worded state law that delineates what duties nurses may legally perform. City nurses need rarely refer to the act, because there are committees telling them what they may and may not do, Stuart-Siddal said. In rural areas, however, copies of the act are well-worn; and country nurses are in the habit of assuming the broadest possible interpretation in order to get their jobs done.
One of the things some rural nurses feel they need to be able to do is prescribe medicine. Assemblyman Richard Robinson (D-Garden Grove) introduced a bill that would have given specially trained nurse practitioners the right to prescribe noncontrolled substances. The California Medical Assn. successfully campaigned against the bill, which was rejected by the Senate last August.
Claude Bergeron and his wife, Barbara, operate the Butte Valley Rural Health Clinic in Dorris, population 900. (Traveling nurse Buehler works out of this clinic.) They are under the jurisdiction of a preceptor physician, Dr. Brian Stuart, located 25 miles away, across the state line in Klamath Falls, Ore. Theoretically, Stuart is supposed to order all prescriptions for clinic patients. In reality, it's not unusual for a patient to walk out of the clinic with an antibiotic in hand. "He (the doctor) has got to trust our medical judgment," Bergeron said.
Bergeron said he and his wife, both nurse practitioners, are licensed to prescribe in Oregon (about 14 states allow nurses to prescribe under certain conditions), and they sometimes write prescriptions for patients who are willing to dash across the state line and have prescriptions filled in Klamath Falls pharmacies.
There's never a day off for the Bergerons. If a patient calls after hours, the call is referred to the couple's home phone number. Since they live less than two blocks from the clinic, it's routine to have patients knocking on their door on a Sunday when the couple are out watering the horses.
Yet Claude Bergeron, 52, says the sacrifices are worth it--even despite the $500 a month pay cut he took when he left his 17-year job as a supervisor with the California State Hospital System.
Visitors to the small brown clinic at the edge of town include ranchers, loggers, duck and goose hunters, migrant workers and forest service employees. They pay for services on a sliding scale. Patient fees make up half the clinic's funding; the other half comes from state agencies including Maternal Child Health, the Rural Health Section and the Office of Family Planning, as well as the National Health Services Corps.
Employed Only Seasonally
Many of the patients are employed only seasonally. After the crops are in and crews are laid off for the winter, the money starts to dwindle and farm workers' health declines, Bergeron said.
Much of the staff's work consists of helping families counteract the unhealthful effects of poverty. That sometimes means going beyond the scope of what's expected of a nurse--Buehler recently installed a missing window pane for a mountain family she found huddled in the back room of a freezing farmhouse.
Poverty-related illnesses, including malnutrition, anemia and parasites, are common. When work starts in the spring, clinic staff see seasonal allergies to local crops--onions, garlic and hay--as well as an occasional large splinter from the lumber mill. Chain-saw gashes across the knee also are common injuries in logging country, Bergeron said.
Visiting the clinic on a recent morning was Elizabeth Streed, 62. She and her husband own a ranch seven miles outside of town and have lived in the Dorris area for 47 years. Before the Butte Valley clinic opened in 1979, Streed said the family drove into Klamath Falls when they needed medical attention. But sometimes the roads were so icy they couldn't get through; and they got in the habit of just not bothering with doctors.
Streed is a typical patient in that she would not get regular health care were it not for the clinic.
"This area has never been able to generate enough income to support a full-time physician, and the people we serve are not really attractive to a physician," Bergeron said. Now that the practice is established, with furniture and files in the office, and a healthy patient load, the situation might look more inviting to a physician. It's been the fate of many a successful rural nurse practitioner to run himself or herself out of business, Bergeron said.
But for now, the nurses work with a sense that they alone are responsible for their patients. "You make a mistake out here--you've got to live with it," Claude Bergeron said. "You really have to know where your skill stops."