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.
[Illustration: 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.
[Illustration: 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]
Footnote 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.
Footnote 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.