Kaiser Health News
On the Night Shift With a Sexual Assault Nurse Examiner
by Katheryn Houghton
Mon, 08 May 2023 09:00:00 +0000
MISSOULA, Mont. — Jacqueline Towarnicki got a text as she finished her day shift at a local clinic. She had a new case, a patient covered in bruises who couldn't remember how the injuries got there.
Towarnicki's breath caught, a familiar feeling after four years of working night shifts as a sexual assault nurse examiner in this northwestern Montana city.
“You almost want to curse,” Towarnicki, 38, said. “You're like, ‘Oh, no, it's happening.'”
These nights on duty are Towarnicki's second job. She's on call once a week and a weekend a month. A survivor may need protection against sexually transmitted infections, medicine to avoid getting pregnant, or evidence collected to prosecute their attacker. Or all the above.
When her phone rings, it's typically in the middle of the night. Towarnicki tiptoes down the stairs of her home to avoid waking her young son, as her half-asleep husband whispers encouragement into the dark.
Her breath is steady by the time she changes into the clothes she laid out close to her back door before going to bed. She grabs her nurse's badge and drives to First Step Resource Center, a clinic that offers round-the-clock care for people who have been assaulted.
She wants her patients to know they're out of danger.
“You meet people in some of their most horrifying, darkest, terrifying times,” Towarnicki said. “Being with them and then seeing who they are when they leave, you don't get that doing any other job in health care.”
A former travel nurse who lived out of a van for years, Towarnicki is OK with the uncertainty that comes with being a sexual assault nurse examiner.
Most examiners work on-call shifts in addition to full-time jobs. They often work alone and at odd hours. They can collect evidence that could be used in court, are trained to recognize and respond to trauma, and provide care to protect their patients' bodies from lasting effects of sexual assault.
But their numbers are few.
As many as 80% of U.S. hospitals don't have sexual assault nurse examiners, often because they either can't find them or can't afford them. Nurses struggle to find time for shifts, especially when staffing shortages mean covering long hours. Sexual assault survivors may have to leave their town or even their state to see an examiner.
Gaps in sexual assault care can span hundreds of miles in rural areas. A program in Glendive, Montana — a town of nearly 5,000 residents 35 miles from the North Dakota border — stopped taking patients for examinations this spring. It didn't have enough nurses to respond to cases.
“These are the same nurses working in the ER, where a heart attack patient could come in,” said Teresea Olson, 56, who is the town's part-time mayor and also picked up on-call shifts. “The staff was exhausted.”
The next closest option is 75 miles away in Miles City, adding at least an hour to the travel time for patients, some of whom already had to travel hours to reach Glendive.
Nationwide, policymakers have been slow to offer training, funding, and support for the work. Some states and health facilities are trying to expand access to sexual assault response programs.
Oklahoma lawmakers are considering a bill to hire a statewide sexual assault coordinator tasked with expanding training and recruiting workers. A Montana law that takes effect July 1 will create a sexual assault response network within the Montana Department of Justice. The new program aims to set standards for that care, provide in-state training, and connect examiners statewide. It will also look at telehealth to fill in gaps, following the example of hospitals in South Dakota and Colorado.
There's no national tally of where nurses have been trained to respond to sexual assaults, meaning a survivor may not know they have to travel for treatment until they're sitting in an emergency room or police department.
Sarah Wangerin, a nursing instructor with Montana State University and former examiner, said patients reeling from an attack may instead just go home. For some, leaving town isn't an option.
This spring, Wangerin called county hospitals and sheriff's offices to map where sexual assault nurse examiners operate in Montana. She found only 55. More than half of the 45 counties that responded didn't have any examiners. Just seven counties reported they had nurses trained to respond to cases that involve children.
“We're failing people,” Wangerin said. “We're re-traumatizing them by not knowing what to do.”
First Step, in Missoula, is one of the few full-time sexual assault response programs in the state. It's operated by Providence St. Patrick Hospital but is separate from the main building.
The clinic's walls are adorned with drawings by kids and mountain landscapes. The staff doesn't turn on the harsh overhead fluorescent lights, choosing instead to light the space with softer lamps. The lobby includes couches and a rocking chair. There are always heated blankets and snacks on hand.
First Step stands out for having nurses who stay. Kate Harrison waited roughly a year to join the clinic and is still there three years later, in part because of the staff support.
The specially trained team works together so no one carries too heavy a load. While being on night shift means opening the clinic alone, staffers can debrief tough cases together. They attend group therapy for secondhand trauma.
Harrison is a cardiac hospital nurse during the day, a job that sometimes feels a little too stuck to a clock.
At First Step, she can shift into whatever role her patient needs for as long as they need. Once, that meant sitting for hours on a floor in the lobby of the clinic as a patient cried and talked. Another time, Harrison doubled as a DJ for a nervous patient during an exam, picking music off her cellphone.
“It's in the middle of the night, she just had this sexual assault happen, and we were just laughing and singing to Shaggy,” Harrison said. “You have this freedom and grace to do that.”
When the solo work is overwhelming or she's had back-to-back cases and needs a break, she knows a co-worker would be willing to help.
“This work can take you to the undercurrents and the underbelly of society sometimes,” Harrison said. “It takes a team.”
That includes co-workers like Towarnicki, who dropped her work hours at her day job after having her son to keep working as a sexual assault nurse examiner. That meant adding three years to her student loan repayment schedule. Now, pregnant with her second child, the work still feels worth it, she said.
On a recent night, Towarnicki was alone in the clinic, clicking through photos she took of her last patient. The patient opted against filing a police report but asked Towarnicki to log all the evidence just in case.
Towarnicki quietly counted out loud the number of bruises, their sizes and locations, as she took notes. She tells patients who have gaps in their memories that she can't speculate how each mark got there or give them all the answers they deserve.
But as she sat in the blue light of her computer screen long after her patient left, it was hard to keep from ruminating.
“Totally looks like a hand mark,” Towarnicki said, suddenly loud, as she shook her head.
All the evidence and her patient's story were sealed and locked away, just feet from a wall of thank-you cards from patients and sticky notes of encouragement among nurses.
On the harder evenings, Towarnicki takes a moment to unwind with a pudding cup from the clinic's snacks. Most often, she can let go of her patient's story as she closes the clinic. Part of her healing is “seeing the light returned to people's eyes, seeing them be able to breathe deeper,” which she said happens 19 out of 20 times.
“There is that one out of 20 where I go home and I am spinning,” Towarnicki said. In those cases, it takes hearing her son's voice, and time to process, to pull her back. “I feel like if it's not hard sometimes, maybe you shouldn't be doing this work.”
It was a little after 11 p.m. as Towarnicki headed home, an early night. She knew her phone could go off again.
Eight more hours on call.
By: Katheryn Houghton
Title: On the Night Shift With a Sexual Assault Nurse Examiner
Sourced From: kffhealthnews.org/news/article/sexual-assault-nurse-examiner-night-shift/
Published Date: Mon, 08 May 2023 09:00:00 +0000
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Kaiser Health News
Journalists Delve Into Climate Change, Medicaid ‘Unwinding,’ and the Gap in Mortality Rates
Sat, 04 May 2024 09:00:00 +0000
KFF Health News senior correspondent Samantha Young discussed Medicaid and climate change on KCBS Radio's “On-Demand” podcast on April 29.
- Click here to hear Young on KCBS
- Read Young's “AC, Power Banks, Mini Fridges: Oregon Equips Medicaid Patients for Climate Change“
KFF Health News contributor Andy Miller discussed Medicaid unwinding on WUGA's “The Georgia Health Report” on April 26.
- Click here to hear Miller on “The Georgia Health Report”
- Read Phil Galewitz' “Millions Were Booted From Medicaid. The Insurers That Run It Gained Medicaid Revenue Anyway.“
KFF Health News Nevada correspondent Jazmin Orozco Rodriguez discussed mortality rates in rural America on The Daily Yonder's “The Yonder Report” on April 24.
- Click here to hear Rodriguez on “The Yonder Report”
- Read Rodriguez' “City-Country Mortality Gap Widens Amid Persistent Holes in Rural Health Care Access”
——————————
Title: Journalists Delve Into Climate Change, Medicaid ‘Unwinding,' and the Gap in Mortality Rates
Sourced From: kffhealthnews.org/news/article/journalists-delve-into-climate-change-medicaid-unwinding-and-the-gap-in-mortality-rates/
Published Date: Sat, 04 May 2024 09:00:00 +0000
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Kaiser Health News
Oh, Dear! Baby Gear! Why Are the Manuals So Unclear?
Darius Tahir
Fri, 03 May 2024 09:00:00 +0000
Since becoming a father a few months ago, I've been nursing a grudge against something tiny, seemingly inconsequential, and often discarded: instructional manuals. Parenthood requires a lot of gadgetry to maintain a kid's health and welfare. Those gadgets require puzzling over booklets, decoding inscrutable pictographs, and wondering whether warnings can be safely ignored or are actually disclosing a hazard.
To give an example, my daughter, typically a cooing little marsupial, quickly discovered babyhood's superpower: Infants emerge from the womb with talon-strength fingernails. She wasn't afraid to use them, against either her parents or herself. So we purchased a pistachio-green, hand-held mani-pedi device.
That was the easy part. The difficulty came when we consulted the manual, a palm-sized, two-page document.
The wandlike tool is topped with a whirring disc. One can apparently adjust the speed of its rotation using a sliding toggle on the wand. But the product manual offered confusing advice: “Please do not use round center position grinding,” it said. Instead, “Please use the outer circle position to grinding.” It also proclaimed, “Stay away from children.” In finer print, the manual revealed the potential combination of kids and the device's smaller parts was the reason for concern.
One would hope for more clarity about a doodad that could inadvertently cause pain.
Later, I noticed another warning: “If you do not use this product for a long time, please remove the battery.” Was it dangerous? Or simply an unclear and unhelpful yet innocuous heads-up? We didn't know what to do with this information.
We now notice shoddy instructions everywhere.
One baby carrier insert told us to use the product for infants with “adequate” head, neck, and torso control — a vague phrase. (The manufacturer declined to comment.)
Another manual, this one online and for a car seat — a device that's supposed to protect your kid — informed readers with words and images that a model baby was “properly positioned” relative to the top of the headrest “structure” when more than one inch from the top. Just pixels away, the same model, slumped further down, was deemed improperly positioned: “The headrest should not be more than 1” from the top of her head,” it said, in tension with its earlier instructions. Which was it, more than one inch or not? So we fiddle and hope for the best.
I acknowledge this sounds like new-parent paranoia. But we're not entirely crazy: Manuals are important, and ones for baby products “are notoriously difficult to write,” Paul Ballard, the managing director of 3di Information Solutions, a technical writing firm, told me.
Deborah Girasek, a professor of social and behavior sciences at the Uniformed Services University of the Health Sciences, told me that for decades, for the young and middle-aged alike, unintentional injury has been the leading cause of death. That's drownings, fires, suffocation, car crashes. The USU is a federal service academy training medical students destined for the armed services or other parts of the government.
Some of these deaths are caused by lack of effective communication — that is, the failure of instruction about how to avoid injury.
And these problems stretch from cheap devices to the most sophisticated products of research and development.
It's a shortcoming that's prompted several regulatory agencies charged with keeping Americans healthy, including the Consumer Product Safety Commission, the Food and Drug Administration, and the National Highway Traffic Safety Administration, to prod companies into providing more helpful instructions.
By some lights, they've had success. NHTSA, for example, has employees who actually read manuals. The agency says about three-quarters of car seats' manuals rate four or five stars out of five, up from 38% in 2008. Then again, our car seat's has a five-star rating. But it turns out the agency doesn't evaluate online material.
Medical product manuals sometimes don't fare too well either. Raj Ratwani, director of MedStar Health's Human Factors program, told me that, for a class he teaches to nurses and doctors, he prompted students to evaluate the instructions for covid-19 tests. The results were poor. One time, instructions detailed two swabs. The kit had only one.
Technical writers I spoke with identified this kind of mistake as a symptom of cost cutting. Maybe a company creates one manual meant to cover a range of products. Maybe it puts together the manual at the last moment. Maybe it farms out the task to marketers, who don't necessarily think about how manuals need to evolve as the products do.
For some of these cost-cutting tactics, “the motivation for doing it can be cynical,” Ballard said.
Who knows.
Some corners of the technical writing world are gloomy. People worry their jobs aren't secure, that they're going to be replaced by someone overseas or artificial intelligence. Indeed, multiple people I spoke with said they'd heard about generative AI experiments in this area.
Even before AI has had its effect, the job market has weighed in. According to the federal government, the number of technical writers fell by a third from 2001, its recent peak, to 2023.
One solution for people like us — frustrated by inscrutable instructions — is to turn to another uncharted world: social media. YouTube, for instance, has helped us figure out a lot of the baby gadgets we have acquired. But those videos also are part of a wild West, where creators offer helpful tips on baby products then refer us to their other productions (read: ads) touting things like weight loss services. Everyone's got to make a living, of course; but I'd rather they not make a buck off viewers' postpartum anxiety.
It reminds me of an old insight that became a digital-age cliché: Information wants to be free. Everyone forgets the second half: Information also wants to be expensive. It's cheap to share information once produced, but producing that information is costly — and a process that can't easily or cheaply be replaced. Someone must pay. Instruction manuals are just another example.
——————————
By: Darius Tahir
Title: Oh, Dear! Baby Gear! Why Are the Manuals So Unclear?
Sourced From: kffhealthnews.org/news/article/baby-product-instruction-manuals-confusing-technical-writing/
Published Date: Fri, 03 May 2024 09:00:00 +0000
Kaiser Health News
California Floats Extending Health Insurance Subsidies to All Adult Immigrants
Jasmine Aguilera, El Tímpano
Fri, 03 May 2024 09:00:00 +0000
Marisol Pantoja Toribio found a lump in her breast in early January. Uninsured and living in California without legal status and without her family, the usually happy-go-lucky 43-year-old quickly realized how limited her options were.
“I said, ‘What am I going to do?'” she said in Spanish, quickly getting emotional. She immediately worried she might have cancer. “I went back and forth — I have [cancer], I don't have it, I have it, I don't have it.” And if she was sick, she added, she wouldn't be able to work or pay her rent. Without health insurance, Pantoja Toribio couldn't afford to find out if she had a serious condition.
Beginning this year, Medi-Cal, California's Medicaid program, expanded to include immigrants lacking legal residency, timing that could have worked out perfectly for Pantoja Toribio, who has lived in the Bay Area city of Brentwood for three years. But her application for Medi-Cal was quickly rejected: As a farmworker earning $16 an hour, her annual income of roughly $24,000 was too high to qualify for the program.
California is the first state to expand Medicaid to all qualifying adults regardless of immigration status, a move celebrated by health advocates and political leaders across the state. But many immigrants without permanent legal status, especially those who live in parts of California where the cost of living is highest, earn slightly too much money to qualify for Medi-Cal.
The state is footing the bill for the Medi-Cal expansion, but federal law bars those it calls “undocumented” from receiving insurance subsidies or other benefits from the Affordable Care Act, leaving many employed but without viable health insurance options.
Now, the same health advocates who fought for the Medi-Cal expansion say the next step in achieving health equity is expanding Covered California, the state's ACA marketplace, to all immigrant adults by passing AB 4.
“There are people in this state who work and are the backbone of so many sectors of our economy and contribute their labor and even taxes … but they are locked out of our social safety net,” said Sarah Dar, policy director at the California Immigrant Policy Center, one of two organizations sponsoring the bill, dubbed #Health4All.
To qualify for Medi-Cal, an individual cannot earn more than 138% of the federal poverty level, which currently amounts to nearly $21,000 a year for a single person. A family of three would need to earn less than $35,632 a year.
For people above those thresholds, the Covered California marketplace offers various health plans, often with federal and state subsidies, yielding premiums as low as $10 a month. The hope is to create what advocates call a “mirror marketplace” on the Covered California website so that immigrants regardless of status can be offered the same health plans that would be subsidized only by the state.
Despite a Democratic supermajority in the legislature, the bill might struggle to pass, with the state facing a projected budget deficit for next year of anywhere from $38 billion to $73 billion. Gov. Gavin Newsom and legislative leaders announced a $17 billion package to start reducing the gap, but significant spending cuts appear inevitable.
It's not clear how much it would cost to extend Covered California to all immigrants, according to Assembly member Joaquin Arambula, the Fresno Democrat who introduced the bill.
The immigrant policy center estimates that setting up the marketplace would cost at least $15 million. If the bill passes, sponsors would then need to secure funding for the subsidies, which could run into the billions of dollars annually.
“It is a tough time to be asking for new expenditures,” Dar said. “The mirror marketplace startup cost is a relatively very low number. So we're hopeful that it's still within the realm of possibility.”
Arambula said he's optimistic the state will continue to lead in improving access to health care for immigrants who lack legal residency.
“I believe we will continue to stand up, as we are working to make this a California for all,” he said.
The bill passed the Assembly last July on a 64-9 vote and now awaits action by the Senate Appropriations Committee, Arambula's office said.
An estimated 520,000 people in California would qualify for a Covered California plan if not for their lack of legal status, according to the labor research center at the University of California-Berkeley. Pantoja Toribio, who emigrated alone from Mexico after leaving an abusive relationship, said she was lucky. She learned about alternative health care options when she made her weekly visit to a food pantry at Hijas del Campo, a Contra Costa County farmworker advocacy organization, where they told her she might qualify for a plan for low-income people through Kaiser Permanente.
Pantoja Toribio applied just before open enrollment closed at the end of January. Through the plan, she learned that the lump in her breast was not cancerous.
“God heard me,” she said. “Thank God.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
——————————
By: Jasmine Aguilera, El Tímpano
Title: California Floats Extending Health Insurance Subsidies to All Adult Immigrants
Sourced From: kffhealthnews.org/news/article/california-legislation-medicaid-subsidies-all-adult-immigrants/
Published Date: Fri, 03 May 2024 09:00:00 +0000
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