BBQ Chips and Rush Limbaugh - Challenges of Building Rapport

Adriene Whitaker, RN, BSN, MPH

Maine CDCSeptember 23, 2009

TB Talk – New England

Patient History

• 48 y/o African-American male

• Self referred to EtOH detox center

• Detox center: TSTs for all new patients upon admission

• TST planted 4/27: cough, night sweats, fever, nebs given q4

• TST read 4/29: 22mm ER

Hospital Admission

• Admitted 4-29-09

• CXR: LUL cavitary lesion

• Placed in airborne infection isolation room

• Induced sputum: smear+, DNA probe+,culture+, pan-sensitive

• Started 4-drug therapy 5-1-09

Medical History

Knowns• Diabetes mellitus• HTN• HIV status

Unknowns• Surgical history?• Symptom onset?

Every physician interview’s results were different

Social History

Knowns• EtOH abuse (currently

detoxing)• Currently unemployed• Smoker• Family out of state• Navy 6 years,

currently on disability

Unknowns• IV drug use?• Drug abuse?• Travel history?• Work history?• Current housing?

Patient Interviewing

• Unable to ask any follow-up questions• “You already asked that question. I’m not going to repeat myself.”

• “Why do you need to know that?”

• No names of close contacts• Time intervals inconsistent• Social history inconsistent• Anxiety over isolation, financial,

privacy

Initial Patient Interview

“I am a very educated man and if I’ve been

able to do my diabetes medications on my

own I am sure I can do the TB medications

on my own without you. On your way out,

would you mind getting me some BBQ chips

downstairs in the cafeteria? I’d do it myself

but they won’t let me out of here.”

What approaches would you take in this challenging

situation?

Game Plan

1. Perceptive observation: what makes them tick, what do they need?

2. Reinforce the good, remedy the bad

3. Trust — Consistently follow through on deliverables

Example: Ego

• Observation: Repeated references to being an “educated man,” trying hard to be in control of the flow of information, “fetch me some chips”

• Got technical in talking about TB

• Gentle in trying to extract information

• Brought chips

Ego: After Discharge

• Continued to praise knowledge

• Started listening to talk radio, reinforced worldview, built rapport

• Tolerant of arbitrary changes to DOT times, incentive days, etc.

Example: Anxiety

• Observation: Detoxing, unable to smoke, fear of TB stigma, out of work (can’t pay bills, can’t get new work in isolation)

• Assured of privacy

• TB Control assists with medical bills

• Nicotine inhaler, anti-anxiety medication

• Promised incentives/enablers

Anxiety: After Discharge

• Delivered on incentives/enablers

• Elaborate PAPR protocol (privacy)

• Physician’s note for school to help obtain tuition reimbursement

• Continued TB education

• Provided timelines

Other Observations

• Hat collection

• New England sports

• Common travel locations– taking trip to his original hometown

• Working out

• Politics

• Social activities

Trust

• Successful treatment depends heavily on voluntary compliance

• Show up when you say

• Do what you say you’ll do

• Validate feelings– Compassion

• Be respectful/nonjudgmental– Leave prejudices at the door

Contact Investigation

• Patient requested PHN NOT test anyone in his residence

• Patient poor historian in identifying close contacts

• Difficult to identify high/med/low contacts• First priority always patient treatment

Where do we go from here?

Contact Investigation

• Former landlord• Current landlord• Contacts• Former employer• Detox Center

• Supervisor TST tested co-residents to avoid associating primary PHN with TB

• Relied on key informants:

Contacts Identified

• Former Residence (last resided 8/08)• 4 contacts identified:

– 2 negatives– 1 Prior positive– 1 Reactor

• Current Residence (8/08 to present)• 60 Residents identified

– 20 Baseline TST– 11 Post Exposure TST

» 1 Converter» 3 Reactors» 1 Prior positive

Contact Identified Cont.• Former Employer

• 1 Contact• 1 negative

• Detox Center Roommates• 7 contacts• 1 previous positive• 4 Baseline TSTs• 2 post exposure TSTs

» No Reactors » No Converters

• Detox Center Staff• 26 contacts• 2 previous positives, 1 Hx of allergic reaction to PPD • 21 baseline TSTs• 17 post exposures

» 1 Converter

Outreach To Contacts

• Landlord forbid on-site TST testing at residence

• Contact letters sent to last listed address

• Contact letters to homeless shelters

• Reviewed contact list with homeless providers and Health Care for the Homeless

Conclusion

• Perceptive observation– Think about what makes them tick– Insights/picking up details can be

invaluable in contact investigation

• Trust– Follow through– Be reliable– Have compassion