DORRIS, Calif. — 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.