Photo by Mickie Winters
A Latino man sits — back straight, hands on knees — in a red plastic chair, waiting and worried. Recently, a sharp pain has been bursting into his chest and radiating into his left arm. The man’s face carries the fatigue of daily 4 a.m. wake-up calls, of decades spent in the sun, of scruff that’s turned silvery-gray in middle age. Despite 80-degree weather outside, he’s buttoned into a flannel shirt. Jeans cover his short, lean legs, a must around the half-ton racehorses he walks and cares for in Churchill Downs’ barn area, known as the backside. Speaking Spanish, the native of Mexico unloads his symptoms to a translator, who leans toward him, listens, nods and relays the message in English to Sara Robertson, a 39-year-old nurse practitioner and director of the Kentucky Racing Health Services Center.
“He’s saying he’s in a lot of pain today,” the translator says. “He’s had this pain for three days.” Robertson, who’s “almost fluent” in Spanish, confirms: “Tres días pasado?” She types into her laptop, her coffee-colored eyes wide and curious, a slight frown tugging at her face, not like she’s upset, just thinking. This is her first patient of the day. Today, like most days, patients are booked every 20 minutes. “If he’s sitting on the couch doing nothing, does he get it?” Roberston asks. “Si,” the man answers, adding that sometimes he’s so startled he jumps up. “Does it alleviate the pain?” she asks in Spanish. He nods. Robertson’s face rests in a state of hmmm.
Over her shoulder, a poster-sized black-and-white print of a Thoroughbred hangs next to scopes and gadgets needed for exams. The Kentucky Racing Health Services Center, or the “racetrack clinic,” was founded by the Kentucky Racing Health and Welfare Fund’s board of directors. Un-cashed parimutuel tickets from all Kentucky racetracks provide funding, through an annual grant, to the clinic, now in its 11th year. Last year about $236,000 went toward the clinic’s expenses. (The fund, a nonprofit, doled out more than $1 million in health benefits for industry workers across Kentucky in 2016.) The University of Louisville’s School of Nursing staffs the clinic. U of L’s Latin American and Latino Studies program contributes translators. In 2016, the clinic served about 1,000 patients, including family members of backside workers. A visit requires only a $5 co-pay. Robertson estimates about 60 percent of clients are regulars or, she jokes, “ones we have tightly controlled.”
Whitney Nash, an associate dean at the School of Nursing and the clinic’s first director, says that, initially, the clinic operated as a safety net for backside workers, a population that nearly always lacks health insurance and can make as little as $300 to $400 per week. Over time, Nash says, the clinic evolved into “more of a primary-care center.” It’s certainly convenient. Located in the basement of an old brick former school building, the clinic is about one block from the track’s far turn. The clinic’s open year-around, with hours that suit early-morning and late-afternoon shifts at the barns.
“Did he have a stressful weekend?” Robertson asks, looking to the translator for assistance. Really, she knows the answer, this being the Monday after Derby. “Sí,” he reports, adding that he was “like a machine,” his boss constantly giving tasks. “Next, next, next,” the patient explains, chopping his thick, scuffed hands like a knife on a chopping board. He took some medicine in an attempt to relieve his aches. He pulls out his wallet, unfolding a piece of foil, a wrapper from medicine he bought at a nearby Latin market. Robertson inspects. “Some kind of Sudafed or Tylenol product,” she mumbles.
This patient isn’t new, though he hasn’t been seen in about a year. And he’s been without diabetes medication during that time. But that’s a separate issue from the one that he’s battling today. She directs him onto the crimson exam table. The chest pain — sudden and short— doesn’t scream heart problems. His blood pressure is fine. She begins a detailed physical exam: He squeezes her fingers, presses his shoulders up into her palms, raises his eyebrows up and down (a test for potential problems with one of his cranial nerves). Robertson determines his entire left side is weaker than the right. Perhaps he has suffered a stroke? She leaves the exam room for a bit and ponders. “You really don’t want to send someone to the ER to go through all the stress and process if you really don’t have to,” she says, pausing. “That’s what I’m trying to figure out right now.”
An ER trip would likely end with a bill of $3,000 to $6,000 given his vague but somewhat troubling symptoms. She decides on a CT scan. The Kentucky Racing Health and Welfare Fund will foot the bill for the test. It will also cover the cost of medical specialists and lab work and probably would’ve covered most if not all of an ER trip had Robertson deemed it necessary. Before she hands the man prescriptions and the referral for a scan, she looks at the translator to crystallize an important message. “Tell him he needs to come see me more,” she says with a warm smile.
Spend a day in the clinic and the ailments vary: heat rashes, warts, swollen limbs, wheezing, allergies, gas. “I need a back transplant,” one older man groans, limping toward an exam room. A middle-aged trainer reports his wife told him he’s been overly grumpy and it’s time to refill his “cuckoo” pills. Robertson, who has worked here about 10 years, has picked up on trends. While Latinos used to make up about 50 percent of the racetrack clinic’s patients, now it’s more like 80 percent. (The clinic is currently compiling data to find out specifics on patient populations and frequency of injuries.)
Robertson says a lot of her patients are at risk for diabetes. So in the last few years, she and her fellow nurse practitioners have tried to get ahead of it, prescribing medicine early on to lower insulin resistance. Posters on healthy eating line the waiting room. “When you’re diagnosed with diabetes, you’ve actually been sick for about 10 years,” Robertson explains. “You don’t feel sick, but metabolically you’re not functioning correctly for 10 years.” In April, the American Academy of Nursing awarded Robertson and Nash a national award for their implementation of practices that delay or, best-case scenario, stop the onset of diabetes and other illnesses that can balloon into serious health and financial crises.
Eligibility for services at the clinic depends on the job within the horse industry, but for a stable worker or exercise rider, that individual must hold a current Kentucky Horse Racing Commission license and work no less than 24 hours per week for the same employer. Patients can’t just walk in. First stop is an office down the hall from the clinic operated by the Kentucky Racing Health and Welfare Fund, which schedules appointments and confirms eligibility. Authorization papers are folded into a white envelope. When it’s time to be seen, patients ring the clinic’s doorbell.
Patient maintenance can be difficult. Every winter, when Churchill Downs is dark, most backside workers disappear for a few months, many to other racetracks — though, Robertson says, the ones they have “tightly controlled” are good about securing enough prescription refills to get them through that period. Drinking and smoking are prevalent. But “not exceptionally bad,” Robertson says, adding, “The person who might not take care of themselves just might not come over here.”
One afternoon, Robertson sees a 40-year-old woman with a rock-hard neck and shoulders and wrists that tingle and swell. The woman wrings her hands as she tells a translator that sometimes she drops things. “That’s a red flag,” Robertson says under her breath. It turns out that in the woman’s native Mexico, she worked in a factory, pulling plastic tops off some kind of assembly-line product for hours on end. Now she grips reins with that same hand. “I think she has carpal tunnel,” Robertson concludes, writing a referral for a nerve study.
Perhaps the biggest challenge for nurses here is that if their patients don’t work, they don’t get paid. Few want to take time off. “Sometimes they can take a couple of days off. Most of the time people don’t want to take off. We can give them a disability letter but it’s really for us,” Robertson explains. “Even if they can’t work, they can keep their medical through us. Sometimes trainers are a little more sympathetic if (a worker) has a note from us. Sometimes, they’re not sympathetic at all.”
Mary Servin, a 38-year-old with wavy dark hair that reaches her shoulder blades, nervously smiles in the exam room. Her sister, Rocio Servin Castellanos, sits nearby for support. For weeks, Servin suffered stomach pain that she described as “lime or alcohol in a wound, raw.” So a nurse practitioner ordered a CT scan. Today, the results.
Dedra Hayden, a longtime nurse practitioner with a blond bob haircut, says the results show no problem in her stomach. She pauses as a translator relays the information. “But they found a nodule in the lower part of the left lung,” Hayden continues.
“Like a cyst?” Servin asks in Spanish, looking at the translator, then Hayden, concern crinkling her brow.
“It doesn’t look like cancer,” Hayden says.
“I had bronchitis in Louisiana,” Servin says. “It was bad. I didn’t go to the doctor.”
Servin and her sister spent the winter as hotwalkers at a track in Louisiana. A doctor volunteered some hours on Sundays, but there was nothing as comprehensive as this clinic. In fact, no other track they’ve worked at has had anything close. (Turfway Park in Northern Kentucky has a much smaller version of Louisville’s clinic, also funded through the Kentucky Racing Health and Welfare Fund. In 2016, that clinic totaled 80 patient visits.)
Servin’s sister chimes in, saying that in Mexico young Mary had what doctors said were “weak lungs.” Hayden listens to Servin inhale, exhale, inhale, exhale. “They don’t sound weak to me!” she says cheerfully, adding that the nodule on her lungs might be scarring from the bronchitis. Just something to keep an eye on, she reassures.
About half of the clinic’s patients are women. There’s a room outfitted for gynecological exams and the clinic provides birth control. Servin and her sister, who’ve been using the clinic for about three years, say they’ll spread the word when they meet a new female worker on the backside. “Women hear about it from other women,” says Castellanos. “Like, if they need a Pap smear or mammogram.”
Hayden has noticed many women taking advantage of a new service — mental health. Last year the clinic added a mental health provider that takes appointments a couple times a month. For years, many patients shared symptoms — headaches, stomach discomfort — that appeared to have no obvious cause. “Many of the women have left their babies at home,” Hayden says. “I see a lot of that. It’s a heartbreaker. When you ask them about it, they get very emotional.”
It’s no secret some backside workers don’t have legal-immigration status and, perhaps, have falsified their Social Security numbers to earn work. For them, crossing borders to connect with family is out of the question. Deep emotional anguish can damage physical health. It made sense to offer mental-health services in the place patients have trusted for more than a decade.
Before leaving, Servin mentions to Hayden that she’s had trouble sleeping. “I’m stressed,” she says through the translator.
“Why is she stressed?” Hayden asks.
“She’s been preoccupied with the (test) results,” the translator says.
“OK, so now you can relax,” Hayden says with a confident nod. “I’m not worried about it.”
Servin and her sister nod in return, their anxious faces softening into relief.
This originally appeared in the June 2017 issue of Louisville Magazine. To subscribe to Louisville Magazine, click here. To find your very own copy of Louisville Magazine, click here.
