Billboard:
(upbeat string music starts)
Annie Strader: I was at the park with Pearl. And I was thinking the I'm having some mild contractions and it was a beautiful day and I came home. And I called my mom and said, You should probably plan on coming in the morning.
(string music turns anxious)
Matt Weedman: The contractions went from seven minutes to three minutes, within like a couple of contractions… and as I'm calling, I'm telling him information, that information is changing, as I'm talking on the phone, and all of a sudden, Annie’s on all fours on the ground. And it was at that point that actually Annie said, and those are the words I'll never forget, she said, it's happening. And I felt the room kind of swell with this pressure, of like, almost as if the air had changed.
Annie Strader: I kept saying my hospital and my doctor is in Indianapolis, they're like, she's not going to make it to Indianapolis.
Ariel Lavery: These are my friends, Matt and Annie. And they live in a desert.
Matt Weedman: And they wheel Annie out. And they had opened up what essentially was a closet with all the stuff in the air. They didn't put us in a regular ER bed, which was still to me to this day strange, because what she ended up on was on a tiny exam table that didn't have stirrups or anything. And it was in a closet where they just had loose materials, books, stacks, all this stuff. And the doctors maybe said one or two words to us, he looked terrified. I have an older woman pulling on my shirt, asking me over and again for insurance information as we are putting Annie up and bending her legs back so she could deliver because she is ready to deliver. It felt like 10 minutes tops. You know, once we were in that weird closet.
(laughter)
Annie Strader: (laughing) That weird closet. And I was screaming.
Matt Weedman: Yes, she's screaming and I'm giving them instructions. And the doctor is just sitting there kind of praying.
(music fades)
Ariel Lavery: If you lived here, you might not know you live in a desert until you decide to get pregnant. Suddenly, your pleasant small town experience is spoiled. Now you have to find a maternal care provider far from where you live and, somehow, get yourself to your appointments regularly, because this baby is not going to wait. This is what it’s like to live in an OB desert. It’s a reality that is all too common in the United States, which leads all industrialized countries in maternal and infant mortality. It seems like every year, lately, we see closers of maternity wards outpacing openings in rural areas. And the women who lose out, as a result, often have more specialized healthcare needs than any remaining hospitals or clinics are equipped to handle.
(theme music starts)
Matt Weedman: There was the smell of the pressure of the liability in that room.
(theme music swells)
Ariel Lavery: We’re talking to women near and far this season about how living in rural America affects their health. OB deserts affect millions of women across the country, most of whom live in rural areas. What can we do, in a nation that leads in innovation, to address this shameful problem? Today, we’ll look at a common sense solution to this complex issue. This is Angels in a Desert, on Middle of Everywhere; sharing big stories from the small places we call home.
(theme music ends)
Scene 1: Along for the Ride
(crosstalk, background conversation)
Kristy: My things on the other ones.
Darren Foreman: Ok, What does your shirt say?
Kristy: Bippity boppity bump.
Nurse: Aw, that's cute!
Ariel Lavery: That is adorable.
(laughter)
Darren Foreman: Alright how have the glucose readings been
Kristy; Uh,high. They're back up to like averaging around 180, 190. She changed…
Darren Foreman: Ok.
Ariel Lavery: Last November, I got to sit in on a pregnant patient’s regular weekly checkup with one of her care providers in the rural Indiana town of Crawfordsville.
Darren Foreman: Usual stuff: nausea, vomiting, bowel issues, bleeding, cramping, unusual discharge?
Kristy: I don't know if it would be cramping but I am very uncomfortable.
Darren: Okay.
Ariel Lavery: And the provider, in this case, is a man who has never worn a lab coat, doesn’t have an MD, and has a background in firefighting.
Darren Foreman: Do you have a belly band?
Kristy: No
Darren Foreman: Look at a belly band. There’s some at Walmart and get them off of all the websites. So what a belly band is is kind of…
Ariel Lavery: The clinic we sat in doesn’t look like what you would expect either. It’s in the dining room of a historic two story home. The original cabinetry lined one wall, the wood floors squeak, and paisley patterned curtains line the tops of the windows. Darren, the firefighter turned care provider, has a white horseshoe mustache and close cropped hairstyle. He wears a black polo shirt that reads Crawfordsville Fire Department on it.
Darren Foreman: Her pregnancy was very complicated.
Kristy: Yeah.
Darern Foreman: This pregnancy has really been kinda straight, hot, and normal.
(baby babbling)
Kristy: … RGF or whatever, the restrictive growth syndrome.
Darren Foreman: That doesn't necessarily mean that developmentally or size wise it's going to make that much of a difference.
Ariel Lavery: Listening in on their conversation, I realized that Darren was providing something that I hadn’t considered to be a part of medical maternal care. He was providing reassurance.
Darren Foreman: Didn’t they tell you, they thought we'd be lucky to get to 31, 32? And now we're saying solidly 37?
Kristy: I'm used to the brunt of doctors telling me that I'm not doing it right, you know what I mean like-. But yeah, he really upset me…
Ariel Lavery: So, you might have guessed that today’s story is largely about a man, which might surprise you, but men are often a huge part of the maternal care equation. Darren Foreman heads up a program in Crawfordsville, Indiana, called Project Swaddle where he gets to spend all day talking to moms about pregnancy, nursing and babycare. And it’s literally all day, as I quickly witnessed when riding in the car with him to his next visit.
Darren Foreman: During the pregnancy, I have what I call the baby phone. It’s on 24/7.
Ariel Lavery: This is not your phone?
Darren Foreman: It is not my phone. it is a, it's a city owned phone, that is password protected. So it's you know, we protect the, the health information. (Baby phone dings) But that phone was answered 24/7 365. That's one of the the things I scream from the rooftops as medicine doesn't happen between eight and 4:30.
Ariel Lavery: You had a conversation with her that I've never had with my providers.
Darren Foreman: (laughs) Well, so, you know, and then this is where this program is a throwback to the olden days where your physician didn't see you like we do today, your doctor would come to your house and the horse and buggy are in the car when they needed something. But a lot of treatment, and especially preventative stuff can be addressed by seeing how you live. If I come to your house and and I'm talking about nutrition and things like that, and perhaps you have boxes that I recognize from food pantries, then I'm really not going to be gaining any ground by saying, Oh, well buy these kinds of lettuce and buy this and this and this, when I see that you are in a position where you really can't do that.
(edgy guitar music starts)
Darren Foreman: The other part of that is, if you're pregnant, you generally will see a different provider, you know, or two or three different providers during that journey. So they know you but they don't KNOW you. I get to see these folks, twice a month at least through the entire pregnancy until the end. Now if they have a complicating factor. A lot of times it's every week. So we really become interwoven into the fabric of each other's lives. I know their children, they know my children..
(music fades)
Scene 2: Surviving in the Desert
Chief Miller: Indiana's infant and maternal mortality rates were rivaling that in certain areas of third world countries.
Ariel Lavery: Project Swaddle is the brainchild of Crawfordsville’s current fire chief, Paul Miller.
Chief Miller: It came about out of need, we were seeing our run volumes drastically increase, almost doubling in some points. And there's not a lot of resources or options we had at that point. It was you call; we haul.
Ariel Lavery: Project Swaddle was created to address the OB desert that was created in Montgomery county, where Crawfordsville is, when the local hospital closed their OB unit.
Darren Foreman: 2011 is when they closed it. It was quite a shock to everyone.
Chief Miller: So it created an OB desert for us. And then we started looking at other health issues affecting care. We had 25% of women smoking during their pregnancies.
Ariel Lavery: I really wanted to know why the local hospital, Franciscan Health, decided to close in the face of creating this desert. Unfortunately, I didn’t receive an answer from them, but I did ask everyone I spoke with if they knew why. I even asked the current mayor of Crawfordsville, Todd Barton.
Mayor Barton: Good question. You know, I think it's just a reality that that the consumer preference had changed. I mean, obviously, healthcare systems make decisions based on dollars. But what they were seeing here was that consumers weren't utilizing in very high numbers. So the people who were utilizing maybe were the lower payers, maybe Medicaid patients.
Ariel Lavery: The county really didn’t become aware of the gap in maternal care until 2017, when it conducted a community needs assessment.
Darren Foreman: I just don't know that anyone had really kind of put those two together and looked at those to say, Oh, my, oh, my. We have a problem.
(serious guitar music plays)
Ariel Lavery: This is where Chief Miller picked up the pieces and started reassembling. Darren had already been moving toward working in public health through the fire department, which happens more often than I ever knew. He had been putting hours in at the ER as a paramedic when Chief Miller asked him to switch gears.
Darren Foreman: And then as I started doing this, I started realizing that, you know, one of the things that we identified also was lack of prenatal care. It wasn't necessarily it wasn't there it was people weren't going to prenatal visits. And so one of the tasks that Chief Miller put with me was: figure out why. It took me all of about a month to figure out that it's multi-faceted, multi-pronged. So maybe you have a family, a working family that has one car, the working partner has to be at work. They don’t have the car during the day to go to an appointment. Maybe the car broke down. Sometimes it is: we have enough gas for X number of visits to town.
Ariel Lavery: People living in rural places where many of these OB deserts predominate have myriad obstacles to overcome just to see a doctor. And it goes beyond just a lack of providers and resources. I spoke with another person who is heavily invested in Project Swaddle and who has been observing the progress.
(quiet string music begins)
Dr Laura Schwab Reese: I’m Dr. Laura Scwab Reese. I’m an assistant professor in public health at Purdue University. Many rural areas are facing four stressors;
(quiet string music begins)
Dr Laura Schwab Reese: There is financial instability and insecurity. Historically, in rural communities there were very strong social networks that were protective. I think we're starting to see some of that breakdown. I think that the lack of infrastructure starts to become a problem in rural areas. So things like access to transportation, public transit, tends to be either poor or non-existent in rural areas; and I think the fourth is stable, happy families. So that starts to tie in to the other three. We're in a situation now in rural areas where parents are having to work one or two, or three, or however many jobs and that makes it more difficult, not that they care any less about their children. But it makes it more difficult to provide that safe, nurturing environment. We start to see… diseases of despair. Where people feel less secure, they feel less hopeful for the future, they don't feel like society cares about them anymore. And we see these, you know, negative coping strategies come as a result of that. Substance use, overusing alcohol, not not caring for their body, not exercising enough, not eating nutritious food. And we start to see this kind of spiral where people do things that feel good in the moment. Using alcohol feels good in the moment, using drugs feels good in the moment, having really fatty, unhealthy food feels good in the moment. But that starts to create cycles where then you're, you feel even worse in your body even worse, mentally, and you do things that aren't healthy for you or for anyone, things like hurting your partner or hurting your children.
Ariel Lavery: When diseases of despair are confronted by the American healthcare system, despair seems to have the upper hand.
Dr Laura Schwab Reese: In the American healthcare system, people generally have to pay to be seen, you know, you go to your doctor, you have insurance, and you have to pay a copay or you have to meet your deductible. And so there becomes that connection to insurance where insurance providers need to see certain things in order to approve the claim and it gets into this very messy tangle of who's paying? How much can you do in a visit? complicated kind of spaghetti bowl of who has their hands in these decisions?
(music fades)
(On-site patient visits fades in)
Ariel Lavery: How old is she?
Bridget: Eight weeks aroundish there.
Darren Foreman: She is 59 days today. (newborn sounds)
Ariel Lavery: We visited another patient, two actually, at their home in Crawfordsville.
Bridget: This program is amazing. I learned so much.
Ariel Lavery: She and her baby live with her mother. They told me that she was integrated into the program because Bridget, the new mother, has a history of mental illness and diabetes.
(serious guitar music begins)
Bridget: …with my ADHD, my undiagnosed autism, and depression, anxiety, agoraphobia…I actually had a small breakdown shortly after having her. Mom was feeding her in the kitchen. It just came to the realization that she’s going to die one day. I apparently, just could not handle that. And I just started, it just, I had a breakdown. Four days. I was, I was, I was not ok for four days.
Ariel Lavery: For Bridget, having Darren and the nurse from Project Swaddle talk her through this, was a necessity. But it’s not the kind of treatment that you’d typically get in a doctor’s office. This is part of the magic of this program. It’s dependent on this one guy recognizing what’s going on in the home and taking action right then and there, with the patient.
Darren Foreman: I have gone literally under bridges to find people and take them to their appointments.
(music fades)
Ariel Lavery: When we come back we’ll hear how well Darren fits into a maternal care community that doesn’t exactly look like him. And we’ll learn how it really took a perfect storm to make this all happen.
(Ad break)
Scene 3: The Guy for the Job
Ariel Lavery: Welcome back! By this point in the episode, I think you have a pretty good idea about how nimble this program can be in ways that fly in the face of sluggish healthcare systems. But something I haven’t stressed much is Darren’s absolutely perfect fit for this role, which is kind of a requirement.
Darren Foreman: So as you become a little bit more senior in the fire department, you realize pretty quick that it's a bit of a young man's game. My avenue was to get a lot of different education and become more of that utility guy that could do a little bit everything. I needed to become breastfeeding cognizant. So I took a breastfeeding class through the state. So I show up in my fireman’s outfit and this burly guy walks into a breastfeeding class, and I had about forty pairs of eyes kinda looking at me, like, are you in the wrong place, are you a pervert, what’s going on? I noticed that a couple of the girls that were looking at the manikins up front had kinda stepped in front of the manikins.
Ariel Lavery: It’s something I encountered when I first learned about this program. People would say every community needs their own “Darren”.
Darren Foreman: Chief Miller calls me a unicorn. I think a lot of what made this go from the initial concept to fruition was I've been entrenched in this community for a long time. So I know a lot of people. And so I can pick up a phone and somebody's going to answer my call. I have been in healthcare both on 911 side, the hospital side. I speak hospital, I speak administrative, I speak fire, I speak you know, I really don't know the right social way to say it, but I can speak street.
Ariel Lavery: I was also struck, in our era of #Metoo and lots of dialogue about toxic male doctors providing subpar healthcare for women, how Darren moved in and out of mother’s lives with such ease. He’s this gruff looking guy, with no resemblance to a medical practitioner, talking about vaginal discharge, and none of these women batted an eye at that.
Darren Foreman: One of the things I tell them in the first visit, the very first visit is this is an adult world. We're going to talk about penises, vaginas, breasts, pee, and poop. I'm a poop expert. I think part of it is I'm a bit of an older guy. So I don't, I'm not seen as a threat.
(serious guitar music begins)
Dr Laura Schwab Reese: I was, I guess we'll say a little bit suspicious.
Ariel Lavery: Dr Schwab Reese again.
Dr Laura Swchab Reese: What I came around to after talking with several of the Project Swaddle moms is that it seemed like it was helpful that he was a man because there was a little bit less of the moms here to scare me. I mean, so much of their interaction with other women was negative around the pregnancy. And it was scary. And, and all of that, that having Darren as a man eliminated some of that, like peer pressure, I think he also became in some ways, like a trusted father figure.
Ariel Lavery: I don’t know that I would have ever preferred a male to a female provider for my pregnancies. But this comment got me thinking about how some of the experiences of Darren’s patient’s are sometimes rooted in heresy and false information from other women who have been through pregnancy and childbirth. When you have questions and you lack access to medical doctors, who’s the next person you’re going to ask? What’s also interesting to think about here is, if paramedicine continues to come out of the fire departments, it may continue to be very male dominated.
Dr Laura Schwab Reese: Disproportionately, many many times more paramedics and firefighters are men than are women.
Ariel Lavery: This all makes me wonder if this is an untapped resource for getting women into community service roles outside of administrative offices. In any case, it’s all about the person at the center of this action.
Dr Laura Schwab Reese: Probably what becomes more important than gender is you have the right person in the role.
Darren Foreman: Now, if you get into some of the diverse diversity kinds of discussions, quite frankly, you know, I don't know that I could walk into the middle of a metropolitan Latino community and be accepted.
Ariel Lavery: Hearing Darren say this gave me pause. To be fair, Montgomery county is 96% white, so he probably has a point. But I don’t know how to feel about a model of care that works within and maintains social segregation. It’s like this very progressive program functions within existing conservative social structures. But if this is what the well connected guy looks like in your community, then you better take him. And with this thought it was suddenly clear to me how and why this all worked. This whole program is about individuals trusting each other because of a shared history. It’s one of the boons of living in small town America we have always heralded – we are interwoven and invested in each other. But, in towns across America, would this model truly serve everyone, even those who don’t neatly fit into the community?
(music fades)
Scene 4: The Perfect Storm
Ariel Lavery: It took the city and county some time to come around to designing Project Swaddle. The city tried out several other avenues, with outside organizations, before trying to tackle the problem themselves.
Darren Foreman: And at some point, it's settled over to the fire department because honestly, if you don't know what to do, who do you call?
Ariel Lavery: (laughing) Ghost Busters! I mean…
Darren Foreman: (laughing) Them too. Oddly enough, they had their first first office in an old fire department. (laughing)
Ariel Lavery: There you go! I think there’s something to that.
Darren Foreman: (laughing) Don't put that in the podcast. (laughing)
Ariel Lavery: What makes this all possible is a new model of healthcare.
(enlightening guitar with string bed music begins)
Darren Foreman: It's actually in its infancy, community paramedicine was born out of the nursing shortage. And we had these folks that needed some home health care and things like that, and there weren't enough nurses and somebody come up with the idea, hey, we have paramedics that are used to going into houses anyway, we have some that have this tertiary experience. How ‘bout we use them?
Ariel Lavery: This is where the unexpected pipeline from fire department to care provider has developed.
Dr Laura Schwaab Reese: Montgomery county was really at the beginning of developing those innovative community paramedicine programs. I think that in some ways the state has been inspired by Paul and his team’s really innovative work.
Darren Foreman: You need to build the team. Before you turn the lights on. Before you see your first patient, you need to have all of these ducks in a row. Otherwise, you're gonna set yourself up to fail. All too often you end up just by the nature of the beast putting the cart before the horse and things fail because you don't have the right infrastructure in place. A lot of the fire departments will come here and say alright, how do we do it? How did you guys start? And my, my standard advice to them is find somebody that speaks hospital. Find one of your firemen that's married to one of the nurses, because that's kind of a thing. And that nurse can connect you with the next nurse up the list who can connect you with the next up through administration, and before you know it, you'll have the connection, that warm handoff connection that you need.
Ariel Lavery: Every one of the people involved in this program described its inception as a perfect storm. There were so many factors that needed to come together in the same moment for the birth of Project Swaddle. From the data that revealed the poor maternal-fetal outcomes, to the Fire Chief’s visionary nature, to the town’s buy-in through the mayor’s office, to Darren, being ready, willing, and capable to take this on, everything, and everyone, had fallen into place.
Mayor Barton: But you know, most communities don't have the levels of cooperation, and that’s what stands in the way.
Ariel Lavery: Mayor Barton again.
(enlightening guitar with string bed music begins)
Mayor Barton : Even if they had a Darren, you know, making it work is very difficult in a lot of communities, because everybody has their turf, and everybody has their little area that they want to protect, and they won't tear down those barriers and have real conversations.
Chief Miller: See, and I think that's one of the things that makes us so successful. So our connections I mean, it's a real relationship. I think we're all friends in this and we see each other's success. And we try to build each other up.
Ariel Lavery: Since its inception, Project Swaddle has continued to grow. They’ve gotten more grants through government dollars and private foundations, which has allowed them to hire more staff, which has increased their ability to organize and disseminate information to other communities who might want to build something like this.
Darren Foreman: Fortunately for us, again, a perfect storm. We received a grant for our QRT, which is our Quick Response Team.
Ariel Lavery: …which allowed them to start to collate their data and create a how to map.
Ariel Lavery: So had you not gotten that grant, would this program remain sustainable for you?
Darren Foreman: It would, but we wouldn't be talking right now.
(music fades)
Scene 5: Is this proven? Can we implement a future that looks like this?
Ariel Lavery: The last part of the equation for any evidence-based medical practice is to collect the data and prove the evidence shows it’s efficacy. This is why I spent so much time talking to Dr Laura Schwab Reese.
Darren Foreman: She heard chief Miller speak at Purdue and she's like, Hey, I think I might want to be involved with that. So again, one of those perfect storms!
Dr Laura Schwaab Reese: I hadn't seen anything like Project Swaddle that used community paramedics. But what I thought was particularly appealing to me about the program was the use of paramedics. Paramedics in general tend to be pretty trusted members of their communities. So if the police show up at your door, you're probably not thinking you're having a good day if a public health tracker and by that I mean like the people doing COVID related tracking shows up at your door you don't think you're having a good day. But when a paramedic shows up, there's kind of an immediate level of trust.
Ariel Lavery: Dr Swab Reese is invested in understanding what makes for good public health in rural areas.
Dr Laura Schwab Reese: That’s really the foundation of my research: that people need a safe, happy, healthy place to live in order to be healthy.
(intense bass with marimba music begins)
Ariel Lavery; It seems like an obvious point to make. But the problem comes in with how healthcare is implemented. Data on public health comes in through reporting from hospitals and clinics to agencies like the CDC. And that data is broad and generalized. Furthermore, they can really only collect data that reports poor health outcomes because that’s when people go to the hospital. So it’s hard to know why there might be a decrease in hospital visitations, illness and death.
Dr Laura Schwab Reese: What we end up with in these database surveillance systems is basically all the terrible things that happen, we don't know about the, the good things that happen that tweak the path that that person was on. As a result of the community needs assessment project Swaddle was born. But they're not able to in a, in a structured way, say, And because of project Swaddle, now, it's not a problem anymore. So I think that tends to be a problem in public health, and maybe medicine as a whole. The lack of data means that we can't say things like Project Swaddle prevented X number of preterm births. We can't say X number of babies lived because of Project Swaddle. What we can say is that people really liked the program. People believe that their lives are better because of the program.
Ariel Lavery: There are ways of getting this positive outcomes data, but it’s very expensive because it requires people going out into the field, going from patient to patient, and collecting the data first hand.
Dr Laura Swchab Reese: In a world where there are never enough dollars for public health, using resources very efficiently becomes important.
Ariel Lavery: So, this might be a tricky question, but does this mean this lack of evaluation from the project? Does this mean that it's, hypothetically a positive program, even though so many other communities are trying to figure out how to model their own programs out of this?
Dr Laura Schwab Reese: I was afraid you're going to ask me that?
(intense guitar begins)
Dr Laura Schwab Reese: Yes. We have no clear data that says that Project Swaddle is effective. It gives me heartburn. It is one of my gravest concerns about community paramedicine. That we are not effectively evaluating these programs. And people like what they see in the program and so we’re running with it in a way that there are millions and millions of dollars being spent on these programs that we don’t know are really effective. But I believe in this program.
(pause)
Ariel Lavery: I might be feeling audacious after everything I’ve learned, but I wonder if this new model of care, one that doesn’t happen in a doctor’s office, has no connection to insurance companies, and seems to address the physical AND mental health of needy patients might be common sense option for a lot of communities that just can’t yet conceive of it. Community paramedicine programs have been popping up around the globe, trying to address the opioid epidemic, chronic diseases like diabetes, and the many diseases of despair that plague so many rural communities.
Dr Laura Schwab Rees: So much about health is so structured, right? So siloed and fragmented in the United States that everyone's kind of pulling their own system in the way that they think is best, but not necessarily pulling in a way that collectively we have the most or the best impact. If I could wave a magic wand, that is the magic wand I would wave.
(music swells and fades)
Conclusion:
Ariel Lavery: I've thought about whether this type of model needed to come out of a small sort of more rural community just because people in those communities are actually used to serving multiple roles more often, than people in big metropolitan areas, and they just know each other a little bit better. They're not needles in haystacks. And I don't know, there's something really curious about that. Like you said, Indianapolis is modeling a program after?
Darren Foreman: Well, they're working towards it.
Ariel Lavery: Yeah. I mean, that's incredible. You should feel proud about that!
(inspirational music begins)
Darren Foreman: You know, I'm humbled. I'm absolutely humbled. Honestly, I'm humbled. I think you're exactly right. Rural community is where this, this couldn’t have probably happened in an, in a metropolitan area. It really couldn't. Out in the country here. We help each other.
Ariel Lavery: Who do you think will take over for you? And how much longer do you want to do this for?
Darren Foreman: Wow. Probably the toughest question you’ve had. (laughter) Uh, I don’t know. I don’t know what the end game is. Right now we have a couple of nurses that could take over just fine. To have another paramedic, which, you know, selfishly I want another paramedic. Um, I don’t know. I don’t know who that’s going to be. Because I didn’t know it was me. And I’m quite certain that the next person doesn’t know it’s them either.
Credits
Thank you to Darren and his team for giving me the time and bringing me along for the ride. Thank you especially to Samantha Swearington for responding quickly to every email request, answering my plethora of questions and to Abigail Campbell for recording several of my interviews. This episode was produced by me, Ariel Lavery. Our editor is Josh Adair. Thank you to Annie Davis, our intern, for helping with all the fact checking and sending out our newsletter this season, which, if you aren’t getting it yet, you can subscribe on middleofeverywherepod.org. You can find images of Darren and his patients on Instagram and Facebook at middle of everywhere pod and Twitter at rural underscore stories. Our theme music was composed and produced by Time on The String Sound Studio in Paducah Kentucky. Other scoring comes from APM music. This is a production of WKMS and PRX. This program was made possible, in part, by the corporation for Public Broadcasting, a private organization funded by the American People.
(music fades)