RMT Gone Wild

Another night of nearly nonstop RMT calls, which can be neatly summed up like one of those Chinese restaurant menus where you choose options from each of two columns...

Column A                                              Column B
S/he was drinking       and               got hit on the head with a guitar
                                                        got shot with a BB pellet
S/he was on a snow                        got stabbed with a knife
machine/4-wheeler     and               fell down
                                                        started having seizures
S/he was playing                             got into a fight
with a BB gun            and                drank 3 bottles of R&R
                                                        got run over by a 4-wheeler

One man who was extremely intoxicated and combative got stabbed in the chest but would not allow the village health aide to apply pressure to the wound.  Under normal circumstances, I would have activated the medevac, but this patient was belligerent and uncooperative and stated he would refuse to fly to Bethel; so I had the health aide monitor him in clinic.  She called with frequent updates (vital signs, bleeding check), and each time, I could hear the patient yelling loudly in the background.  Finally, the health aide had the VPO (village police officer) cart the patient off to jail because he was out of control.  I figured if the patient was running around and throwing things in clinic, the likelihood of a pneumothorax, hemothorax or cardiac trauma from the stab wound was pretty low.

Cama-i

Cama-i means hello in Yup'ik.

The Cama-i Dance Festival occurs over a 3-day weekend each year in late March, drawing performance groups (showcasing mainly traditional Yup'ik and Inupiat story dances) from rural Alaska and other regions.

It is an exceptionally well-attended event accompanied by a Native crafts festival featuring intricate beadwork and fur accoutrements.  There was even the promise of Hmong lion dancers this year [which I did not see because it's really really hard to sit on bleachers in a crowded high school gymnasium for more than a few hours at a time...]

Night Float

Major highlights from the previous night:

19:05  RMT call from a village health aide regarding a 37-yr-old female who had been drinking, then blacked out and had an unwitnessed fall onto an unknown object that left a puncture wound at the crown of her head.  During the day, we would have just put the patient on a commercial flight to Bethel for further evaluation in the ER and a possible head CT, but at night the major mode of transportation is medevac which should only be activated when critical care is necessary.  Pt was as lucid as one can be while intoxicated, no alarming neurologic deficits, but the health aide called to report that the puncture wound was actively bleeding.  The photos she sent over telemed were a bit blurry and did not give any sense of the depth of the wound.  How to manage this by telephone?  I told her to put several layers of gauze on the wound, then wrap it as tightly as humanly possible with an ace bandage, then apply ice to the region of the wound.  20 minutes later she called to report that the bleeding had stopped and the patient was sobering up.  Disaster averted.

20:53  I admit a 16-yr-old boy with suicidal ideation whose parents were involved in a tragic murder-suicide just a few months ago; he was the one who discovered their bodies and had to break the news to his younger sisters.  Suicide has become such an alarmingly common problem in the Yukon-Kuskokwim Delta that several of the Iditarod competitors this year dedicated their race to suicide prevention.

21:30  A 16-yr-old primip in OB who had just given birth several hours ago after a 3-day induction for mild preeclampsia starts bleeding.  We give her 1000 mcg of misoprostol and the bleeding ceases.  Her post-delivery CBC shows a drop in hematocrit from 34 to 23.4.

22:44  I pick up several ER patients, one of which is a 13-month-old girl with a nasty-looking abscess on her R posterior thigh with a large area of surrounding cellulitis.  Her mother seems unconcerned about the infection, and I am worried about mother's ability to administer daily medication and manage dressing changes, so I decide to hospitalize the girl and start her on IV antibiotics.  After perusing her old chart, I discover that she has been hospitalized twice in the past 8 months for large MRSA abscesses with cellulitis,  and that her mother has been investigated by the Office of Children's Services for suspected neglect.

00:13  The OB nurse pages me because the 16-yr-old primip produced another large gush of bright red blood. I medicate her with fentanyl & versed, then manually extract a large 200 cc blood clot from her uterus and order an additional CBC for morning.

02:22  More RMT calls about infants in respiratory distress, both of whom end up getting medevac'd.

03:10  More ER patients, mostly with viral respiratory infections that are stable for discharge.  The ones who don't have family or friends in Bethel can stay in the hospital-owned hostel overnight and return in the afternoon for a recheck before flying home to their villages.

04:31  Several RMT calls about minor injuries from fisticuffs.  The health aides aren't trained to do laceration repair, so they mainly irrigate the wounds and apply butterfly bandages to hold the wound edges together.

06:17  A 21-yr-old primip is admitted to L&D in active labor and quickly progresses to complete dilation.  Instead of the usual stoic tolerance of labor, this primip yells, "That f*ing hurts!" every 10 seconds while pushing her baby out.  Thankfully, it only takes 4 pushes to deliver her vigorous baby boy.

Breaking & Entering

From the Delta Discovery, a local newspaper serving Bethel and the villages of southwestern Alaska:

"Burglar Caught On Video, Befriends Guard Dog
An intruder broke into the Westlake Hangar at the Bethel Airport during the early morning hours between 4:30 am and 5:15 am, causing extensive damage to a window and a steel door.  The thief stole 42 bottles of alcohol.  The vandal used a sledgehammer.  He also rifled through everything.  The thief left behind 3 hammers."

Balmy, then...KABOOM!

For the past few days, it has been downright balmy, with temperatures in the mid-30s, ice melting, puddles forming on the side of the road.  Last night brought the emergence of the Supermoon (the largest full moon since 1993!), as the moon arrived at its perigee, the point in its orbit closest to the earth.

All was well until the spring equinox today brought gale force winds and a snow storm.  All flights between Bethel and the outlying villages have been canceled due to weather; even the medevac has been grounded.  The RMT calls from the villages were pouring in nonstop:
-A 61-yr-old male with blood intermittently oozing out of his penis but no recent injury or trauma...the health aide estimated a half cup of blood had dribbled out within the past hour.  I spoke with the on-call urologist in Anchorage who suggested attempting gentle insertion of a foley catheter for tamponade until the planes can bring the patient in for further evaluation.  Apparently urethral injury is not a urologic emergency.
-A pregnant multip in active labor at 39 weeks who had missed her "Be in Bethel" date, baby delivered by the health aide who gave us a blow-by-blow account over the phone as it was happening.
-A 6-month-old baby in respiratory distress: tachypnea, hypoxia, tachycardia, fever of 100.7.  The health aide was treating the baby with oxygen, albuterol nebulizer,  and ceftriaxone IM and checking in with us every 2 hours while waiting for the weather to improve so medevac could resume flights.

As Aurelie has mentioned, if medevac is grounded, a Blackhawk helicopter can be summoned in life & death situations...and it's nerve-racking to be the one who determines what constitutes "life & death".

Meanwhile I was attempting a massive diuresis of my service before the next set of ward docs start tomorrow.  My two loony-bin suicidal adolescent patients (one pregnant, the other withdrawing from an alcohol binge) on Title 47 (involuntary psychiatric hold for danger to self, danger to others, or grave disability) were awaiting transfer to the psychiatric facility in Anchorage.  My intoxicated 49-yr-old female with fractured ribs and a tiny pneumothorax not apparent on chest x-ray, but seen on chest CT: when would it be safe for her to fly home to her village?  I checked with the on-call pulmonologist in Anchorage who estimated 5 days after complete resolution of the pneumothorax.  My patient can't get home without flying...unless she goes on a several-hours-long ride via snow machine over the bumpy frozen river, which would be quite painful with cracked ribs...

At the end of a very hectic day, I walked home from the hospital in the middle of a blizzard.  At least all the waterproof gear I got at REI has proven to be truly waterproof.

A Word About Permafrost

It's underground. It's composed of rocks, soil and frozen water.  It forms when the depth of winter freezing exceeds the depth of summer thawing.  If permafrost begins to melt, the ground above becomes waterlogged, soft, and prone to collapsing.  Hence the proliferation of boardwalks & ramps in Bethel.

To avoid melting the permafrost, the buildings in Bethel are built on stilts, and water & sewer pipes are installed above the ground.

Contact with the outside world?  You can't get cell phone reception here unless you use a phone card or have an account with the local wireless company, but there is decent internet access and satellite television.

Overheard on Labor & Delivery

Here, in the land of pregnant ladies (both primips and multips alike) who are mysteriously able to deliver most of their babies in just 3 pushes, one of the OB nurses was musing over a non-native delivery she had just seen in which the expectant mother (loaded up on pitocin, with FSE & IUPC in place) had to push for 90 minutes before her baby emerged.
Nurse: (somewhat puzzled) I heard that's normal...

I confirmed that yes, in the lower 48 states, many primips do end up pushing for up to 2 hours.  It really gives me pause about the medicalization of labor:  in medical school & residency, most of the deliveries I saw involved breaking down the bed, feet placed in stirrups for pushing; intrauterine pressure catheters to measure the force of contractions; fetal scalp electrodes to better capture the fetal heart tracing; and of course IV pitocin for augmentation/induction of labor.  Here in Bethel, the bed is often kept intact and instrumentation is kept to a minimum.  Shorter 2nd stage of labor, cuter babies...

Qayagaluku

The difficulty of working on the wards is that your attention is pulled into 3 different directions:
1. Hospitalized patients (both adult and pediatric): the most prevalent reasons for admission on my service currently are multilobar pneumonia, frighteningly large & out-of-control abscesses, and alcohol withdrawal.  There was a bit of drama today with a young lady brought in for suicidal ideation who turned out to have been diagnosed with TB one year ago and somehow successfully evaded treatment.  Now she's captured in a negative-pressure isolation chamber, moody and crying, while Public Health tries to get a court order for her to remain in isolation until adequate treatment has begun.
Alcohol withdrawal came in the form of a married couple, both prone to DTs, sharing a room and a 24-hour sitter.
Day 1: Rowdy and drunk
Day 2: Still drunk
Day 3: Sleepy and drunk
2. OB patients: I delivered my first Native Alaskan baby a few days ago, an adorable rosy-cheeked infant who popped out after just 3 pushes.   The L&D nurses here are refreshingly pleasant and extraordinarily helpful.  And they gave me a salad!  My first fresh veggies since arriving a week ago!  I feel like my hospital-issue lime green scrubs are mocking the lack of fresh fruit in my diet:

3. RMT: a.k.a. Radio Medical Traffic, a term from the old days when communication was via two-way radio.  In order to provide health care even in the most remote villages, each village has health aides who are on-call 24 hours.  The health aides are equipped with a rudimentary clinic and modern technology that enables them to transmit digital images of patients and fax clinical notes to doctors at the hospital for feedback.  I'm responsible for reviewing the notes & images from health aides, then calling them to discuss the patients.  If you don't call them soon enough, they will hunt you down and have you paged repeatedly. In my head, I've been lumping the cases into 3 different categories: Benign (OK to treat in the village), Scary (take a commercial flight to Bethel for further evaluation!), and Scarier (medevac NOW!).  Sometimes the health aides are frighteningly complacent.
Me: Is this 4-month-old baby really breathing 80 breaths per minute?
Health aide: (calmly) yes
Me:  AAAAEEEEEEEEAAGGGGGHH! (translation: give her oxygen & a nebulizer treatment while I activate the medevac!)

I Need Ice Cleats, Stat!

Once again, I find myself practicing medicine in a wintry climate, this time in the small community of Bethel which is located near the mouth of the Kuskokwim River in southwestern Alaska.  The Yukon-Kuskokwim Delta region is populated by 56 tribes in remote villages spread all the way to the west coast of Alaska adjacent to the Bering Sea.  Admissions to the local hospital are divided by village, with one group comprised of villages clustered along the Yukon River and the other group consisting of villages scattered along the Kuskokwim River.

The Yup'ik name for Bethel is Mamterillirmuit ("smokehouse people") in reference to its origin as a trading post with a fish smokehouse in the late 19th century.  Although Bethel can only be reached by air or by river, it has the highest number of taxicabs per capita in the entire country; paved roads constitute a very modest 10 miles within the town itself.  I love how the hospital supplies its locum tenens providers with cab vouchers that resemble Monopoly money:

Temperatures have been in the single digits, but really more like -15 degrees with the wind chill factor.  I'm making good use of my gore tex goose-down L.L. Bean parka and insulated Sorel boots.  For those of us who enjoy ambulation, there's a shortcut to the hospital that involves walking across a teetery boardwalk hovering over a large snow-covered marsh.

  

The roads are super porcelain icy, and the main challenge in getting to work (other than the chill of the tundra) is trying not to get run over by a snow machine (a popular form of transportation, given the exorbitant cost of importing a car by barge or cargo jet).  The approach of a snow machine is heralded by a loud high-pitched buzzing remniscent of a giant mechanical mosquito.

I was warned about the high cost of food [thanks, Aurelie!] but I was still bowled over during a trip to the grocery store that revealed 6 oz of slightly moldy blueberries selling for $9.59 and a wilted head of cabbage for $6.99.  Half of my luggage was an experiment in food transport: I made pasta sauce with ground turkey & spinach, packed frozen in quart-sized ziplock bags tucked into gallon-sized ziplock bags wrapped in larger plastic bags to protect against leaking.  I also packed black beans, salsa, wild rice, shredded mozarella, and rotini.  I froze a loaf of whole grain bread to make almond butter sandwiches with dried mangos & dried cherries.  So far, the food supply seems to be holding up, but it's reassuring to know that if I do run short, I can always head to the hospital cafeteria for elk meatloaf.

ATLS and a Casino Heist

What I did while visiting my friend Jules in Denver:
1. ATLS: We both signed up for Advanced Trauma Life Support, a grueling 2-day course taught by trauma surgeons bursting with testosterone.  One particularly manic instructor with rapid pressured speech entertained us with such comments as, "Big whoop!  No one ever died of an EJ laceration!" and "Oh, you did a thoracotomy?  What kind of suture did you use?  Silk?! [raising his eyebrow judgmentally]...mmm hmmm..."
2. Dinner at Table 6: The highlight was dessert--an amazing sweet potato cinammon roll with carmelized pecans and cream cheese sorbet

3. Casino Heist: A mystery-solving dinner held in a 3-story Victorian mansion, whereupon entering, we were approached by a very young person in sunglasses with a fedora and a camera

Me: A minor just took our photograph!
Jules: He's a sixth-grader!
We played several rounds of fake roulette and blackjack before retiring to the 3rd floor ballroom for dinner and guessing which of the eccentric characters had stolen "millions" from the casino.  I was rooting for our blackjack dealer, a mysterious woman in a mask and a black wig with an endearingly unidentifiable accent, but alas it was someone else...