Implanon Is My New Best Friend

Listen up, teenage girls of the Yukon-Kuskokwim Delta region: birth control is a really, really useful thing!    Yes, I am talking to you, teenage primip being induced at 42 + 1/7 wks for postdates and oligohydramnios, crying between pushes.  And you too, 18-yr-old girl admitted for a septic abortion at 8 weeks EGA, getting IV doxycycline and unasyn.

Last night, I had a very long talk with the 18-yr-old about the pros and cons of all the birth control methods available in the universe and gave her a detailed educational handout with tiny pictures of everything we discussed.  This morning, she told the nurse, "I want my birth control.  When can I have it?".  Asked which method she had chosen, she replied, "The poke."  Poking could describe either the depo provera injection that's good for 3 months, or the implanon implants that are good for 3 years.  Luckily, she chose the fantastically low maintenance implanon which was inserted posthaste just before she was discharged home.

Dishes Are Dangerous

My pager goes off incessantly, and it's hard to predict whether it's the ER doc asking me to admit a sick child, a village health aide asking what to do about a man whose right index finger is almost completely severed after getting his hand caught in a flywheel, or the lab calling to report a sky-high INR value of 18.  When I saw the page from OB this afternoon, I assumed that my 23-yr-old G7P2 being induced for cholestasis of pregnancy was on the verge of delivering...but it was actually one of the OB nurses who whispered sotte voce: "This is not urgent, but I cut my thumb and I was wondering if you would take a look at it."  She had been washing dishes and accidentally shattered a mug, producing a curvilinear laceration that crossed the PIP joint of her left thumb.  The bleeding had stopped after she applied pressure, and her range of motion was perfectly preserved.  "Do you think I need stitches, or can I just keep it wrapped up in a bandage?"

Because of the awkward position of the laceration over a joint, I decided to give her a few stitches to hold the wound edges together during the healing process.  One of the other OB nurses broke into the surgical wing and gleefully returned with 4-0 nylon suture, 1% lidocaine with epinephrine, Adson forceps, and the most beautiful, delicate needle driver  I have ever seen.  "It's a Webster," she told me.  "It costs $300."  It took all of my willpower not to surreptitiously sneak it into one of the myriad pockets on my scrubs.  In the end, the injured nurse got 3 stitches and we all agreed she had to fabricate a far more swashbuckling explanation for the mechanism of her injury.

Of Maggots And Mental Status Exams

My most entertaining patient is a 67-yr-old monolingual Yup'ik-speaking man admitted for weeping ulcers on his lower extremities that were infested with maggots.  His legs are completely discolored with thick layers of exfoliating skin.  He has had several amputations due to severe frostbite: he is missing 2 toes from his left foot, 1 toe from his right foot, and 4 fingers from his right hand.  Despite all of these physical quirks,  he is frequently smiling and joking.  A young man from the patient's household is accompanying him during this hospitalization, but displays a curious lack of knowledge about the patient's baseline level of functioning ("I don't know, I just got out of jail" is his standard answer to our inquiries).  On his second day of hospitalization, the patient's primary caretaker called to tell us that she can't take care of him anymore (not that she was taking particularly good care of him to begin with, given the maggots on his legs).
Patient (via Yup'ik interpreter): Was she drunk when she called?  Because she always talks like that when she's been drinking.

To be fair, the patient's lower extremity ulcers are healing quite nicely now, possibly because of the neat work of the maggots: they're quite adept at digesting rotting organic material.  The hospital social worker is filing an Adult Protective Services report for elder neglect, and she asked me to conduct a mental status exam to facilitate the patient's placement in a nursing home.

Here's my dilemma: the traditional Folstein MMSE is a 30-point questionnaire often used to screen for dementia.  Questions include asking the patient to spell "world" backwards, to subtract 7 from 100 and keep subtracting 7 serially from the resulting answer, and to name the year/month/date/weekday.  Are these questions appropriate for a patient who doesn't speak English and has limited exposure to formal education?  I looked at the Mini-Cog Assessment Instrument for Dementia which is supposedly valid regardless of culture and educational status, but one of the items asks the patient to draw the face of a clock, then draw in hands to set the time to "10 minutes past 11 o'clock".  Is this relevant to someone who lives in a remote village in rural southwestern Alaska and uses the position of the sun and the moon to tell time?

Patient (via Yup'ik interpreter): These questions are making my legs itch.

You & me both, baby...

Back in Bethel

If you're wondering what Bethel, Alaska looks like without all that ice and snow, look no further:  There is grass!  Trees with green leaves!  Daylight until 1 am!  And lots & lots of rain which produces copious amounts of mud.  I forgot my umbrella, but I did arrive equipped with an insanely cheery pair of child-size "fireman style" rubber boots:

I'm staying at one of the hospital-owned apartments next door to the jail (I will not lie--the barbed wire fence does give off penitentiary vibes).  So far, the prisoners have been extremely quiet and neighborly.  There is a super muddy trail leading from the apartments straight to the hospital that can be traversed in less than 5 minutes.  It's hard to believe that I can squeeze through the narrow gap between two barbed wire fences--wearing all my waterproof gear and my internal frame pack--without setting off several alarms and alerting the Alaska State Troopers.

Meanwhile, back on the inpatient wards, I feel like I'm swimming in jello,  and everything I do is soooo slow and cumbersome.  I have a large service of patients who have been here forever, many with tricky family dynamics that must be navigated carefully.  The RMT calls are as crazy as I remembered, and today's top prize goes to a call about a 79-yr-old woman who had chest pain, then dramatically collapsed in the doorway of the village clinic, then went into bradycardia with a pulse of 40 followed by a seizure after receiving one dose of nitroglycerin.  After being medevac'd to the ER, she was found to have a very low hemoglobin of 6!  Oh Bethel, how I've missed you...

How My Job Search Is Like An Episode of The Bachelorette

It really is, if you imagine each potential employer as one of the bachelors.  Also imagine the physician recruiter as Chris Harrison, the host of the show who guides the bachelorette through her deliberations before each rose ceremony when she has to decide which bachelors to keep and which ones to send home. I interviewed with 2 urgent care clinics and 2 primary care clinics, with the following impressions:
Bachelor/employer #1: practical, down-to-earth, confident
Bachelor/employer #2: organized, detail-oriented
Bachelor/employer #3: alarmingly charming
Bachelor/employer #4: arrived 10 minutes after I had already checked in for my interview.  Didn't really ask me any questions, just rambled on about random topics and how "nobody in this clinic ever works full-time [wink wink]".  I began to wonder if bachelor #4 had been imbibing alcoholic refreshments.

In the end, I went with bachelor/employer #1, an urgent care clinic with 12-hour shifts.  A 3-year contract was signed, just like in professional sports, with a start date in October.  I expect to see my face on a box of Wheaties any day now...