These Boots Were Made For Walk-Ins

The clinic has 6 exam rooms and 1 small trauma room which is often used for minor accidents, since the closest hospital is 60 miles away in Forks (the land of Twilight aficionados).  Most of the visits are walk-ins, and after a while it all blurs together at a very brisk pace: from the woman who marched into the waiting room demanding "PowerPoint injections" for bilateral elbow pain (I'll call Microsoft, stat! I thought to myself) to the young man who sheepishly admitted his chief complaint wasn't coughing, as he told the nurse, but actually a 3-day history of green penile discharge (Condoms! I croaked, while injecting him with ceftriaxone and making him swallow 1 gram of azithromycin)...at the end of the day, I'm usually dazed and hypoglycemic--that is, if I'm not too busy cursing the cumbersome Cro-Magnon era EMR.

I had the opportunity to use the trauma room yesterday when we received a radio report about a grass fire, which turned out to be a man on the grass who was on fire.  The town was hit with an influx of visitors for the Makah Days Festival, a celebration of Makah culture involving canoe races, traditional dancing, vendors, a talent show, and a salmon bake.  In the midst of all the excitement, a large barrel of heated roofing tar spontaneously combusted, and the patient sustained 2nd degree burns on his R hand and R leg.  The EMTs brought him in on high-flow oxygen with a nonrebreather mask, already hooked up by IV to a 1-liter bag of normal saline.  Although his nasal mucosa was mildly singed, he was breathing normally with no signs of airway edema.  The blisters on his skin were starting to pop, and we debrided quite a bit of the dead skin from the burns.

After all the drama, I was able to slip away quietly this morning to meet up with my brother & his family who were camping 54 miles away at the Olympic National Park.  We took a trip to La Push to spend the day at Rialto Beach which has a wildly beautiful rocky shoreline punctuated with silvery driftwood that has been tempered by centuries of ocean waves to look quite sculptural.

When I arrived back at Neah Bay just as the sun was setting, I found the entire town shrouded in fog and the main road blocked off by an ambulance, a fire truck, and 2 police cars.  Which somehow did not surprise me...

Neah Bay

Goodbye, Space Needle!

For my final locums gig, I'm working for the Indian Health Service in Neah Bay which is in the northwesterly corner of Washington state on the Olympic Peninsula.  The drive from Seattle involves a leisurely ferry ride that is especially pleasant in the early morning.

Hello, Bainbridge Island!

The town of Neah Bay is on the Makah Indian Reservation, bordered on the north by the Strait of Juan de Fuca and on the west by the Pacific Ocean.  The coastal view is spectacular.

The shoreline in Neah Bay

The Makah Marina

Whaling was a significant part of ancient Makah tradition, and the tribal logo is a reference to an old legend about a thunderbird delivering a whale to the Makah people during a time of starvation:

You can see representations of this legend in various forms around town:

My temporary home for the next 6 weeks or so is across the street from the police station and jail:

In fact, one of my first clinic patients was a young man in a bright orange jumpsuit, sporting handcuffs and accompanied by a guard.  He had pain in both of his forearms, most likely a repetitive stress injury from lifting 60-lb baskets of fish the day before.  I suggested releasing the young man ever so briefly from the handcuffs so I could conduct a more thorough exam.  This, according to the guard, was not possible.  I explained that the repetitive stress injury would resolve faster if the young inmate was allowed to rest from the aggravating activity.  The guard shot me a look as if to say, Lady, have you completely lost your marbles?!  Apparently there is no rest for the wicked.

Fly Away With Me

My final night float elicited all kinds of excitement:
-A 77-yr-old woman who had collapsed and was found to have a blood glucose level of 12!  After several amps of D50, her blood sugar increased temporarily to 70, then precipitously dropped again.  I started her on an intravenous infusion of D10, then ordered some extra D50 for back-up.  Turns out the hospital was running low on D50 and had to reserve a few amps for the crash carts.  Meanwhile, the patient's blood sugar dropped to 41 despite the D10.  Theory: I'm guessing she took some "extra" doses of her extended release glipizide--an insulin secretagogue that can take quite a while to metabolize completely in elderly patients.   I ordered glucagon to be administered every time her blood sugar level dropped to the 50s.  After 6 or 7 doses, we finally got a blood glucose reading of 124 which fell a bit to 90 an hour later, but managed to stay consistently above 75.  By which time, the patient was alert enough to drink juice when prompted.
-A 13-yr-old boy with an impressively large R knee laceration after taking a tumble off his skateboard.  The gaping wound revealed some subcutaneous tissue which astounded his parents.  You know you're among hunters when the most frequent remark about large lacerations is: "You can see the meat sticking out!"  As I was carefully suturing the laceration (13 stitches total),  the boy pulled a tiny replica of a skateboard out of his pocket to reenact the scene of the accident for me.
-A cab driver with posterior epistaxis that had been bleeding nonstop for 2 hours, complicated by hypertensive urgency with systolic blood pressures in the 180s.  He got a double lumen balloon catheter inserted into his right nasal cavity for tamponade, and several doses of IV labetalol for his blood pressure.  Ultimately, he would need to fly to Anchorage for definitive treatment by an ENT specialist.

The funny thing about coming off of night float and taking the morning flight back to Seattle is that almost inevitably you end up on the same Bethel-Anchorage flight as some of your patients!  On my flight, I spotted the woman who had the breech delivery in the village (on her way to the NICU in Anchorage to see her newborn), and a little girl who had been treated for R cheek cellulitis secondary to an odontogenic abscess (scheduled for oral surgery in Anchorage later that day).  If only the cab driver with the nosebleed had driven us all to the airport and hopped on the flight with us, it would have been a perfect trifecta.

Night of Incredibly Bad OB Mojo

My night float started off with a 24 yr old G1 P0 at 36 + 2/7 wks with her baby in footling breech position, having contractions every 5 minutes, cervix dilated to 2 cm and 60% effaced.  We gave her IM terbutaline, but 90 minutes later she had made more cervical change, so high-risk OB came in to attempt an extraversion (to turn the baby around so s/he would be in head-down position).  Which failed.  Which led to an uneventful C-section that went very well.

After completing several ER admissions (including a 32-yr-old male in diabetic ketoacidosis who was not very compliant with his daily lantus regimen and whose last known HbA1c was a whopping 15.9%; and a tiny 82-yr-old woman with dementia, visual hallucinations, and a 4-night run of insomnia, who promptly fell asleep after 1 mg of haldol) I got a phone call from the village of Emmonak.

Things you never want to hear a health aide say:
1. This woman is having contractions every 3 minutes and she says she's 38 weeks pregnant, but I think she's only 30 weeks pregnant: The patient had no prenatal care for this pregnancy and we had no reliable records of her LMP or even of a positive urine pregnancy test.  I started to activate a medevac, thinking that the on-call pediatrician & I would have to fly out to Emmonak for the delivery.  I checked her old medical chart and found out she had no history of preterm delivery, just one baby delivered at 37 weeks in 2009.
2. I think her cervix is completely open and I think I can feel the baby's nose:  This is a very bad sign that the delivery is imminent and the presenting part is not the head.  There's no way the pediatrician & I can get to the village in time.
3. She started pushing, and I think a foot is coming out of her vagina:  OMG, it's another footling breech!  The health aide had me on speaker phone as I coached him through the breech delivery.
4. The baby is out but he's not breathing: The pediatrician took over the speaker phone and started coaching the health aide & his helpers through the process of neonatal resuscitation.
5. It's been almost 50 minutes and the placenta hasn't come out yet: By this time, the baby was doing better and the pediatrician was en route to Emmonak with the flight crew.  The health aide was trying to get pitocin started, as his helpers were applying gentle traction on the umbilical cord and massaging the fundus.
6. Do you think the medevac flight is bringing blood for transfusion?:  The health aide estimated a total blood loss of one liter and the mother was still bleeding.  The placenta finally came out, and I had the health aide insert his hand in the uterus and manually extract several blood clots and a possible fragment of placenta.  I could hear the mother screaming in the background on speaker phone.  The only medication for postpartum hemorrhage in the village clinic was methergine which I was hoping not to use.  The bleeding finally trickled to a halt, and I had them run IVF at full speed, given mother's tachycardia of 120 bpm.

Meanwhile, I was paged for an OB patient who presented with intractable vomiting, coffee ground emesis and one episode of emesis containing bright red blood, after she drank an entire bottle of R&R the day before.  She had been drinking through her entire first trimester, stopped for most of her second trimester, and was now at 26 weeks.  I wrote for IV zofran alternating with PR phenergan, then a loading dose of protonix 80 mg by IV, followed by a protonix drip at 8mg/hr to stop the GI bleed.  When she complained of epigastric pain, I ordered the magic "GI cocktail" (10cc each of maalox, viscous lidocaine, and benadryl) which soothed her and put her to sleep almost immediately.

Shortly before change of shift, I got a call from the village of Napaskiak: a G3P1 at 34 + 4/7 wks (with excellent dates by 10-wk ultrasound) was having contractions every 3 minutes.  After 2 doses of IM terbutaline and a liter of normal saline, the contractions had spaced out a little and were much shorter and less intense.  The health aide tried to check the cervix for dilation: "I put my entire hand up there as far as it could go and I still didn't feel anything, " which is a good sign.  I spoke with high-risk OB and we agreed to have the pt come to Bethel by boat (just a short 30 minute ride) for further evaluation.

Then I went home and fell, exhausted, into bed.

There's Not Enough Room In This Town For You & Me & All That Pus

Skin infections appear to be running rampant on the wards this week:
-an affable 56-yr-old man who accidentally knelt on a nail while working on his fishing boat and ended up with an abscess on his R knee and extensive cellulitis from thigh to mid-shin.
-a very tired-appearing 47-yr-old woman who had incision & drainage of an abscess on her R upper back, then developed a severe allergic reaction (enormous hives and swelling which required an H1-blocker, an H2-blocker, epinephrine and prednisone) to the antibiotic she was prescribed.  Several days later, the infection evolved into a rapidly-spreading cellulitis running from her upper back to the RLQ of her abdominal wall
-a 7-yr-old child with pus seeping out of an infected occipital laceration

60% of the RMT calls this week have been about abscesses and cellulitis.  It's hard to fight skin infections in the villages when people live in rather close quarters and some houses don't have running water.  Many people are thoroughly repulsed by pus.  Call me morbid, but I find it very satisfying to open up an abscess with a #11 scalpel and release a gush of suppurative fluid...

Jackie Chan, Meet Dr Chan

"Everyone thinks I look like Jackie Chan," says my 52-yr-old patient who was admitted for dilantin toxicity.  Only he makes it infinitely more amusing by swooping into a karate chop gesture every time he says "Jackie Chan".  Which is quite frequent.

This delightful patient has a seizure disorder for which he takes dilantin and valproic acid.  He has a special mantra to remind himself how many tablets of valproic acid to take: "Five in the morning, six at night, no whiskey".  I suspect he accidentally used the valproic acid mantra with his dilantin tablets and ended up with a supratherapeutic serum dilantin level.

Our Jackie Chan lookalike also has an oddly low serum sodium level which dipped down to 123 without any apparent neurological symptoms.  I was able to get his serum sodium to climb up to 128 (still low) with a bit of intravenous 0.9% saline. With a urine sodium >40 and a slightly low serum osmolality, he probably has SIADH, which is often treated with free water restriction and oral salt tablets.  It's the antithesis of what we usually tell our patients: Drink less fluid!  Use at least a 1/2 teaspoon of salt with all your meals!  The hospital is on a "healthy eating" kick and has substituted all salt packets with Mrs Dash's Salt Substitute.  I had to rummage through 3 different staff break rooms before I finally unearthed a plastic container brimming with contraband salt packets.  After I sprinkled his scrambled egg breakfast with one of the salt packets, my patient grinned and said, "My brother looks like Mr Miyagi."

Bethel, We've Got To Stop Meeting Like This

This is my last foray to rural Alaska before I start my new job in October, and I'm still amazed by the lovely greenness of summer.  All of my familiar icy landmarks have melted away into an unrecognizably verdant landscape of tall grass and bushes.

Some of the hospital patients, however, remain a little too familiar--for instance, the 49-yr-old woman who is frequently admitted for one of two reasons: alcohol intoxication or alcohol withdrawal.  She was just discharged last week, and she bounced back onto my service yesterday.  After multiple doses of ativan and haldol administered at regular intervals, the patient woke up this morning requesting a shower.  She was in that very narrow window between intoxication and withdrawal where she was fairly lucid and cooperative.  Hold her any longer and she goes into a full-blown and very unpleasant withdrawal.  Let her go and she finds enough alcohol to keep herself adequately inebriated to avoid withdrawal.  Since she has never shown any interest in detox or any other treatment, I discharged her and kept my fingers crossed that she would stay out of trouble for at least another week or two.  She beamed at me, looking rather raccoon-ish with her bilateral periorbital contusions, and I couldn't help smiling back at her.