TB Or Not TB

A 15-yr-old girl came to the ED after 9 days of fever, night sweats, and productive cough that did not improve with antibiotics.  She had been very healthy with no significant illnesses, so we were all shocked to see her CXR which revealed an astounding plethora of tiny pulmonary nodules.  A chest CT also showed multiple tiny pulmonary nodules, along with a 1 cm cavitary lesion, which the pulmonologist in Anchorage agreed was highly suspicious for miliary tuberculosis which is disseminated hematogenously.  Other conditions on the differential diagnosis included collagen vascular disease and neoplasm.  Per protocol, I alerted the authorities (in this case, Alaska State Public Health and the office of Infection Control at the hospital) and started our patient on the potent 4-drug tuberculosis regimen.  Two days later, her PPD was looking extremely positive, with a raised erythematous induration of 25 mm.

Medevac Wars

The other doc on wards with me got a call about a 50-yr-old male with bright red hematemesis and a rapidly falling hematocrit in one of the northwestern villages, so he activated the medevac to pick up the patient and bring him to the hospital.  Fifteen minutes later, he got a call from one of the northeastern villages about a 61-yr-old male on antiepileptic medication who had been in status epilepticus for 20 minutes.  The health aide did not have any ativan or diazepam in the clinic.  My colleague had to activate the medevac again--but there was only one plane, and the two villages were quite far from each other.  He & the ED doc conferred about which patient should be picked up first.  They decided the man with the GI bleed was more critical, and as they directed the medevac to head northwest first, I called some of the northeastern villages to ask if they had any ativan or diazepam that someone could transport by snow machine to the patient having nonstop seizures.  An hour later, the patient did get some diazepam delivered from a nearby village, and he was going to be next in line for the medevac, but then another call came in about a 5-yr-old girl with no known seizure disorder also in status epilepticus.  The decision was made to medevac the girl first--it turns out she had a serum sodium of 110 (!) and marked neurologic abnormalities, and she ended up being transferred to Anchorage.

If Work Doesn't Kill Me, This Virus Might

It's -24 degrees (closer to -40 degrees with the wind chill factor) and my lungs are very unhappy.  The walk between the hospital and my current habitat is getting more painful as frost develops on my eyelashes, and my face literally hurts from being pummeled by the gelid winter wind.  Bottom line: I have a huge stockpile of cab vouchers and I'm not afraid to use them!

I definitely have some kind of viral respiratory infection which makes my crazy work day feel a bit surreal. You! I mutter to my airways.  Don't you dare succumb to a bacterial infiltration!  One of the nurses very kindly offers me a highly prized (and much appreciated) chocolate truffle from Dilettante which I eat immediately, along with zinc gluconate lozenges and a ridiculously high dose of vitamin C.  I make several calls to the hospital in Anchorage and to the medevac team about an 85-yr-old man with severe dementia and a slow GI bleed who needs to be transferred to a higher level of care.  I am glad that I document everything so well in my notes, because I can't remember a single thing I said to either Anchorage or Lifemed.  One of the ED docs hijacks my patient's medevac flight for a police officer who accidently shot himself in the leg with his service revolver and shattered his own femur.

Now I'm discharging 5 patients in rapid succession (including the 400-lb woman with a COPD exacerbation who keeps making up reasons to ask for ativan and morphine but still manages to be quite endearing).  But wait!  Is the 4-yr-old with RLL pneumonia really ready to fly home?  Why has his WBC increased to 22?  Can I blame it on the prednisolone?  Five minutes later, his CRP comes back as 10.39, which is much improved from the initial value of 23--hooray!  I have managed to complete all the discharge summary dictations, pushing through my viral haze with herculean effort.  But I immediately get hit with 2 direct admissions: a elderly man with pneumonia from Kusko Clinic, and a 42-yr-old male with a bad case of LLE cellulitis extending to his groin from Delta Clinic.  Then there are multiple garbled RMT calls from the health aide in Kipnuk: something about a possible suicide in the village...there's a pool of blood on the floor of someone's home...but the health aide isn't allowed inside the house because the state troopers are investigating the scene.  It took an accumulated 30 minutes of phone calls to garner those juicy bits of information.

Now I'm swabbing the posterior fornix of a 20-yr-old primip at 31 weeks with preterm contractions in order to get a fetal fibronectin test.  Don't touch your vagina, I told her 24 hours ago.  Don't put anything inside your vagina, including your boyfriend's penis.  Her ultrasound yesterday revealed a closed cervix measuring 2.7 cm which was mildly reassuring, but we couldn't get the FFN at the time because she was a couple of hours post-coitus.

Three hours later, an alternate medevac arrives to transfer my GI bleed patient to Anchorage and I am greatly relieved, because his hematocrit has dropped 10 points in 2 days and he can't get an EGD or colonoscopy at our tiny hospital due to his multiple comorbities.  Where is the fried dough that the inpatient clerk gave me, I wonder.  Did I eat it in my feverish delirium without realizing it?  Probably.

My Nemesis Dr Tran

There is locums hospitalist named Dr Tran whose visits to Bethel often precede mine by one week or less.  This causes a great deal of confusion, as many village health aides and hospital staff that I speak with on the phone will address me as "Dr Tran" even after repeated corrections.  Although I have only met Dr Tran once (for about 5 minutes in March 2011), one of the OB nurses often asks me, "How is your little friend?" [referring slyly to Dr Tran].  It's mildly amusing, but I would be lying if I deny that some tiny evil part of me is occasionally tempted to wreak havoc and embark on a minor crime spree under the guise of being Dr Tran.  But only while I'm in Bethel, of course.

You Know You've Been Thoroughly Bethel-ized When...

...you're excited to purchase your very first pair of ice cleats!  Which, it turns out, I didn't really need because we're in the middle of a blizzard and snow drifts are blowing everywhere.  I was completely blinded by the flurries furiously pounding my face and couldn't find the trail leading from the boardwalk to the hospital this morning; consequently, I found myself frequently stepping into knee-deep snow (2 thumbs up for my excellent ski pants, by the way, which marvelously kept snow out of my insulated boots!).  All flights were canceled today--yes, even the 737 planes that fly between Bethel and Anchorage!  Fortunately, the medevac is still running, and when I left the hospital tonight, they were duking it out over which kid in respiratory distress to pick up first (Emmonak vs Mekoryuk: discuss).

I was hoping to sample some elk stew or a reindeer burger during this week on the wards, but, alas the cafeteria has been serving mainly fried chicken, pork tenderloin, and tacos.  My favorite patients are two frail elderly ladies (one who wears her hair in pigtails), both with hyponatremia and sharing the same hospital room.  I finally got their serum sodium levels back to normal (one with a slow infusion of normal saline, the other with free water restriction) but now the one in pigtails is persistently dizzy, so I started her on a baby dose of meclizine.  In other news, the hospital is still using paper charts, but there are intriguing rumors of an EMR launch scheduled for January 2013...

Mormon Fisticuffs and Other Sources of Excitement

New Year's eve was a wildly eventful day in clinic.  From a 36-yr-old woman with probable pneumonia who was tachypneic and only satting 65% on room air but didn't want us to call an ambulance to transport her to the ED... to a tall 24-yr-old man with excellent cheekbones and a tiny laceration on his face requesting "just one stitch" and lamenting that the scar would ruin his not-yet-launched "modeling career"... to the most fresh-faced wholesome-looking 19-yr-old blond teenager in a dress shirt and pressed trousers sporting a swollen black eye and a scalp abrasion after getting in a fist fight with another church member at a Mormon holiday event...

We thought all the excitement was over after we finally finished treating the last patient about an hour after clinic was officially closed...but when I arrived back at work on New Year's day, there was a huge gaping hole in the northwestern corner of the clinic building, cordoned off with caution tape.  Turns out  a very inebriated driver from the nearby air force base collided into the clinic late at night, completely totaling his car...then he got up and walked over to Taco Bell (where he was arrested) because he suddenly felt extremely hungry.