Thanks to freezing rain and the prospect of an ice storm, flight 42 to Anchorage has been canceled, so I am stranded in Bethel until tomorrow. To add insult to injury, I've developed a minor case of impetigo, a Staph infection most commonly seen in small children and wrestlers; luckily, I am paranoid enough to have brought Bactroban with me so I can slather my right philtrum with its strong antibacterial formula TID.
Thankfully, I also have the tendency to bring too much food with me on these excursions to rural southwest Alaska. This time, I cooked and froze lentil soup, chicken casserole, and runza (a Nebraskan treat made of ground beef, cabbage and onions with allspice & coriander, enveloped in a delicious homemade dough). The food gets transported efficiently in my checked baggage, and is usually still frozen by the time I land in Bethel, because the cargo hold on the plane is very chilly. I must confess I did eat runza for breakfast this morning (Beef! The breakfast of champions!). For the rest of the day, I will most likely imbibe hot tea, munch on popcorn, and watch 1000 consecutive episodes of "The West Wing" on DVD. Any television show or movie about medicine, hospitals or Alaska (or about practicing medicine in hospitals in Alaska) is strictly off-limits.
Tuesday, November 13, 2012
Monday, November 12, 2012
Where Are My Jelly Candies???!
Yes, this is what I've been reduced to: after 9 exhausting days on the inpatient wards and the possibility that my flight out of Bethel tomorrow may be cancelled due to freezing rain, all I can do is turn my room inside out in a herculean effort to locate the tiny prized bag of berry-shaped jelly candies with vitamin C that I got from the hospital vending machine in a feat of fortuitous timing. The vending machine can remain in a sad state of neglect and near-emptiness for quite a while before it gets re-stocked with snacks, and I was lucky enough to venture by just after a new supply was deployed. Combine that with my fear of scurvy, and you can see why I am so preoccupied...
My patient with endometritis & postpartum hemorrhage was discharged home today, freshly showered, hair in pigtails, looking much happier. Her first night here was a frightening one that involved being transferred from the floor to the ED (which functions as a pseudo ICU for patients who are too sick for the wards and are awaiting transport to a higher level of care in Anchorage), massive blood transfusion (5 units of pRBCs) and fluid resuscitation (5 liters of NS!). After a few days on a triple cocktail of clindamycin, gentamicin and ampicillin, she looks fantastic and no longer needs antibiotics.
Mr Lice Infestation left AMA this morning, but was willing to carry home several large bottles of permethrin for his wife and adult son to slather themselves in.
My 63-yr-old patient who was admitted for seizures after a 3-day drinking binge in which she completely abandoned her daily dose of keppra has finally started eating and looking a little more lucid. She was getting wheeled down the hallway as I left, and she gave me a perfect Queen Elizabeth coronation wave of her right hand, nodded her head, and gravely shook my hand, telling me "Quyana" which is Yup'ik for thank you.
My patient with endometritis & postpartum hemorrhage was discharged home today, freshly showered, hair in pigtails, looking much happier. Her first night here was a frightening one that involved being transferred from the floor to the ED (which functions as a pseudo ICU for patients who are too sick for the wards and are awaiting transport to a higher level of care in Anchorage), massive blood transfusion (5 units of pRBCs) and fluid resuscitation (5 liters of NS!). After a few days on a triple cocktail of clindamycin, gentamicin and ampicillin, she looks fantastic and no longer needs antibiotics.
Mr Lice Infestation left AMA this morning, but was willing to carry home several large bottles of permethrin for his wife and adult son to slather themselves in.
My 63-yr-old patient who was admitted for seizures after a 3-day drinking binge in which she completely abandoned her daily dose of keppra has finally started eating and looking a little more lucid. She was getting wheeled down the hallway as I left, and she gave me a perfect Queen Elizabeth coronation wave of her right hand, nodded her head, and gravely shook my hand, telling me "Quyana" which is Yup'ik for thank you.
Friday, November 09, 2012
Mucomyst for Dummies
Now we've got a strange combination of rain from the sky with stubbornly persistent slush and ice on the ground, and all flights have been cancelled. Medevac has been on hold for most of the day, so the RMT calls have been out of control. There are patients in the villages with broken ankles and dislocated shoulders who can't book a flight out because of the weather, and we can't activate a medevac for a non life-threatening condition. Some of the smaller clinics are running low on morphine and tylenol #3 for the patients with painful injuries who can't get to Bethel.
To top it off, I get 12 calls from a health aide about a 17-yr-old girl who was drinking last night and suspects she may have been sexually assaulted but can't recall the exact details. She started feeling depressed, so she decided to overdose on tylenol. She tells the health aide that she took 10 of the 325 mg tablets; when I briefly consult with the ER doc, he says there is no way to confirm whether the girl took 10 tablets or 100 tablets since depressed adolescents are notoriously unreliable historians, so she needs to take the oral mucomyst that is standard issue at all the village clinics, given the astoundingly high rate of suicide attempts here by tylenol overdose. The health aide tells me she can't find the mucomyst. I ask her if maybe someone else knows where it is. She calls me back to say no one can find any mucomyst anywhere. I ask her to check with Emmonak which is the nearest village. She calls me back to say that Emmonak has no mucomyst. After conferring with the ER doc again, we decide the girl needs to come in because excess tylenol could seriously fry her liver, so I activate the medevac. The health aide calls 10 minutes later to say actually Emmonak does have mucomyst and they will send it over. I call medevac and apologize profusely for wasting their time.
Meanwhile, between checking on my 82-yr-old patient admitted for an egregiously out-of-control lice infestation (I feel mildly pruritic just thinking about it) and chatting with a floridly psychotic 31-yr-old male on a psychiatric hold who wants to know if my pager is a recording device and whether I believe in human clones, I have sketched out a frighteningly detailed flow chart for the health aide who is waiting for the mucomyst to arrive because she seems a little...confused. Mucomyst for Dummies, based on the 17-yr-old girl's weight in kilograms, tracing out various dosing schemes depending on whether Emmonak sends the 10% or the 20% solution. Apparently mucomyst has an extraordinarily unpalatable flavor, so it needs to be mixed 1:3 with a deliciously cold beverage like orange juice or soda. Otherwise, no one would want to drink it. Frankly, I think their marketing department should consider changing the name of the product to something that sounds more...appetizing.
To top it off, I get 12 calls from a health aide about a 17-yr-old girl who was drinking last night and suspects she may have been sexually assaulted but can't recall the exact details. She started feeling depressed, so she decided to overdose on tylenol. She tells the health aide that she took 10 of the 325 mg tablets; when I briefly consult with the ER doc, he says there is no way to confirm whether the girl took 10 tablets or 100 tablets since depressed adolescents are notoriously unreliable historians, so she needs to take the oral mucomyst that is standard issue at all the village clinics, given the astoundingly high rate of suicide attempts here by tylenol overdose. The health aide tells me she can't find the mucomyst. I ask her if maybe someone else knows where it is. She calls me back to say no one can find any mucomyst anywhere. I ask her to check with Emmonak which is the nearest village. She calls me back to say that Emmonak has no mucomyst. After conferring with the ER doc again, we decide the girl needs to come in because excess tylenol could seriously fry her liver, so I activate the medevac. The health aide calls 10 minutes later to say actually Emmonak does have mucomyst and they will send it over. I call medevac and apologize profusely for wasting their time.
Meanwhile, between checking on my 82-yr-old patient admitted for an egregiously out-of-control lice infestation (I feel mildly pruritic just thinking about it) and chatting with a floridly psychotic 31-yr-old male on a psychiatric hold who wants to know if my pager is a recording device and whether I believe in human clones, I have sketched out a frighteningly detailed flow chart for the health aide who is waiting for the mucomyst to arrive because she seems a little...confused. Mucomyst for Dummies, based on the 17-yr-old girl's weight in kilograms, tracing out various dosing schemes depending on whether Emmonak sends the 10% or the 20% solution. Apparently mucomyst has an extraordinarily unpalatable flavor, so it needs to be mixed 1:3 with a deliciously cold beverage like orange juice or soda. Otherwise, no one would want to drink it. Frankly, I think their marketing department should consider changing the name of the product to something that sounds more...appetizing.
Thursday, November 08, 2012
Flakes of Snow
The inpatient wing recently got a makeover with mesmerizingly gorgeous simulated wood laminate flooring that makes it look like a spa. Very soothing to look at in the midst of complete chaos. Upon arrival to the hospital this morning, I was given a heads up from the night float about a patient arriving via medevac who had given birth to a stillborn infant at 29 + 5/7 wks EGA, had retained placenta for more than 3 hours, and was being transfused in transit with 2 units of blood for postpartum hemorrhage. By the time the patient arrived, I had already discharged 4 patients and admitted 2 new ones. She was strapped to a gurney, very quiet, with part of a placenta (clamped umbilical cord still attached) protruding slightly from her vagina, actively bleeding. The paramedics had given her almost 5L of IVF and her SBP was only in the high 80s to low 90s.
After drawing blood for CBC, type & cross, and bile acids (cholestasis of pregnancy is a common cause of fetal demise here), the OB nurses started infusing 20 units of pitocin. The placenta was manually extracted, and I did a quick repair of the patient's 1st degree vaginal laceration. Only after all the procedures were completed did the patient burst into tears. Admit her to OB or to the inpatient unit? The OB nurses were skilled with postpartum care, but it seemed insensitive to keep the patient where there were so many mothers with healthy newborns. The nurses pulled me into the supply area to assess the stillborn infant. He weighed just over 4 lbs and appeared to be at least 34 weeks old. They debated whether it would be all right to clean him up so the mother could have photographs taken; a quick call to the Medical Examiner (autopsy is mandatory in fetal demise beyond 20 weeks) confirmed that the stillborn infant had to be left in his current condition without any alteration.
The patient was transferred to the adult inpatient unit, doing well until she suddenly developed chills and tachycardia 20 minutes before the end of my shift. Minimal vaginal bleeding since the manual extraction of the placenta, no significant uterine tenderness, no dysuria or foul vaginal discharge. Pt's temperature skyrocketed from 97.6 to 101.8 within a matter of minutes. I got blood cultures, started clindamycin and gentamicin for presumed endometritis, and kept my fingers crossed.
Walking home, I noticed gentle flakes of snow falling from the sky and landing softly on the ground.
After drawing blood for CBC, type & cross, and bile acids (cholestasis of pregnancy is a common cause of fetal demise here), the OB nurses started infusing 20 units of pitocin. The placenta was manually extracted, and I did a quick repair of the patient's 1st degree vaginal laceration. Only after all the procedures were completed did the patient burst into tears. Admit her to OB or to the inpatient unit? The OB nurses were skilled with postpartum care, but it seemed insensitive to keep the patient where there were so many mothers with healthy newborns. The nurses pulled me into the supply area to assess the stillborn infant. He weighed just over 4 lbs and appeared to be at least 34 weeks old. They debated whether it would be all right to clean him up so the mother could have photographs taken; a quick call to the Medical Examiner (autopsy is mandatory in fetal demise beyond 20 weeks) confirmed that the stillborn infant had to be left in his current condition without any alteration.
The patient was transferred to the adult inpatient unit, doing well until she suddenly developed chills and tachycardia 20 minutes before the end of my shift. Minimal vaginal bleeding since the manual extraction of the placenta, no significant uterine tenderness, no dysuria or foul vaginal discharge. Pt's temperature skyrocketed from 97.6 to 101.8 within a matter of minutes. I got blood cultures, started clindamycin and gentamicin for presumed endometritis, and kept my fingers crossed.
Walking home, I noticed gentle flakes of snow falling from the sky and landing softly on the ground.
Wednesday, November 07, 2012
Dust Bowl of the North
Against my better judgement (what sane person would want to willingly trek northward to subzero temperatures?), I'm back in Bethel for another round of pummeling on the inpatient wards. There's something very endearing about the staff and the native Alaskan patients...or maybe I'm overconfident and delusional because I have a pair of ice cleats and a goosedown Goretex parka rated to -40 degrees, neither of which are needed at this moment because of the odd weather situation: daytime temperatures in the teens (but mildly subzero with the wind chill factor) and not a speck of snow on the ground.
The roads are hazardous to pedestrians when the climate is dry and windy; sidewalks are rare, and with every car that passes by, a giant cloud of dust swirls up to assault your eyes, nose and mouth. Luckily, I just had my annual respiratory fit test and my teal blue N95 respiratory mask matches my REI windbreaker. Making my twice daily trek between the residence and the hospital armed with the N95 mask and my headlamp, I look like a crazed (but stylish?) coal miner who is afraid of SARS.
Speaking of N95, I seem to be accumulating quite a few patients who require isolation rooms for a TB rule out. They're all awaiting results of sputum cultures for acid-fast bacilli. One patient was admitted for hip pain after being hit by a van and had a RLL cavitary lesion found incidentally on CT. Another was admitted for pneumonia with slightly blood-tinged sputum and mentioned being in contact with someone with active TB a few months ago. The third patient told the nurse she coughed up blood, then later back-pedaled and said the blood came from her nose. Too late, you win an instant PPD placement and a couple of days in isolation, booyah!
The roads are hazardous to pedestrians when the climate is dry and windy; sidewalks are rare, and with every car that passes by, a giant cloud of dust swirls up to assault your eyes, nose and mouth. Luckily, I just had my annual respiratory fit test and my teal blue N95 respiratory mask matches my REI windbreaker. Making my twice daily trek between the residence and the hospital armed with the N95 mask and my headlamp, I look like a crazed (but stylish?) coal miner who is afraid of SARS.
Speaking of N95, I seem to be accumulating quite a few patients who require isolation rooms for a TB rule out. They're all awaiting results of sputum cultures for acid-fast bacilli. One patient was admitted for hip pain after being hit by a van and had a RLL cavitary lesion found incidentally on CT. Another was admitted for pneumonia with slightly blood-tinged sputum and mentioned being in contact with someone with active TB a few months ago. The third patient told the nurse she coughed up blood, then later back-pedaled and said the blood came from her nose. Too late, you win an instant PPD placement and a couple of days in isolation, booyah!
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