Monday, April 20, 2009

Bethel posting #3: Radio Medical Traffic

One unique part of a family doctor’s job out here in Bethel, Alaska is answering “Radio Medical Traffic.” Before there were phones, docs would call the different villages by radio and check-in to see if there were any sick patients. They would treat, arrange transportation, and provide medical advice by radio.

Today, much the same process occurs with the addition of some new technology. I spent one afternoon answering radio traffic from the 48 villages for which Bethel serves as the healthcare hub for. Here are some examples.

First, a fax came through from the Village Health Aide about a sick patient that they she had just evaluated. Village health aides are usually a local village person who undergoes training to use a manual to diagnose and triage conditions. They do an extraordinary job. Back to the example…A health aide from one of the village faxed her notes about a 3 year old that they just evaluated with a high fever and cough. I looked at the list of villages and called by telephone to talk to the health aide directly, asking further questions to determine how sick the child was. The child was wheezing a bit, so I looked at a list of the medications available in the village and stated that the health aide should give the child albuterol nebulizers and Tylenol. I called back shortly after to see how he was doing. He was still having some difficulty breathing and was now requiring oxygen. At that point, because he needed oxygen, I activated the medivac system to send a plane to get him immediately. A plane flew out, picked him up, and brought him back to Bethel. He was evaluated in the ER and I admitted him to the children’s unit of the hospital. He had pneumonia and was doing much better after 24 hours of IV antibiotics and breathing treatments.

The next call was about an 86 year old woman who had been coughing for the last week, with a low-grade temperature. She also had underlying lung disease. The decision was whether to treat her there in the village or to have her come in to Bethel by regular commercial flight to be further evaluated. There are daily flights between each of the villages (unless there is bad weather). Because she was completely stable, we offered her the choice. Some elders do not want to leave their village, but others are more willing to come in. She decided to come in on the next commercial flight (in 2 hours) to Bethel, where she was able to get a chest x-ray and other labs completed. She was prescribed antibiotics for pneumonia and flew back to her village the following night after her follow-up appointment at the clinic the next day. I could have given her the antibiotics over the phone if she hadn’t wanted to leave her village, but it was better to be able to get the chest x-ray and blood tests. However, ultimately, it was up to her.

Then you add weather into the picture. I found myself advising one person to be taken by snow machine to the nearest sub-regional clinic with an x-ray; then having the clinic send the image by telemedicine system (they also send photos of rashes, etc by telemedicine). They couldn’t fly out (runway was covered with blowing snow) and this way we could at least start the diagnosis process and appropriate treatment.

Finally, I attended a birth by telephone. The woman had gone into labor in the village. Usually all pregnant women come into Bethel 3-4 weeks before their due date, have the baby in Bethel, then return to their village. However, this woman hadn’t come in and presented to the village health aide in active labor. It wouldn’t have been safe to have her deliver in the airplane on the way to Bethel. Instead, we coached the health aide about the steps on delivering a baby, all while listening over the speaker phone to the entire process. The delivery went well and the mom and new baby flew to Bethel a few hours later to be evaluated.

I’ve found that Radio Medical Traffic is quite tricky; it’s like running an ER for 48 villages over the telephone! There is an art to deciding who is really sick and whether or not they need to fly in from their village; then deciding whether that flight can be a regular commercial flight or a medivac flight. It’s a part of the job that I hadn’t anticipated, but that I’ve really enjoyed.

Sunday, April 12, 2009

Bethel, posting #2

I finally was able to post some pictures. The first is Bethel from the Life Flight plane. The second is a Life Flight trip out to Kasigluk.

It’s Easter today, sunny outside but cold, and I’m stuck inside with the “Bethel crud,” a cold I must have picked up on the airplane here or on one of my ER shifts. My experience here has been a continuation of “collecting unique experiences.”

Yesterday, in the middle of my ER shift, I went on another Life Flight out to Kasigluk, a village of 600 people located 25 miles west of Bethel. Most of the villages in the YK Delta are along the Yukon or Kuskokwim Rivers, stretching from inland all the way to the Bering Sea. However, there are three villages known as the “tundra villages,” and Kasigluk is one of those, located on the smaller Johnson River. We landed in blustery winds on an airstrip of solid ice. The snow machines with sleds behind them were out to meet us and we climbed on board. Off we went to the clinic, cold tundra winds biting at our faces. In the entrance room of the clinic we were greeted by over ten people, all family of our patient, a 96 year old Yupik elder who had fallen. She spoke only Yupik, which made the explanation of why we needed to take her from her village (where she had lived her entire life) to go to Bethel where we could get images of her hip and make sure it wasn’t broken. She was a pleasantly demented elder, making fun of my “inadequate boots” and my silly “jump suit” and smiling grandly at everyone. However, when it came time to load her up onto the sled and plane, she became agitated. Luckily, we were able to take along two of her relatives, who calmed her in her Yupik tongue. One hour later we were looking at the x-rays of her hip in the Bethel ER and trying to decide what to do with this elder with a broken hip who simply wanted to go back to her village.

Day to day work in the ER is also interesting and I get to do many procedures, from draining boils to suturing cuts, from resetting broken bones to splinting and casting. Yesterday, a teen came in two days after sustaining a cut on his hand, which he stated was from falling on the gravel. He felt as if something was still imbedded in the wound. I opened it and explored it…and found a TOOTH! He sheepishly admitted that it wasn’t a fall, but rather a fight.

There seems to be two main seasons here, marked by “freeze-up” in October (when the rivers freeze and winter is here) and “break-up” in May (when the ice in the river breaks up and winter is over). I hope to be here for break-up. There is a large tripod set up on the ice of the Kuskokwim River for the “Ice Classic,” a competition to see who can guess the exact date and time that the tripod moves 100 feet down the river, signifying break-up. Break-up is also marked by the return of geese and white swans to the area. Snow keeps falling, which makes me wonder when it will get warm enough to cause break-up. However, a lady informed me that the elders state that the snow is light and fluffy, the kind to quickly melt, and that break-up is going to come suddenly and unheralded this year.

Bethel has two radio stations, a Christian radio station and their public radio station KYUK, which is a bilingual (Yupik/English) station. Also, of interest, 1975 saw the first telephone in Bethel. In the last month since I’ve been here, Bethel has seen their first cell phones.

That’s all from this kass’aq (white person) living out here with the Yupik (“real people”) on the YK Delta. I can't believe I've been here a week already.

Wednesday, April 8, 2009

Jen in Bethel, Alaska

In my first three days here, I’ve driven on a lake, had water delivered to my home in order to shower, and have flown in a small plane to a tiny village on the Bering Sea to pick up a patient. Already, this has been an adventure. (Sorry, no pictures yet, as it is too slow to download from here).

I’m in Bethel, Alaska for my six week rural medicine rotation. This is not just rural medicine – it is FRONTIER medicine. Bethel is a town of 6,000 people situated on the Yukon-Kuskokwim Delta (YK Delta) in southwest Alaska. It is only accessible by airplane.

My adventure started when I left Anchorage on the one-hour commercial flight out to Bethel, flying a little too close for comfort to the ACTIVE volcano, Mount Redoubt, that was puffing away. From the air, I could see the ash-colored snow below.

We landed in Bethel and I walked into the “airport” (a one-room building) where the signs are in both English and Yupik Eskimo. I was picked up and dropped off at my home for the next 6 weeks, a condo with my truck plugged in out front (so it starts; it’s not quite spring here yet). The water is delivered by truck every week, the sewage is pumped out of the holding tank every week, and the oil for heating delivered when we get close to running out. I also share a phone number with the neighbor in the condo next door, which is slightly comical as we knock on each other’s homes if the phone is for them! I unpacked my 4 LARGE boxes (50 pounds each) that I had jam-packed with food (it is REALLY expensive here) and my collection of many sized clothes (I’m going to be getting a bit bigger in these next 6 weeks, as I go from 22 weeks pregnant to 28 weeks pregnant).

I realized that my truck, an official hospital truck that “beeps” as I back up, was almost empty and went in search of the gas station. Luckily my neighbor (who is from France?!) offered to come along and show me to the gas station. After filling up with gas ($6/gallon), he gave me an impromptu tour of Bethel. There’s a combination of cement and dirt roads, houses on stilts (to avoid the melt/flood), two grocery stores, and six restaurants. Also, oddly enough, there are more taxi cabs here per capita than in New York City!!! It’s a $7 flat rate anywhere you want to go and, often, there are others sharing the cab with you. We drove around town. As I turned onto one “road,” he stated, “Go faster here; it’s a little soft when you first drive onto the lake.” Hmmm…so I was driving on a LAKE! The roads here tend to include rivers and lakes until May, when “break-up” happens.

My first day of work was in the ER, seeing many people from villages that I could not pronounce (though I definitely am trying!). Also, English is most people’s second language out here. The main culture is Yupik Eskimo (there is also a small number of Cupik Eskimos and Athabaskans). The people are quiet; I have to remind myself not to jump into "dead space" in conversations in order for them to talk. It’s difficult for me to leave silences in conversations, but I'm working on it. The people are also very friendly and genuine. When I was one dollar short on my cafeteria lunch, the lady smiled, took a dollar off the price, and said, “Welcome to Bethel. We help each other out here.”

My next day of work was an ADVENTURE! About half way through the day, there was a call from Hooper Bay about a woman who was having seizures. The ambulances here are airplanes, so a Medi-Vac plane was needed to pick her up.

Let me back up briefly and describe the health care system out here on the YK Delta. The Delta is the size of the state of Oregon (about 75,000 square miles). Bethel is the main hub, but it serves 58 tribes in 48 surrounding villages – a total of 27,500 people. The people are 90% Native Alaskan, mostly Yupik Eskimos. They are some of the poorest people financially, but are the richest land in terms of land and subsistence (fish, birds, game, berries, roots, etc). Only about 1/3 of the villages have running water. There is a hospital in Bethel (where I’m working). However, in each of the villages there are locally-trained Health Aides. If they have a really sick patient, they call Bethel. Bethel sends out an airplane to pick up the person (unless the weather is too bad). If the person cannot be cared for in Bethel, they get sent on to Anchorage or the Lower 48 (such as Seattle, Washington). Now that we have a CT scanner in Bethel, fewer people need to be sent to Anchorage for imaging. Additionally, all pregnant women in the villages leave their village and come to Bethel 30 days before they are due. They have their babies here and then are flown back to the village. It’s an amazing system of providing health care and employs over 1,500 people to do this.

So…back to the seizing woman in Hooper Bay… we took off in a Cessna Caravan. It was the pilot, two health care workers (EMS), and myself. We had room for two patients and one other person. We flew the hour-long flight to Hooper Bay (I was in the front with the pilot), flying over very FLAT land. There are no mountains out here! Every now and then we’d fly over a village, a group of homes in the middle of this flat expanse of land. When we landed in Hooper Bay, I noticed that we were quite a ways from the village itself. Locals on snow machines with sleds behind them had lined up to meet us as we exited the plane. We stashed our medical supplies in the sleds and hopped on, riding across the snowy frozen tundra with wind and snow lashing us in the face on our way to the clinic! We arrived at the small clinic, unloaded, then immediately went to work on the patient. We loaded her up in one of the sleds, then off we went again on snow machines, back to the airplane. An hour later we landed back in Bethel, loaded her into the ambulance, then brought her to the hospital. Total time from the initial call was about 3-4 hours. She did well. The entire experience was very rural Alaskan and I kept thinking to myself in disbelief, “How did I end up here?!”