Tuesday, May 16, 2006

Radio Medical Traffic

One of the more unusual aspects of practicing medicine in bush Alaska is Radio Medical Traffic, or RMT. It is integral to the concept of health care delivery via community health aides. When a patient comes into a village clinic to be seen by a health aide, there is a prescribed order to how things happen. The health aide takes vital signs and records the chief complaint on the Patient Encounter Form. She (80% of health aides are female) then consults the bible of her practice, the Community Health Aide Manual, or CHAM. The CHAM is a large, three-volume reference and cookbook of medicine, organized by presenting problem. It is extremely detailed and thorough. She fills out the encounter form with history of present illness, past health history, medications, allergies, other history (including tobacco use, immunizations, LMP/pregnancy history), physical exam, assessment, plan, medications given in clinic, medications for home, special/other care, and recheck/follow-up. Very thorough, and all by the book.

Depending on the health aide’s level of training, the encounter form may stop at assessment; more advanced and experienced health aides will include what they think the plan should be. In some well-defined instances, the higher level health aides have standing orders that they may implement. A positive rapid strep test, for instance, may be treated on the spot with an LA Bicillin injection if the patient has no penicillin allergy and no other problem.

Most of the time, however, the health aide stops at assessment, tells the patient she must confer with a hospital provider and will get back to the patient later in the day with a plan. She then faxes her encounter form to the hospital and waits to be called back. The faxed encounter forms are collectively known as RMT, from the days not so long ago when medical traffic was actually done on VHF radio.

It is the responsibility of each provider to do the traffic with their assigned villages. Faxes come in throughout the day and are placed on the provider’s clipboard in clinic. As time allows throughout the day, we call our villages and talk with the health aides about the patients they have seen, going over the encounter form, asking additional questions, sometimes requesting additional tests. Often there is a good opportunity for one-on-one teaching with the health aide. The provider’s assessment is recorded on the encounter form next to the health aide’s assessment, and a plan for the patient is agreed upon.

Each village clinic has a limited pharmacy supplied by the hospital from which the health aide can dispense medications on the order of the provider. Antibiotics available in the village are amoxicillin, penicillin, trimethoprim-sulfamethoxazole (single strength only), doxycyline, erythromycin, cephalexin, and ceftriaxone. The health aides are trained to mix suspensions as needed.

The patient returns to the clinic later in the day to pick up the medications and read (or have read to them) the CHAM’s “Education for patients” pages according to the provider’s assessment.

The whole system works pretty smoothly as long as the patient is not of high acuity and the provider is not overwhelmingly slammed in the hospital. (For urgent cases, the health aide does not have to wait for a call back; she can have the hospital operator page the physician covering the inpatient unit, or the ER physician on nights and weekends.) But on any given day, there are always “orphan” villages, those whose assigned provider is out of the hospital; and those whose provider is so slammed in clinic that he or she is not able to do RMT. So each afternoon, two providers are assigned to do nothing but RMT, calling their own villages and all the orphans.

When the traffic is not too heavy, this is a really fun assignment. You get to talk with health aides in lots of different villages, find out what the weather is doing all over the region, how the hunting or fishing is going for the different villages, how the health aides themselves are doing. You can come to know health aides fairly well that you’ve never met.

On a slow afternoon, I’ll have a stack of less than 50 patient encounter forms on which I have written my assessment and the plan I agree upon with the health aide who saw that patient. My copy then goes to medical records for inclusion in the patient’s hospital chart. The health aide’s copy goes into the patient’s village chart. On a killer afternoon, that stack will have more than 80 encounter forms; my personal record is 116. At that rate there is no time for chit-chat or amenities. We depend strongly on the health aide’s ability to know which patients are truly sick, and which ones simply don’t feel well. They are very good at that. And quite forthright about saying “I really want this patient to go in to the hospital for further evaluation.” When that is the case, the patient comes in, either by scheduled flight, charter, or medevac.

RMT is an essential part of how we provide care in the far-flung corners of this giant region. We couldn’t do it without the amazing health aides, who are truly “the eyes and hands of the doctor”. They do an incredible job.



Anonymous Dawn said...

You write the most amazing things. You make me want to come out and see and experience all of your life there. Thanks for sharing the beauty of your life.

Wednesday, May 17, 2006 3:47:00 PM  
Anonymous mchebert said...

I am currently engaged in a "discussion" with my hospital about the speed of my response when I was on call. I saw the patient 30 minutes after I was first called.

Those people don't know when they have it good. I am amazed at how people, when access to goods and services is difficult, figure out a way to get the most out of what they have.

Monday, May 22, 2006 7:02:00 PM  
Blogger TheTundraPA said...

Dawn--it is life here that is amazing, and has inspired me to write again. I'm so happy about that!

Dr. H--wow, a 30-minute response time is lightening fast! What's to discuss? If your administrators aren't happy with that, they're crazy. I feel lucky when I can get a patient seen by a specialist in the same week.

Thursday, May 25, 2006 10:14:00 AM  
Blogger TheTundraPA said...

This comment has been removed by a blog administrator.

Thursday, May 25, 2006 10:15:00 AM  
Anonymous neopa said...

I started reading in Nov. first and now have gone back to the beginning and reading forward. I wanted to ask what happened when there was an emergent case at your hospital that needed something or someone emergently that you didn't have access to there and then what if that happens in a village??
Also, I am a PA who works in an NICU. I was wondering what happens there with high risk deliveries, preterm babies, etc???

Thursday, November 09, 2006 6:14:00 AM  
Blogger TheTundraPA said...

NeoPA--wow, you've really gone back to the beginning! Thanks for such dedication. The answer to your first question is medevac, medevac, medevac. From any village to Bethel, and from Bethel to Anchorage. Occasionally from Anchorage to Seattle, but that is rare.

The answer to your second question is more "it depends." Many high-risk pregnancies are planned for delivering in Anchorage. We have no ICU whatever, not for babies or adults. We do emergent C-sections and distressed infants are medevac'd to Anchorage. Overall, we do as much as we safely can here, and that is often quite a lot, considering our remoteness. But our backup is always to get the patient(s) out.

Thursday, November 09, 2006 7:51:00 AM  
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