Sunday, September 10, 2006

Boils 101, A Workshop for Health Aides

Community Health Aides are the backbone of the health care delivery system in rural Alaska. They are Alaska Natives who live in the villages and have, at most, a high school education. The majority are women between the ages of 18 and 40; most are the sole monetary breadwinners for their families (husbands are doing the hunting and fishing of subsistence lifestyle), and many have five or more children of their own at home. Employment as a health aide provides them with an income that gives them significant social status in their villages where generally few jobs are available; but that position brings with it huge responsibility for the health and well-being of their families, friends and neighbors. It is a difficult job to do, and a highly stressful one.

The majority of training for Community Health Aides occurs at the hospital in Bethel. Each of the five levels of certification for health aides requires a two- to three-week training session in Bethel. Each training session will be attended by eight to twelve health aides, all at the same level, who wish to advance to the next level. About half of their time in each session will be in the classroom, and the other half will be spent working one-on-one with a Basic Training Instructor, a PA or an NP, seeing patients in the hospital. Invariably, the health aides prefer the hospital portion of their training. They learn by watching and doing far more proficiently than by lectures and reading. This is universally true in cultures that are based on an oral tradition, as Yupik Eskimo culture is.

One of the highlights of the year for the Community Health Aide Program (CHAP) is the annual health aide training conference held each August in the Yukon River village of St. Mary’s, Alaska. Health aides generally love to attend. The week-long conference is able to host fifty to sixty attendees, so about one third of the 158 health aides in our region are allowed (and have transportation paid) to make the trip, and any one health aide is able to attend about every three years.

The health aide conference is held at the old Catholic boarding school in St. Mary’s, which is no longer in operation as a school. No other village has a facility capable of hosting such a large group for a week; in a village of 500 people, 70 visitors (attendees plus staff) is a huge influx. The school’s dormitory provides reasonably comfortable housing, and the cafeteria is adequate to feed such a large group.

Various members of the hospital’s medical staff fly up to St. Mary’s for a day or two and teach hour-long sessions on different subjects for the health aides. It is a great opportunity to meet the people we spend so much time on the phone doing radio medical traffic with. For the health aides, it is an exciting opportunity to get away from their village and home life responsibilities, and meet and socialize with other health aides. Going to St. Mary’s allows them to develop collegial relationships, which enhances their own sense of professionalism.

One of the CHAP priorities in teaching health aides is to help them acquire skills that will allow them to treat patients in their home villages, rather than having to send the patients in to Bethel. A few years ago, after draining innumerable boils on village patients who had to come in because the health aides had not been trained to do Incision and Drainage (I&D) in the village, I went to the CHAP director and asked if I could teach a session on boils at the next conference in St. Mary’s. She was delighted.

When I gave some thought to how to organize a workshop on Boils 101, I knew the most important thing would be to provide a hands-on type of experience. The health aides needed to practice holding a scapel, doing blunt dissection with a hemostat, packing gauze into a hole. I developed a model which worked beautifully.

The star of the show was—you guessed it—pig’s feet! I bought four dozen fresh pig’s feet from the grocery store, along with two quarts of lemon yogurt. It took a little experimenting, but the technique that ultimately worked the best was to use an 18 gauge needle on a 20 cc syringe, insert it subcutaneously and advance it at least an inch; inject air to raise the largest bubble possible, then switch syringes (without removing the needle) to one filled with lemon yogurt and inject the yogurt into the air bubble. A little red food coloring on top of the “dome” and--VOILA--a reasonably decent boil! And one of the best parts, for the health aides, was that all materials were food-grade; many took their pig’s feet home and cooked them up for dinner.

The health aides loved it. My workshop was the hit of the conference that year, and everyone wanted to try it. I brought bottles of lidocaine with syringes and 27 gauge needles for numbing up, I&D kits, culture tubes, bottles of plain ¼” gauze, and sterile gloves. They were able to practice the entire procedure, from doing a V-shaped anesthetic block to packing the wound. I had them use the hemostats as if they were doing blunt dissection of loculations within the abscess, and described for them the feel of that, but the model did not reproduce that aspect for them.

Another visual aid that helped a lot was a video. One of the ER physicians allowed me to videotape her doing an I&D on a really choice BOB (boil on butt)—with the patient’s permission, of course. It required moderately aggressive destruction of loculations and yielded about 60 cc of thick yellow pus. The health aides were squirming in their chairs while watching it, but they got the idea about getting the pus out. They really understand that that is the key, not antibiotics.

We have a LOT of boils here, and the great majority of them are methicillin-resistant Staph. aureus—the dreaded MRSA. Almost all are sensitive to trimethoprim-sulfamethoxazole (Septra, Bactrim). We only use antibiotics if the erythema (redness) is greater than 10 cm in any one direction--i.e., a cellulitis in addition to an abscess. For patients who are allergic to Septra, we use clindamycin or levofloxacin.

Teaching health aides to I&D abscesses is now a routine part of their training. For abscesses on the face, in the ear canal, or directly over a bony joint such as a knee or shoulder, the health aides still send the patient to Bethel. Or if the patient is younger than 4 years old. But many patients are now spared the expense and inconvenience of having to travel to Bethel to have a boil drained. It is one small thing that has made life easier for rural Alaskans, and I am pleased to have been a part.

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9 Comments:

Blogger medstudentitis said...

I hope you don't mind but I'd like to use this boils 101 workshop model for a family medicine interest group workshop at my medical school. Sounds fantastic!

Monday, September 11, 2006 8:14:00 AM  
Blogger TheTundraPA said...

Med--that's great! Hope it works for you. If you're going to try it, there is one further detail. When you inject the air, it tends to dissect the tissues and spread out while remaining flat. To get more of a dome, take a flat piece of plastic with a half inch or bigger hole bored in it (like a drafting template). Once you advance the needle, place the hole over the needle tip. This will help to pump-up your boil rather than letting it stay wide and flat.

Let me know how it works for you!

Monday, September 11, 2006 1:52:00 PM  
Blogger medstudentitis said...

Thanks for the tip!I'll let you know how it goes. I sent your description to a few med school friends this morning and the general consensus is that we're never going to eat lemon yogurt again :)

Monday, September 11, 2006 5:54:00 PM  
Blogger Borneo Breezes said...

Great practical lesson. We used to see an entity called Seal finger which looked like a staph infection, often like a boil, but did not respond to the usual drugs only erythromycin. Do you see that in Bethel. I think the reason I didn't get it published before on your comments was because I signed as Borneo Breezes but lets see if this works. BB used to work?#

Thursday, September 14, 2006 6:56:00 AM  
Blogger TheTundraPA said...

Hey BB--yes, we do see quite a bit of both Fish Finger and Seal Finger, infections resulting from cutting one's finger while skinning a seal or filleting a fish (usually salmon). I've never seen either one develop a boil, just a fat, red, warm painful "sausage" digit, often with a red streak to the wrist or higher. We treat 'em with doxycycline and warm soaks and they usually respond quickly.

Thanks for the extra effort to get a comment in! You know how much I love them...

Thursday, September 14, 2006 7:08:00 AM  
Anonymous sara said...

Is there a reason there's a lot of MRSA there? That makes me curious - wouldn't have expected it.

Saturday, November 04, 2006 9:53:00 AM  
Anonymous Alex said...

There was a nurse practitioner who worked in the emergency room there and did a thesis on why there is so many boils there in the kuskokwim region. It studied water accesability and boils. It found that villages with better accessibility to running water had a decreased incidence of boils as oppossed to villages that did not have running water (i.e. villages that relied on steam baths for their hygeine). It was interesting for a thesis report.

Friday, January 26, 2007 11:34:00 AM  
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