Distance Triage

Monday afternoon’s Radio Medical Traffic was intense. The community health aides in the far-flung villages of southwest Alaska were seeing lots of patients with acute viral symptoms ranging from mild to severe. Most were not toxic and could be managed at home with symptomatic and supportive therapy. Most health aides are very good at assessing whether a patient really needs to come to Bethel or not. If anything, they err on the side of sending a patient in too soon, rather than too late.

The Yupik Eskimo people of this region have a huge burden of respiratory disease. Many of the elders had tuberculosis in the 1940s and 1950s, and bear the large diagonal scars on the upper back from lobectomy to treat it. Many more people, including younger ones, have gone through year-long INH/Rifampin courses for having positive TB skin tests. The incidence of common bacterial pneumonias (community acquired) is considered to be fifty times the rate of the lower 48, for all age groups. An astounding number of infants have severe RSV disease, and almost every Yupik home has a nebulizer for administering albuterol. Many infants have multiple admissions for pneumonia before they are 12 months old. Severe asthma. Severe COPD. Even quite a lot of moderate to severe bronchiectasis in all ages from young to old. Sometimes it seems like the entire Yukon-Kuskokwim Delta is coughing.

On Monday afternoon, the volume of traffic from health aides reporting their patients was huge. By the end of a long afternoon shift, I had triaged 112 patients with them. Anything over 75 is a lot, but over 100 is especially brutal. I did not finish talking to health aides until nearly 7 pm. Health aides are finished working at 4 pm, and do not like having to wait up to two hours to get a call from the hospital RMT person to discuss their patients and decide on a plan of care. I can’t blame them, they have families to get home to. When traffic volume is high, there is just no way to call every health aide before 4 pm. The stress is always there to move quickly with the traffic, to try to get it done as early as possible.

It was after 5:30 when I called one of the coastal villages that was still waiting to hear from me. Over two hundred miles away, the last commercial plane flight left the village at 4:30. The health aides know that if they have a patient that might need to come in to Bethel on that last flight, and they have not heard from the regular RMT person, they can page the physician assigned to inpatient duty for urgent decisions regarding their patient. The system and its back-ups usually work pretty well.

I read the Patient Encounter Form as I waited for the health aide to come to the phone. 3 mo. old female with cough and fever x 3 days, worse today. OK; quick check of vitals, and holy cow! Temp 104.7 rectally. Heart rate 200. Respiratory rate 56. O2 sat 90%. What time was this? 11:05 am.

When the health aide answered, I managed not to jump on her. She has only recently advanced to the first level of health aide training past entry level. But “where is the patient? What’s going on, did you send her in already?” tumbled quickly out of my mouth.

“No, she’s good. She went home. Her mom’s not worried,” the health aide told me.

Oh. Not worried. When I first came here, I was repeatedly amazed at how well the Yupik compensate for their respiratory disease. Children with multi-lobar pneumonias and fevers greater than 101 degrees play tag with their cousins through the hospital lobby. Elders with COPD on daily inhaled steroids and bronchodilators go hunting in the fall and winter. The fact that mom wasn’t worried did not mean that I wasn’t worried. I asked the health aide to get mom and the baby back to the village clinic immediately and reassess the baby.

“She’s much better,” the health aide assured me when she called back. Temp 103.6 after Tylenol which she did not throw up. Heart rate 180. Respiratory rate 56. 02 sat 91%. “She’s alert, taking bottle, even her eyes aren’t too heavy,” she added. A health aide assessment of “heavy eyes” is a very bad sign. The baby was still retracting some, but had no nasal flaring or cyanosis.

Despite the baby’s apparently compensated state, I wanted her in Bethel. The question was how fast. The last commercial flight for the day ($100) was gone; the next would be the following morning, arriving in Bethel about 11 am. Sending out a medevac for her costs about $3500 (not to the patient), in addition to taking the team out of availability for the duration. Limited resources require careful monitoring. I called my friend Dr. G over in the emergency room. He agreed that the baby should come in, and took over the patient’s management from there, activating the medevac team and coordinating with the health aide her removal to Bethel. I was delighted, as I still had two more villages to finish doing radio traffic with.

The following morning, the baby was on my schedule for “ER followup.” She looked great. X-rays in the ER had shown a dense right lower lobe pneumonia. With nebulized albuterol her O2 sat improved to 96%. (Everything causes bronchospasm here, it seems.) She was given a first dose of IV ceftriaxone, and would have been admitted, except that the inpatient unit was on divert (due to full beds, or not enough nurses, or both). Because she was stable, eating/peeing/pooping well, acting alert and vigorous, she was discharged to stay at the hostel for three days with daily follow up in clinic and return to ER if she suddenly got worse. The hostel owns its own fleet of nebulizers for overnight use by the patrons/patients.

I was glad to see her looking so good. She still had mild retractions and both wheezes and rhonchi and probably some rales too, in those junky sounding lungs. She improved noticeably after a neb treatment and some percussion and postural drainage. She and mom went back to the hostel with plans to neb every 4 to 6 hours and follow up the next day.

By the third dose of ceftriaxone she was ready to go home. Her vital signs were nearly normal (still a bit tachypneic with a respiratory rate of 24) but afebrile and her lungs sounded much clearer. Bright-eyed and vigorous, I watched her suck a bottle with gusto. Mom was very happy to take her home.

Patients like this one make me long for a day when we will have limited radiology availability in the village clinics. A small x-ray machine that would do chests and extremities and telerad the images to Bethel for interpretation would be fabulous. With so many people coughing and running fevers, I want chest x-rays on everyone. And a complete blood count (CBC). This patient could have been treated in the village with IM ceftriaxone and/or oral Augmentin and nebulized albuterol, if we had the technology to make the diagnosis from there. Once we do have the technology, it will save a lot of patient-travel miles.

This is the level of care currently available at the four sub-regional clinics in Aniak, St. Mary’s, Emmonak, and Toksook Bay. I hope someday that every village clinic will be staffed by a pair of physician assistants or nurse practitioners, have some limited lab and xray, and a slightly expanded pharmacy. The sub-regionals could then have physicians on staff, an ultrasound tech, a dentist, a pharmacist, a certified medical technologist in the lab… Maybe some day. The Tundra PA loves to dream.

Photo by The Tundra PA.