Sunday, November 19, 2006

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.



Blogger Shinga said...

As ever, Tundra PA, a rollocking good read.

Forgive my ignorance, but is there a really obvious reason why there is such poor respiratory health? Has it always been like this? Is it genetic? Is it housing density? Does the cold make for everybody having hyper-responsive airways?

I can see how cold climates would influence both physiological and pathological respiratory responses. With that level of cold, there must be impacts for airway smooth muscle, the pulmonary and the tracheobronchial vasculatures. I'm too lazy to try and figure out the impact of temperature on blood gases and gas exchange but it must be striking.

I've nipped through Entrez Pubmed searching for papers on respiratory health in your region. It just sounds so fascinating.

Regards - Shinga

Monday, November 20, 2006 6:04:00 AM  
Anonymous Anonymous said...

Enjoying all your blogs, Dixie Belle

Monday, November 20, 2006 6:49:00 AM  
Blogger TheTundraPA said...

Hey Shinga! Really good questions, and the answer is that nobody really knows. Apparently it has always been like this for the Yupiks. Bad lungs, bad ears, and bad skin infections. There is some cold-induced bronchospasm (which seems as crazy to me as Yupiks who are allergic to salmon), but overall there seems to be more viral-induced bronchospasm. Housing density, which is routinely high, definitely plays a part in the spread of bacterial infections, both respiratory and skin. Level of hygiene also. I'm not thinking that the temperature outside the body would have much effect on blood gases and gas exchange, but it is an interesting thought.

Let me know if your Pubmed search comes up with anything.

Anonymous--thanks! Glad you are...

Monday, November 20, 2006 7:46:00 AM  
Anonymous neopa said...

Great read! I was wondering what your season is for RSV there. In the southern states, it is a year round thing but high season from ~ November to March? I think the winter is the time in the rest of the Lower 48.

Monday, November 20, 2006 1:32:00 PM  
Anonymous wolfbaby said...

Wow I would have been freaking out if one of my kids was that sick.. it says alot on how often they deal with it that mom was able to be so calm about it. Poor little ones to be sick like that all the time...

I tend to think it might be genetics playing a part. I myself have bad ears, skin problems and throat problems. Chronic upper respratory infections etc. Both my kids do as well. But the odd thing is neither my mother nor father did... perhaps there is a rather large hole in my logic.

Monday, November 20, 2006 5:05:00 PM  
Blogger always learning said...

Wow. That's a lot of patients.

Why is there such a high incidence of respiratory disease in the young?

That's amazing how well they cope with illness - must be something about the cold weather that makes them heartier...

nice read,

Monday, November 20, 2006 6:14:00 PM  
Anonymous Peter said...

Hey, good stuff, thanks for writing. My wife and baby and I actually live in Kasigluk (a tundra village about 25 air miles west of Bethel for those of you not from the area). Yes, we're teachers. Our baby has been having scary health stuff lately so your post strikes a chord. She actually stopped breathing for 15-20 seconds the other night, which happened to be the same day I stumbled on your blog, reading about the baby with pertussis who also had an episode of apnea. Pretty amazing. After she started breathing I ran to the computer and pulled up your column on that to reread it and show my wife. One of the hardest parts about living here is the lack of medical care, like when my wife broke her leg badly in a storm in March, but that is another story... : - )

Anyway I wanted to compliment you on your blog and thank you for having an obvious interest in the well-being of those of us who live here. In this column, I really liked the part where you dream about a nurse practitioner or PA in every village. Good, good stuff--a dream worth sharing and hopefully it eventually spreads to those who control the funding! : - )

Responding to Shinga's question about why the poor seems to me that we get killed in a whole host of nagative statistics, whether its dropouts or tobacco use or domestic violence or sexual assault or child abuse or rate of accidental death. I don't think there is a simple answer. As the author wrote about tuberculosis, it was awful here. Yupiks have a concept today they call "the great death" referring to the period where people went away with influenza or TB, and they simply didn't return. Huge numbers of them were just wiped out, in the 1930s and '40s. Most of them will not speak of this, even now.

Remember that this culture had very late first contact with Kass'aq (western) culture. Moravian missionaries founded a settlement in Bethel around 1880 I believe, and as I understand it they were the first Kassaqs most Yupiks in the area had ever seen. Some of the more out of the way villages didn't see anyone for years after that. So a lot of the problems experienced here could be said to be in parallel to what other lower 48 native cultures encountered in the first century or century and a half after contact. I'm no historian, but I think it generally meant devastation by disease and cultural conflicts. OK, this is too long, sorry to write so much! As a resident of a village who goes to the clinic and then awaits the mysterious 'return call from YKHC', it is cool to hear about the process on your end. Thanks for being professional and compassionate!

Monday, November 20, 2006 7:14:00 PM  
Blogger Shinga said...

Hi Tundra PA,

Perhaps very simplistically, I imagined that the cold would have an impact on the lungs and that would shift the Oxygen Dissociation Curve to the left. Beyond that, there would be spasm of the smooth muscle, vasoconstriction of peripheral capillaries etc.

I'm assuming that the ETCO2 changes when exposed to the cold but I can't find any monitoring studies.

Repeated and regular episodes of breathing large minute volumes of subfreezing air during vigorous work can lead to obstructive lung disease and increased wall thickness of pulmonary arteries.

There have been several recent papers that report that abrupt changes in temperature and humidity can trigger subclinical bronchial obstruction in healthy subjects. If people already have hyper-reactive airways, rhinosinusitis etc. then the obstructions and exacerbations may be significant.

Thanks for the comment, Peter. It sounds like, as with so many issues, it is the tandem effect of genetics and environment.

Regards - Shinga

Tuesday, November 21, 2006 7:48:00 AM  
Anonymous ozziedoc the 4th yr med student said...

Once again, another wonderful post.

You are doing a fabulous job. I wish there was something that I could do to help with healthcare in your area.

Wednesday, November 22, 2006 8:48:00 AM  
Blogger TheTundraPA said...

neopa--RSV is a year-round thing here, though definitely worse in winter (October-March). And a lot of it is severe, requiring nebulizer treatments of albuterol and ipratropium every 3-4 hours and oxygen support. Traveling Doc over at Borneo Breezes (see my blogroll, I don't know how to put links in the comments) referred to it as "death-defying bronchiolitis" which is quite apt.

wolfbaby--it is Yupik nature to appear calm, even in trying circumstances; that mom may have been freaking out on the inside too. There certainly seems to be a genetic predisposition to respiratory problems in this population, as all age groups are affected in one way or another.

wv--the Yupik are definitely a hearty people, yet they remain very susceptible to bacterial infections, almost as if they are immunocompromised. No one has figured it out yet.

Peter--welcome! Thanks for visiting and for commenting (extensively; I love that). I've seen Kasigluk show up on the site meter and wondered who in the village was reading the blog. Glad you enjoy it, and I hope your baby's breathing and your wife's leg are both doing well now.

Delivery of health care services with limited resources in an area this large is a huge challenge. As a provider, I tend to think we do a good job with what we have. But I have never lived in a village and had a sick child who I was afraid would need services that would not be available in time. Thanks for reminding me. And thanks for the historical perspective you've added.

I hope you and your wife will be regular readers, and keep me honest about life here. Look me up and say hi if you're ever at the hospital.

Shinga--all I can tell you is that the Yupik have more cold-induced bronchospasm than I would expect after thousands of years of adaptation to this climate.

Oz--so glad you enjoy the blog! Think about coming here for a locums during residency perhaps...

Wednesday, November 22, 2006 10:22:00 AM  
Blogger Goesh said...

- reminds me of my time in the African bush as a Peace Corps volunteer. I was supposed to be working with agriculture but did first aid the whole time, rehydrating babies, treating cuts and punctures, dispensing malaria pills when I could get them and anti-biotics. At times all I had was boiled water, peroxide, rubbing alcohol, neosporine and boiled cloth to wrap wounds. Dirty water killed alot of babies.

Monday, November 27, 2006 5:04:00 AM  

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