Practicing Bush Medicine
Southwest Alaska is a huge geographic area within which to provide medical care. It the size of the state of Oregon, and contains one single small hospital. The health aides in each village are the starting point of a system of care which works well most of the time. Health aides consult daily with their village’s assigned provider (physician, physician assistant, or nurse practitioner) regarding the patients they see in their small remote clinics; these consults are collectively called Radio Medical Traffic (RMT), which I have described previously. The primary question to be addressed for each patient through RMT is whether that patient needs to come to the hospital in Bethel or can be observed and treated in the village. Many times that question is not easy to answer.
The first consideration is always: how sick is the patient? Any person in any village who is seriously, emergently ill will be medevac’d (weather permitting, of course, and sometimes it doesn’t). Health aides are very astute at differentiating the patients needing medevac from those who don’t. They stabilize the patient to the best of their ability, maintain frequent phone contact with the ER physician in Bethel, and pray for clear weather while waiting for a plane to come and get the patient. That wait may last an hour, or a day. If the patient is a pregnant woman in pre-term labor, they may deliver a baby before the plane arrives. The health aides in one of the Yukon River villages successfully delivered a 36-week double footling breech infant during a bad snowstorm when the plane could not land.
For patients who are less acutely ill or injured, the decision to come to Bethel for evaluation has other considerations, primarily financial. It often comes down to who has Medicaid or private insurance, and who doesn’t, especially for the residents of the more distant villages. Doing a quick mental tally, I believe there are nine (out of 58) villages that are within a thirty mile radius of Bethel, and so reasonable to travel in by boat or snowmachine for non-emergent health needs. The rest must come by small plane.
Any patient in our region can make an appointment in the Family Medicine Clinics for any reason at any time, if they choose. By treaty agreement with the federal government, Alaska Natives receive 100% free health care, including all prescriptions and over-the-counter medications, any needed supplies for things such as wound care, and any necessary medical equipment such as home hospital beds, nebulizers, wheelchairs, home oxygen concentrators and bedside commodes. Transportation to receive the care is the weak point in the system. If the appointment is not considered necessary by the provider in Bethel doing RMT, then the patient will have to buy the plane ticket—generally one to three hundred dollars round trip, depending on distance. Neither Medicaid nor private insurance will pay for transportation beyond the closest point of contact where service is available. They will not pay for a trip to Anchorage if the needed service is available in Bethel, or a trip to Bethel if the service is available at a sub-regional clinic closer to the patient’s village. If the patient simply wants to go to the higher level of care, they may do so at their own expense.
For the provider doing RMT on non-urgent patients, there are several agendas going on which must be kept in mind. From the hospital’s perspective, the RMT providers are the floodgate-control operators. They can direct the health aides to send in every patient with puzzling or slightly concerning symptoms for further evaluation. When one is new to RMT, the temptation is very strong to do just that; the questions of “what if the patient gets worse quickly?” or “what if the weather goes down?” are always present in the back of one’s mind. The problem is the overwhelming volume that would create. Two to three hundred patients per day are triaged through RMT. The hospital’s outpatient clinics and ER are already operating at or near capacity most of the time, with a medical staff that is undersized for the job we face, and overworked.
From the health aide’s perspective, a moderately ill patient in the village who is being watched and rechecked daily increases the likelihood of pulling an all-nighter at the patient’s bedside and then having to work the next day. When any patient is challenging the limits of their ability to give care, the health aides (understandably) do not want that patient in the village. The difficulty for the RMT provider is in assessing just where that line lies. Some health aides, whether by the nature of their personality or by the amount of experience they have, are less comfortable with even mildly ill patients being treated with watchful waiting, with or without oral antibiotics. Health aides sometimes lobby hard for their patients to be “trafficked” in to Bethel, even though the physical exam may not support the need for it.
From the patient’s perspective, traveling in may be highly desirable or absolutely despised. If the patient doesn’t really feel terribly ill, and could use a shopping trip to town, he or she may be pressing the health aide to request further evaluation in Bethel. If the patient does feel somewhat ill (or “sick-weak-and-tired” in the language of the Community Health Aide Manual), getting on a small plane in often marginal weather to be bounced around for an hour or so and then waiting an hour or more in the always-crowded hospital lobby with other sick and coughing people is not a welcome suggestion. Some patients would rather stay home until they get sick enough to need medevac.
A single RMT provider may triage as many as a hundred patients in an afternoon. When the traffic is heavy and the faxes are coming in from the health aides by the handfuls, it is important to move quickly, scanning the Patient Encounter Form for serious concerns or exam findings, and establishing a plan of care and follow-up. With such heavy volume, it could be easy to miss crucial details; fortunately that doesn’t often happen because health aides don’t miss much and are strong advocates for their patients.
Doing high-volume telephone triage with health aides through Radio Medical Traffic requires a bit of juggling to balance the actual needs of the individual patient, the collective needs of 160 health aides in 58 villages, and the capacity of a small hospital to provide top-notch medical care in a severe and remote location. There is not a lot of fat in the system; we operate most days with very tiny margins. To the credit of the entire team, we usually make it work.
Photos by The Tundra PA
Labels: Bush Medicine