Sunday, December 17, 2006

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



Blogger Shinga said...

As ever, Tundra PA, you make these descriptions so immediate and vibrant. This is a thoroughly enjoyable and interesting read that gives a flavour of the juggling that you must do everyday in triaging the health needs of everyone through RMT etc.

The little ones in the photos are remarkably cute.

Regards - Shinga

Sunday, December 17, 2006 9:45:00 PM  
Blogger Sarah said...

Beaut photos, some really cute kids. I really like the one of that guy and his baby :)

It's nice to know that some free health care is provided; do non-native Alaskans face problems with obtaining affordable and/or easily obtainable health care?

Sunday, December 17, 2006 10:15:00 PM  
Anonymous Anonymous said...

I am a non-native Alaskan living in Bethel and while access to YKHC is pretty immediate, we have the same issues with wait times and a lot of procedures are shipped out to Anchorage (Providence, not the native hospital)... our insurance doesn't pay for flying back and forth unless you're admitted as an inpatient. We're also charged for our care at YKHC just like any other hospital.

Monday, December 18, 2006 1:54:00 PM  
Anonymous peter in kasigluk said...

I've always thought that the fax system would be better as a backup to an online form they could fill out and just send with a click of the mouse. And they'd save a ton of money seeing how expensive United Utilities is for in-state calls. Many of the clinics are getting connected with high-speed internet right? I read in the Delta Discovery about the towers going in so they could do some kind of tele-medicine stuff where the experts in Bethel or wherever could actually view the patient using a webcam and have more of a dr/patient interaction. Just a thought. I was surprised to learn they use the fax so much, when I moved out here. Anyway, just a thought. Maybe it would cause more trouble than it would be worth, technology can be temperamental.

Monday, December 18, 2006 11:23:00 PM  
Blogger TheTundraPA said...

Shinga--thanks. I was a bit concerned that this post was more detail than anyone cared to know. I'm glad you found it interesting. It is a large part of what I do almost daily. And I'm glad you like the photos. The Yupik are a beautiful people, and I love taking their pictures.

Sarah--I like the Proud Dad photo also. Regarding health care for non-Natives, see the next comment by anonymous. Until about 25 years ago, our hospital only provided routine care for Native people; non-Natives were seen for emergencies only. As the non-Native population of the region grew, the demand for care brought about the formation of Bethel Family Clinic, an independent clinic run by PAs and NPs with periodic visits of physicians from Anchorage. This clinic is still in operation, and both Natives and non-Natives go there to receive care. Sometime in the late 80s, the hospital began providing routine and emergency care for everyone.

As anon points out, not all services are available in Bethel. We have no CT scanner or MRI. We have no ICU. We have no routinely available specialists. Access to these things requires travel to Anchorage, and most private insurance does not pay for transportation. Services to non-Native patients that are provided at our hospital are billed for, just as at any other hospital or clinic.

Anon--all true. As a hospital employee, I get no special deal over other non-Natives. Thanks for your comment.

Peter--very good idea, and one that is probably about 20 years in the future. The problem at this point in time is multi-fold. One part is health aide level of comfort with the technology. For many, esp. older health aides, it would shift the focus from providing care. A second part is access. There is one computer in each clinic, and as many as five health aides working on a given day. We can't get a computer in each exam room in the hospital, much less in all 58 village clinics. A far more immediate technological focus is getting the telemedicine access up and running in all clinics. This is a recorded, not a live interface. It allows the health aides to send photos of their patients (including ear drum pictures with a special camera head) along with details of patient history via a secure communication line. Photos are not send via email, as it is not secure for confidential patient information.

But good ideas, and thanks for commenting!

Tuesday, December 19, 2006 7:59:00 AM  
Anonymous Kim said...

You can never have too much detail in your posts. Your blog is a fascinating look at a health care system and a way of life I would never have known about!

Great post!

Wednesday, December 20, 2006 12:27:00 PM  
Blogger TBTAM said...

Great post - you really show all sides of a very difficult issue, from the patient through to the central hospital.

Do you do any tracking on outcomes by provider, or time of day or type of symptom? It would be a great public health project for someone..

Friday, December 22, 2006 1:57:00 PM  
Anonymous PPLIC said...

Nice article. very interesting, thanks for sharing.

Wednesday, October 09, 2013 1:33:00 AM  

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