Saturday, February 07, 2009

Back to Work

After four and a half months off work—the longest non-working period in my adult life—I was afraid I had forgotten all the medicine I ever knew. Fortunately, such was not the case. I started working again in mid January, and everything has gone smoothly, with the help of several dedicated people in Bethel.

My entire job now consists of doing Radio Medical Traffic (RMT), which I described in detail in the early days of this blog; see this post and this post. The best part is that I am doing it from my home in Kenai. That is a luxury I have never had before, and I absolutely love it. The hospital sent me an industrial-strength printer/fax machine capable of cranking out hundreds of faxes per day without breaking a sweat. And the technology department is working to set up a laptop computer for me that will have the database for all 20,000 patients in our region on it.

This is not an EMR (electronic medical record). Individual patient visits are not electronically recorded into the database, which is known as RPMS, and I have no idea what the letters stand for, something about Patient Management. We are still handwriting patient visits! What RPMS provides is a health summary for each patient, with demographic information, chronic diagnoses, prescriptions filled, lab results for the past two years, radiology results for the past five years, surgical histories, and more. It is a thorough thumbnail of the patient; about the only thing it lacks are the details of any specific patient visit in the hospital. To get those, the hard copy of the chart must be ordered, which is something I can’t do from Kenai.

But if I really need those details, I can contact the medical staff’s administrative assistant and have her request the chart and fax me a copy of the relevant visit. So far, I have only needed her to do that once in the last three weeks. The process of doing RMT without access to RPMS feels somewhat like flying blind, as health aides often have questions about such things as availability of medication refills, or recent lab results. But the process has gone reasonably well even without access to the database since I started back. I am excited about getting a new laptop with RPMS on it, however.

And—what feels like icing on the cake—is that I will also have access to the telemedicine program on the laptop. Telemedicine has been in the village clinics for years, but most of the time was not utilized due to health aide resistance to learning the technology. That is becoming a thing of the past as younger people are entering health aide training who are more comfortable with computers.

The telemedicine carts in each village contain a computer tower/monitor/keyboard, a digital camera which can take still photos or short video clips, a camera mounted into an otoscope for taking pictures or videos of ear drums and other things located at the bottom of dark holes, an EKG machine, and all the software needed to transmit this info confidentially to Bethel or to Anchorage. It is an invaluable tool for doing distance triage on patients with things like rashes, where a picture is worth a thousand words, or patients whose complaint is simply “heart feels funny.”

The telemedicine carts in each village clinic have been replaced this past month with the absolutely latest and best that technology has to offer. And the health aide training program has made it a high priority to get all health aides trained up and comfortable in using that technology. It will help to make assessment of distant patients so much easier and more accurate.

Talking to health aides about their patients has always been enjoyable to me; I really like doing RMT. I have the greatest respect and admiration for health aides. They do a very tough job, and generally do it well.

All the 160+ health aides in our region are Alaska Natives, and most were born and raised in the village where they work. Given that most villages have less than 500 people in them, they are generally related (“somehow” as they say) to everybody who lives there. That makes it even tougher when the job requires attending to serious trauma or illness, and the patient is a loved one.

Health aides are trained to use language that is descriptive without being diagnostic. Lung sounds may be “snoring” or “scraping” or “popping.” Patients are “sick-weak-and-tired” or they aren’t. Really sick babies have “heavy eyes.” Translating these descriptions into accurate assessments can be challenging at times.

One of the more interesting comments I’ve received recently from a health aide was that a patient’s urine looked “thick.” I had to wonder what thick urine looks like. Honey? On questioning, the health aide said the urine wasn’t “junky” or cloudy, and dipstick test revealed a normal specific gravity (less than 1.020, therefore not concentrated, indicating no dehydration) and negative for nitrites or blood, indicating a low likelihood of bladder infection in a non-pregnant patient.

I asked the health aide to send a clean catch sample of the urine in to the lab in Bethel for culture and sensitivity, and a dirty catch sample for gonorrhea and chlamydia testing. The health aide and I agreed that the patient could be encouraged to increase fluid intake and be observed for new or increasing symptoms and rechecked in a few days—sooner if worse, as always.

Chief complaints for which patients seek care in the village clinics can also be puzzling. Last week, an otherwise healthy, twenty-something male came to the health aides for a complaint of “can’t burp.” He looked fine, had no complaint of abdominal discomfort or cardiac symptoms, and attributed his complaint to being “aired up.” In the Yupik concept of physiology, being “aired up” can explain anything from chest pressure to flank pain. It may mean nothing serious or it may mean time to medevac the patient in to the hospital.

In this patient’s case, a man who was young, looked fine, had no complaint of pain and had normal vital signs, I was not overly worried. I suggested to the health aide that he try drinking carbonated beverages for a day or so and recheck if he developed new or worsening symptoms. Our patients are generally very reliable for rechecking with the health aides when they perceive anything to be wrong; he has not returned to the village clinic in the subsequent few days, so presumably he is feeling better and burping away.

And then there was the best chief complaint maybe ever. “I want a pregnancy test.” The patient was a seventy-five year old woman. She was many years post-menopausal (or “menopaused” as the health aides say), but because she had all the reproductive parts, she was sure she could be. The health aide and I laughed about it as he explained that she is recently remarried and she and her new husband are “very active.” Good for them! The pregnancy test was negative.

Being back in contact with the health aides has been wonderful for me. It keeps me in touch with what is going on health-wise in the villages, and provides an opportunity to catch up on how the health aides I’ve known for years are doing. It has also made me aware of how much I miss doing hands-on patient care.

And for that, there is the best news possible: tomorrow I fly out to Bethel for a week of seeing patients at the outpatient clinics in the hospital. I hope to be able to make such trips about every other month. After four months away, it feels a bit like going home, and I’m really looking forward to it. Surely, a few blog posts will result.


Sunday, February 01, 2009

Volcano Watching

Kenai awoke this morning to bright blue skies and temperature almost 20 degrees below zero. The entire range of mountains to the west, including Mt. Redoubt and Mt. Illiamna, were stunningly clear and looked amazingly close. To an untrained observer like myself, Redoubt looks just as it always has. But volcanologists are watching it closely, and continue to believe that an eruption is imminent. One of the glaciers on the north face shows signs of increased heat nearer the surface, with an expanding hole emitting steam and gases. So far, the expected increase in frequency and magnitude of earthquakes beneath the volcano has not happened, according to the experts.

Redoubt is about 50 miles west southwest of Kenai, so our view of it is of the east northeast face. In real life it seems much closer than this photo suggests. Even with binoculars, Dutch and I are not able to see any plumes of steam rising into the air. Kenai is the closest town of any size to the mountain, and experts are gathering here to watch the mountain. Last week, Dutch and other city officials were approached with the request to set up monitoring equipment at some of the city's buildings which are located on a high bluff at the edge of Cook Inlet, and have a gorgeous unobstructed view of the mountain. They were happy to comply with the request. The volcanologists are working to establish a ring of observation points around the mountain so that they can monitor its activity from all directions.

The air around town is one of watchful waiting for the shoe to drop. There is nothing to do about it except wait, and hope that, like a watched pot, if we watch hard enough it will never boil.

Photos by The Tundra PA