January 30, 2009 - Radiotraffic

The Radiotraffic Room in Maniilaq Hospital in Kotzebue is the medical command and control center for all eleven bush villages that it services covering 3000 square miles of northwest Alaska. I had my baptism by fire there last week.

My on-the-job training the day before I was due to start was aborted after 40 minutes because they needed another body (unfortunately mine) in the Outpatient Walk In Clinic to see the hoards that were lining up at 3 PM. The doors shut at 4:30 (unless you happen to be a friend or family member of the receptionist or triage nurse) and whoever is there has to be seen. Because most people don't get moving in the morning, there's an afternoon rush most days despite the fact that we open at 10AM.

The reason I was nervous about working in radiotraffic is that I don't have any experience as a first responder. Medical providers who work in city clinics don't get the first call when bad accidents or potentially fatal illnesses occur - that's why we have ambulances and emergency room doctors and nurses. And physicians have heftier experience with the scary stuff due to their training and work in-hospital than nurse practitioners like me.

So I walked with trepidation into the Radiotraffic room that first morning. My job was to receive between 40 and 80 faxes as well as phone calls in an 8 hour period from the 11 bush villages. The faxes are descriptions of the medical problems that the CHAPs (Community Health Aid Program) are seeing. CHAP's are people with at least an eighth grade education who train for varying amounts of time in Juneau to become lay medical providers in their own villages. They have a book of algorithms that they follow. Some have been doing it for years and are pros. Others are still learning and adept at dealing with most problems. A few should be part of a Displaced Worker's Program but no one ever gets fired.

My job is to make sense of the CHAPs' patient evaluations and tell them what to do if they don't know, tweak or abort their plans and substitute one of my own, or approve their evaluation and plan. When I see patients in clinic I rely a lot on my intuition, using all my senses (except taste of course.) In fact I'd say I use myself - body language, humor, personality even - to tease out the information I need to cinch the diagnosis. However, in radiotraffic I must help make a diagnosis without the benefit of seeing the patient in person and laying on of hands. More difficult is not knowing the level of expertise of the CHAP making the report. And worse is wondering if I'm the person they should be consulting about potentially life-threatening injuries and illlnesses.

Judgement in clinical medicine is the sin qua non of practice. There's nothing like experience to hone one's diagnostic and treatment acumen and one's judgement. I was relying heavily on my confidence in my judgement that first day. For I was in the challenging situation of having to rely on clinicians whose judgement I didn't know I could trust with patients I didn't know from Adam with health problems I may never have addressed in my 27 years of practice.

The first day was a rollercoaster ride.

But the saving grace was technology. A year ago I wouldn't have believed I would be writing this. I am both indifferent and deficient in anything that involves a series of operations involving a keyboard and mouse. Access and verify codes used to obtain lab and record reviews on patients have cost me countless hours up here. I have used every breathing technique I know to maintain patience with twenty-something IT staff members who are supposed to be fixing systems-related problems without apparent success.

The video teleconferencing apparatus was spectacular. I got a call about an infant having seizures - every clinician's nightmare. Fortunately he was breathing and had just returned home from the Alaska Native Medical Center in Anchorage where he had a normal head MRI and had started an anti-convulsant medication. Knowing how a parent's fear, especially when a child has seizures, can sometimes distort their description of events, I wanted to be certain that the baby was seizing. So the CHAP and I turned on our respective video cams, and I was able to watch the baby in real time. He was holding his bottle while lying in his mom's arms and then his arms suddenly jerked and the bottle went flying. Exellent verification! By phone the neurologist in Anchorage gave me a nifty recipe for Valium (yeah the same stuff our mothers abused in the 70's) mixed with mineral oil and then shot into the rectum with a small syringe. Finding mineral oil in the village proved to be difficult until the CHAP remembered that she had some at home. We probably could have used Wesson Oil but I forgot to ask about it while I was on the phone with the neurologist. This method of medication administration works about as well as delivering the Valium intravenously and is far easier for our lay medical personnel to do.

I used the videocam for a woman with an unusal rash. As the video became live, she looked off self-consciously like someone who was in a movie she didn't want to be in. Her rash may have been a drug allergy to Ibuprofen or the disease systemic lupus erythematosis. I treated her empirically and tried unsuccessfully to reach her by phone to see if she was better. One of the great frustrations and weaknesses in this system is that it can be difficult to follow up to see if your hunch was right.

An inebriated man who crashed his snowmachine was a tougher case. I followed him by phone in between faxes and calls most of the afternoon as he slowly came out of his concussion and drunken stupor. The videocam pretty much showed a guy who was out of it. Not much help. He had post-accident amnesia, perseveration - asking what happened over and over - and a big headache. So the question was whether to bring him in by commercial flight to evaluate him neurologically or wait to see how he was doing. By the end of the day the flying conditions had worsened to the point where sick patients couldn't fly because the bush planes were grounded.

Changing flying conditions is an added pressure when trying to time when to bring someone to the hospital ER for medical evaluation. In this case I told the CHAP to see if his mom could do neuro checks through the night - waking him and peering in his eyes. The CHAP called back to say that his mother, who is mentally unstable, screamed at both of them to leave and not come back. At last contact, the CHAP was still looking for shelter for this homeless man with forty below outside.

More frightening was the baby with respiratory distress who also didn't make the commercial flight that day. I called in our emergency flight team to go get her. Our EMT/ pilots will sometimes fly when the commercial bush airlines cancel. It's dangerous for everyone. I was reading a protocol based on a symposium on managing head injuries in Alaska, in which it said that bush pilots die in plane crashes at a rate that is 5 times their counterparts in the lower 48. So what does that mean for the average villager who travels away from home, often to obtain medical care?

The CHAPs send us photos of rashes, eardrums, burns, and anything else that is better evaluated with a picture in addition to written descriptions. I pull it up on the computer, look, and fax back a diagnosis and medication suggestion. I suppose there are days when the visual communications would qualify as X-rated.

But most of the time it's the hum drum stuff of daily medical practice. I like talking to the various CHAP's, mostly Native women from the different villages. I try to use humor when I can -if I'm not too frazzled from hours of multi-tasking. I also use the interactions to teach the less experienced people how to think about the problems that they're consulting me about.

By my third day in the radiotraffic room, I was feeling more comfortable.

But I would still much rather see the patient in person in clinic in Kotzebue with the ER and its staff just a few steps away.