Even more to learn!

12/27/2012

Even more to learn!

     Some of you are wondering why I blogged about the CHAP program. The health aides are people I interact with on a daily basis. As the “first call” provider for the ER, I am also the medical control for 22 village clinics and about thirty community health aides. The aides are very well trained, their CHAMs (Community Health Aide Manuals) are very detailed, but unfortunately they can not cover everything. This is the point in the process where I come in.

     Every week day, the CHAPs are contacted for “radio traffic”. The term “radio traffic” is a throwback to the days before Alaska had a statewide telephone system and all communications with the village clinics was by two-way radio. Today it is actually a phone call. Because of the frequent outages of land based phones and power outages there are three different phone systems available in each clinic. A dedicated IT line (like in the city where you only dial 4 digits to connect to an extension), a land based telephone line provided by the local telephone provider, and a satellite phone.

     Each village clinic has a basic stock of common medications: amoxicillin, Augmentin, Levaquin, Bactroban ointment, Tylenol III, etc. Their CHAM provides diagnosis/appropriate medication guidelines that the aides are required to follow. About now this is beginning to sound like a real “no brainer”.  Could one of these “magic manuals” make your life as a provider easier?  Several of you are already writing me an email wanting me to get you a copy of these “magic manuals”. Your “Ralph” is asking you, “what could be easier?” He has it all figured out, the scenario goes something like this:

Patient presents with bilateral ear pain.

Physical exam reveals bilateral otitis media.

CHAM tells you to prescribe amoxicillin.

     Ralph figures all you need is a CHAM and a street corner. As usual, Ralph did not read all the way to the end of the “otitis section”. What if you patient is allergic to penicillin (you know the real anaphylactic kind), CHAM tells you to contact me (your medical control). What if the TM is perforated, the CHAM tells you to call me. What if, as for the past several weeks, the weather has prevented village supply deliveries which include the medications to restock the clinics, and the clinic has no amoxicillin?  You guessed it, the CHAM tells you to call me.





     While we are playing “what if”, let’s make it really fun.

      The CHA calls in on the phone with this patient presentation:

62 yo female in the clinic with her family members complaining of increasing weakness over the past several weeks. Denies cough, SOB, fever/chills, NVD, swelling, recent changes in medications, no recent sick contacts.

Pertinent  PMH: chronic anemia

PE:

General: Well developed elderly female, NAD, ambulatory with assistance from her family, no staggers, speaking in clear-complete sentences.

V/S: B/P 88/62, P 64, R 20, T 91.8 (recheck of temp in other ear 92.1)

HEENT: PERRLA, EOMS intact, TM pearly gray bilaterally, no redness or pus in the throat, moves head around and shows no stiffness in the neck, no stridor, thyroid not palpable

Lungs: BBS clear and equal, no retractions or accessory muscle use

Cardiac: RRR, no extra heart sounds, no murmurs

Abdomen: good BS

Ext: no edema CRT <3 sec

Neuro: CAOX4, no motor changes, thoughts appropriate and complete

Hgb in clinic today = 8.2 (you quickly reviewed the patient’s previous labs and find this is their norm)

So now the big question is WWRD (what will Ralph do)?

Remember, you have a patient 232 miles away in a remote village. There are no roads; rivers are frozen; only transport is by airplane.

Now to make it interesting, I am going to let you think about this a while. You are the one sitting here at the desk. You have the telephone you are talking on; you have a Polycom system, and EHR access.

What questions are you going to ask?

What differentials are you formulating?

Does the patient need to come to Dillingham?

If you think you can treat the patient there, what are you going to do?

If you think the patient needs to come to Dillingham, how are they going to come?

Your options for transport are:

1)      In matters of life and limb = Emergent MEDEVAC by fixed wing aircraft by the Hospital (flight crew would include pilot, co-pilot, two RNs, and yourself) The cost of aircraft operations for this flight is about $4200.00, plus team members salaries and expendable supplies.

2)      In other matters = Transport to Dillingham via commercial airline. (Cost of patient’s ticket and companions’ ticket, about $215.00.

     Post your ideas in the comment section. I think it will be an interesting challenge; at least it is for me.