Blog 2017 January 5, 2017
Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.
In private practice last century, I got a call from a mother of a sick child late in the afternoon. Despite a tight schedule, I told her to bring the kid up, now, and I would attend to the problem. In a hurry, and in traffic, her car collided with another. No injuries resulted, but since then I have always kept in mind the risk of patient transport.
Many Alaskans live in places inaccessible by road. You can get there by plane, train, or boat, or, in winter, by snow machine. Rivers thus become highways, not barriers. The geographical imperative colors medical decision making.
Game theory forms the basis for making a lot of choices, and medicine becomes a microcosm of the human condition. Any course of action carries a risk, and, at the same time, not taking that action carries a risk. As physicians, we deal with the real world when we play games with incomplete and imperfect information.
Consider, for example, a hypothetical patient in alcohol withdrawal. At first evaluation, I would generate a CIWA (Clinical Institute Withdrawal Assessment) score based on temperature, blood pressure, pulse, sweating, agitation, irritability, restlessness, memory, and overactive sensations of touch, hearing, and sight. In Iowa, where transport to the hospital carries almost no risk, a score above 8 would mean hospitalization. But here, a score of 25 would make me consider sending the patient to Ketchikan by boat.
Not so fast. If the wind keeps the floatplane from flying, it whips up whitecaps on the water. I would have to consider the risk of drowning 5 people.
I also have to consider the risk that the patient, once stabilized in the Ketchikan ER to a score less than 8, might be discharged to the streets.
In such a case, I would do as much as I could (in this example, fluids, vitamins, and sedatives in the family that includes Valium, Xanax, and Ativan), keep the patient in my ER, and, if I could get the CIWA score under 8, get twice daily follow ups for a couple of weeks.
When we refer patients out, they usually go to Ketchikan, but our obstetrics patients go to Sitka. Major illness requiring subspecialists could go to Seattle or Anchorage. And every transport carries a risk.
Tags: alcohol withdrawal, alcohol withdrawal treatment, CISA score, Clinical Institute Withdrawal Assessment, game theory, geographical imperative, incomplete and imperfect information, Ketchikan, medical decision making