First Week in Whiteriver!

 

It has been an interesting week in Whiteriver, AZ so far. 

I arrived to Whiteriver on Sunday, May 2. The terrain surprised me; I was expecting desert, but I drove through forests full of pine trees on my way to Whiteriver. They are putting me up in the "male locums house" which is a small pre-fab house on the compound by the hospital. There is a town of 4,000 down the road 10 minutes from the hospital which has a basic grocery store, a Burger King, a post office, and a single stop light. The hospital serves the entire Fort Apache reservation, which occupies 1.6million acres of land in SE Arizona and has a population of around 13,000. After going through an exhausting 9 hour orientation to the hospital and its computer systems on my first day, I started working on the "wards." The wards is mainly inpatient medicine with a little OB mixed in. They had a fairly small census for most of the week, around 8-10 patients. They had two family doctors running the service, and these docs would also take care of OB patients who came to triage or who came in for clinic visits.

The inpatient service was interesting. There are a lot of patients with alcohol use disorder, which means alcohol withdrawal is a common reason for admission to the hospital. The general surgeon was on vacation for the week, so we were not able to admit anyone who needed general surgery; however there are a couple podiatrists here, so we were able to admit a couple patients with diabetic foot wounds which had turned into osteomyelitis, and the podiatrist was able to assist in their care by performing the necessary surgeries.

One of the things I learned in my week on the wards is how to manage alcohol withdrawal with phenobarbital. Although I have never seen this used before, it is the drug of choice here at Whiteriver IHS. Although it can’t be used in severe liver dysfunction, it is otherwise a very safe and effective way to treat alcohol withdrawal. Some of the attendings referred me to some studies which showed that the risk of needing intubation and ICU level care is substantially lower with phenobarbital protocols with additional benzodiazepines PRN compared to benzodiazepines only approach. This is a pretty important outcome in Whiteriver, because they don’t have an ICU, so any patient who needs an ICU needs to travel by ambulance or helicopter to another hospital. In the several cases I saw on my week on the wards, phenobarbital was effective, and we did not have to transfer anyone to another hospital for alcohol withdrawal.

One of more fun mornings on the wards happened when a patient with a history of a prior cesarean with a high transverse incision came in laboring at 5 cm. Since Whiteriver does not perform Cesarean deliveries, we had to transfer her via ambulance to the hospital up the road about 30 min (Summit hospital– this is a community hospital which lies off the reservation in a nearby town of Show Low, AZ). Since the woman was at risk of delivering in the ambulance, a physician had to ride along, so I got to ride along with the attending and the nurse, as well as the paramedics. On the ride the attending told me some stories about having to deliver some babies in the ambulance. Some attendings tell the ambulance driver to stop, to have a more controlled delivery, but she doesn’t, because that means they would be farther away from the hospital when the delivery happens. If a delivery is imminent, she wraps her legs around the stretcher, throws the woman’s legs over her shoulders, and tells the driver to drive faster. Fortunately, she didn’t have to demonstrate this technique on our patient, who made it to Summit hospital with plenty of time to spare and was met by an OB/GYN ready to take her to the operating room.

In my next post I will talk about the Emergency Room experience. From computers going down and paper charting for a night, to some interesting medical cases, there will be more stories to share!