RMT Pearls

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  • Vital signs are vital. Please always take the time to address ANY abnormal vital signs. Many of the patients whose charts are referred for peer review because of an adverse outcome have abnormal vital signs that are not addressed. Comment on them in your response, take actions to correct them and get new ones if indicated.
  • If you are not sure what to do ALWAYS consult (do not hesitate to get another opinion) from a more experienced peds/night float/ER/hospitalist/clinic/HROB provider as needed.
  • Follow our guidelines…especially for community acquired pneumonia for adult and peds, OM, UTI in peds, abcess/celluitis for outpatient management or guideline for severe abcess/cellulitis that needs to be evaluated and treated in the ER and/or admitted.
  • Bethel resources are slim. Try not to send everyone into the ER or clinics…with close CHA follow up and management in the village, watchful waiting and some therapy (albuterol nebs, hot soaks, antibiotics, I&D, steam, etc.) many patients will improve over a few days. Those that get worse can be sent in (or on occasion be medevaced) when they declare themselves as ill enough to be seen in Bethel.
  • Listen to your CHA’s and/or read their documentation carefully. They will often highlight their concerns in a narrative at the top. Look carefully at the history and physical exam. If they are concerned about a ‘stiff neck’ or ‘dehydration’ or being ‘pale and sickly’- document this concern as validated or describe why you don’t think they have meningitis or anything else concerning going on. It is important to write out a short assessment and plan so the provider seeing the patient next has an idea of what you are concerned about and the plan.
  • If you have a CHA that is new in training (CHA I) and you are having trouble deciding what to do with the patient, you can ask them to get a second opinion from a more experienced CHA about whether the patient can be managed in the village or needs to be sent in, if available – sometimes they are alone in the village. Then utilize the videophones as discussed below.
  • There are three videophones available to visually assess patients in most village clinics. These phones are located in the ER, NW Hospitalist and NW Peds office. You can have the patient taken into the VTC conference room. You call them or they can call you on these phones. The VTC phone numbers are on a laminated list on the wall, next to each of these phones. If the village clinic staff does not know how to set up or turn them on, Technology (#6070) can help too.
  • Use VTC in the ER and on inpatient unit to help evaluate urgent or emergency RMT whenever possible. This tool is especially great for assessing sick kids to decide if they can go commercial or need a medevac. It is also a great way to see the patient yourself and connect with the CHAs.
  • AFHCAN TeleHEALTH Images & ECG can be critical in assessing the village patient and to make a decision on stay, come commercial or medevac. Try hard to take the few extra minutes required to e-bill in Raven for your clinical decision-making as a result of viewing the image (over $1/2 million was collected from this effort over the last fiscal year alone). To bill – open the patient chart and select “orders” and choose “E/M Telemed billing.
  • Remember that medicines that have to be sent out to the village may take 3-7 days to arrive (or not at all). Therefore try to use a medication that is available in the village or if it is important (like a seizure or HTN medications), think about bringing the patient into Bethel… OR talk to the pharmacist about how long it will take to get the medication to the village and how to facilitate expedited delivery.
  • For kids, especially the younger ones, do not try to get labs/blood draws in the village. Have them sent in (except cultures of throat and cellulitis/abscesses). Bring the patient in—not the specimen in J.
  • You can always ask for an IV. Often the CHA’s can get them in older children and adults, but usually they are not able to get them in the little babies, so consider how you use your limited personnel resources in urgent or critical circumstances.
  • Labs the CHAs can obtain point of care are Hgb, Glucose, Dip urine, Pregnancy Test and RST. Throat culture should be sent for all negative RSTs. Dirty urine for GC/CT can be sent in as well as urine for culture (not recommended under 5 years of age). Abscess /wound cultures can be obtained and sent in, but blood cultures are not an option.
  • Don’t forget to ask the CHAs to check glucose in very sick patients and all seizing patients! Hypoglycemia is a potentially correctable condition in the village. There is glucagon in clinic pharmacy and you can always make sugar slurry to rub on the gums or drip on the oral mucosa. Glucose is not well absorbed rectally.
  • Do not treat possible pneumonia (all kids seem to have ‘crackles and wheezes’) or UTIs (dysuria is often from vulvovaginitis) in kids less than five years of age in the village…bring them in. You will end up over treating with antibiotics and contributing to antibiotic resistance.
  • Regional UTI organisms are becoming increasingly resistant to Amoxicillin and Septra, therefore empiric treatment is not easy. Many kids under five with dysuria have penile irritation or vulvo vaginitis. Dip urines and culturing urine in the village and sending it in does not work well for the younger children. Get a good history (dysuria, increased frequency, new day and/or night accidents, fever, prior history of CULTURE DOCUMENTED UTI etc). If a young patient looks good and does not have concerning symptoms, you can try sitz baths and A&D for a day or two and see if the symptoms resolve or send them in if you are worried and need a UA/Culture.

Younger kids with possible pneumonia, who look good and have no evidence of significant systemic illness can be watched. Many kids have crackles and wheezing due to bronchiolitis that can be managed in the village with nebs and close follow up for a few days. They will either declare themselves sick enough to come in or improve.

  • Always consider the weather in Bethel and in the village when deciding what kind of follow up the patient will need. A patient that is stable but has the potential to get worse should be brought in on the next commercial flight especially if the weather is marginal or has the potential to get worse-this may avoid having to medevac or have a patient stranded in a village and getting sicker.
  • Try not to pre-treat patients with antibiotics that need to come in to the ER, but pre-treat them if you need to. If a patient is toxic looking or there is going to be a significant delay in getting a potentially very ill patient, to Bethel, then it is important to treat.
  • H/O amoxicillin allergy is rarely a true allergy. Get more information about what the reaction was, at what age it occurred, look at telemed pictures if you can, consult a pediatrician if they are little and consider amoxicillin challenge in the village OR bring them to ER or clinic in Bethel for this. see amox allergy info link here. Over 90% of the time there was not a true allergy and the flag was put on EMR because a parent reported a h/o rash or hives that was not really hives OR it was imported from our old medical record system and was not validated.
  • If you are thinking of sending a patient in, or debating when/if they need to come in, always ask when their next flight is. Sometimes, even for very sick (but stable) patients, it is quicker to send commercial then to send med evac. Always make sure they are stable if sending commercial.
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