Alternate Common/Unique Diagnosis

Practicing Medicine in Bush Alaska—Some ABCs

Category:YKHC Guidelines

Emergency Department

• High-Flow Nasal Cannula
• Acute Myocardial Infarction
• Acute Ischemic Stroke
• Sepsis (Adult)
• Sepsis (Pediatric)
• Fever (0-90 days)
• Influenza
• Pneumonia (Adult)
• Procalcitonin (PCT) in Adult Lower Respiratory Tract Infections
• Pneumonia (Pediatric)
• Croup/Stridor
• Bronchiolitis/Wheezing
• Tuberculosis (Active and LTBI)
• Skin and Soft Tissue Infection
• UTI – Adult
• UTI – Children 3 Months–5 Years
• Seizures (Pediatric)
• Head Injury / Concussion Under 18 Years
• First Trimester Vaginal Bleeding
• Frostbite
• Burn Evaluation and Treatment
• Rabies
• Acetaminophen Overdose
• Alcohol Hangover/Withdrawal
• Title 47 Hold
• Amoxicillin Allergy Trials
• Botulism
• Fish Finger

Neonatal

• newborn Early-Onset Sepsis/GBS
• Neonatal Jaundice
• Neonatal Glucose Screening

Pediatric

• CPT1A Arctic Variant
• Congenital Adrenal Hyperplasia (CAH)
• Congenital Sucrase-Isomaltase Deficiency (CSID)
• Haemophilus influenza type a (Hia)
• Kuskokwim Syndrome (Arthrogryposis-like syndrome)
• Metachromatic Leukodystrophy (MLD)
• Micro-aspiration (in Apparently Neurologically Typical Children)
• Rickets and Vitamin D Deficiency
• Septo Optic Dysplasia

Abdominal pain

• This is another very common reason for a visit to the ED. Most of our patients do not have access to fresh fruits and vegetables and reliable safe drinking water and therefore constipation is very common. The nursing staff has standard orders for triage for this problem. We do not have surgeons in Bethel (except for OB related issues) and so all appys need to travel to Anchorage if the surgeon wants to take out the appendix. They can often travel in on a commercial flight if they are stable. If unstable, or if pain can’t be controlled, they will need a medevac.

Injuries/Fractures

• Please send all x-rays with fractures diagnosed to ANMC orthopedic telerad. This is a paper form you must complete. That allows for non-urgent consultation to take place via the ambulatory clinic. If there is an urgent need, please call ANMC and speak to the on-call ortho doc. They can give you some advice over the phone and, during the day, look at your x-rays.
• If the patient is a trauma victim, call ANMC surgeon on call. They handle all calls related to trauma, even if the primary injury is orthopedic.

Bronchiectasis/Chronic Cough

Pathophysiology: Recurrent pneumonia and lower respiratory tract infections cause airway damage that leads to "ectasia" and lossof elasticity of bronchi. Loss of muco-ciliary function leads to difficulty clearing secretions.
Risk Factors:

• low birth weight
• Prematurity
• Early recurrent respiratory infections
• Previous injury
• Enironmental effects (lack of piped water, household crowding, woodstove in the house)

Demographics: Alaska YK Delta: 1 in 63 children, Central Australia: 1 in 68, U.S.: 1 in 250,000. low income.
Signs/Symptoms: Chronic wet cough
Diagnosis: Progression of disease from protracted bronchitis to chronic suppurative lung disease (3 episodes at least 3 months each) and CT scan confirmed Bronchiectasis
Management:

• Reduce infection-inflammation: treat early and exacerbations 'aggressively' with antibiotics, airway hygiene clearance, vaccinations
• Improve other factors contibuting: attention to nutrition, detect complications, pllutants
• Systemic care: regular review, multi-discplinary care, education, enhance self care and management

Critical Times for Affected Patients: during exacerbations, if untreated can lead to early COPD and death
Resources:

• Bronchiectasis: Prevention and Management 2016 (Powerpoint Presentation by Rosalyn Singleton, MD)
• Singleton RJ et al. Indigenous children from three countries with non-cystic fibrosis chronic suppurative lung disease/bronchiectasis. Pediatr Pulmonol 2014.
• Redding et al. Respiratory Exacerbations in Indigenous Children From Two Countries With Non-Cystic Fibrosis Chronic Suppurative Lung Disease/Bronchiectasis. CHEST 2014:146;762-4
• Healthy Homes Study
• YKHC Clinical Guideline for Bronchiectasis

H. pylori

Pathophysiology:
Inheritance:
Demographics:
Signs/Symptoms:
Diagnosis:
Management:
Critical Times for Affected Patients:
Resources:

• Updates on H. Pylori Research in Alaska 2016
• Dyspepsia (H. pylori) YKHC Clinical Guideline

Hepatitis B

Hepatitis B is common here with the probable major mode of transmission being sexual or close contact. There is a high carrier rate and the “Hepatitis B” program does an excellent job in following AFPs and LFTs to screen for hepatomas bi-annually in these carriers. Children not vaccinated at birth and all Alaskans and health care workers working in Alaska should receive the three part vaccination. Pregnant women who are carriers need to have their HepBeAg tested. If it is positive the child at birth should get the Hep B immunization as well as the immunoglobulin. If the mother is just HepBsAg positive – they do not get the immunoglobulin. If the mother is just HepBsAg positive—they do not get the immunoglobulin—Epidemiology per our State recommendations.

Resources:

• Hepatitis B Neonatal Prevention 2017

HLA-B27

This is frequent in this population with all of its associations (Reiters syndrome, Rheumatoid arthritis, and spondyloarthropathies are much more common here. We manage patients with rheumatic arthritis on Methotrexate with the assistance of ANMC specialist. Remember the labs that need to be done Q 1-2 months – kidney, liver, and blood count – CBC and Comp Chem.

Otitis Media/History of Mastoiditis

Lots and lots on the Delta. Please refer to our Otitis Media Guideline. If the TMs are red and have no mobility – then recommendation is to treat them. Our antibiotic recommendation include—first line high dose Amoxicillin, second line Augmentin, third line Omnicef, and lastly Rocephin x 3 days. If the child has a long history of ear infections – referral for audiology for hearing eval . Tube placement referral is very common – it is done in Anchorage.

Many people over the last few decades had mastoiditis and had mastoidectomies to treat it in our population. They should be seen by ENT every 1-–2 years to have their mastoid bowls cleaned out and examined.

In general, children should be direct referred to ENT for PE tube placement if they have recurrent (>3 in 6 months or 4 in a year) infections or persistent effusion >3 months (especially with hearing loss). You may also refer these patients to audiology if there is a question of hearing loss/speech delay secondary to recurring infections; this is another route to ENT care as the audiologists routinely do telemedicine consults with the ANMC ENT’s using TM photos. We no longer do antibiotic prophylaxis for recurrent OM’s, as this has not been shown to be effective. All infants fewer than 3 months of age that are diagnosed by a CHA to have otitis media should be seen and evaluated in Bethel before being started on any antibiotic.

Resources:

• ENT Guidelines 2015
• Otitis Media
• The Draining Ear
• Acute Otitis Media (3 months to 12 years) YKHC Clinical Guideline

Septic Joint

Any children with a red, swollen joint with or without fever and refusal to use the limb should be evaluated in Bethel. Suspected toxic synovitis should also be evaluated here and not managed in the village. Some joints can be tapped in Bethel for evaluation; several of the family practitioners and ER providers are trained in aspiration of some joints, although hip joints and other complicated joint aspirations are usually done by ortho in Anchorage. You can always consult with other providers here or with ortho in Anchorage if you are uncertain of how to manage a patient.

Strep Pharyngitis

This is usually caused by a Group A (strep pyogenes), but can be caused by groups C and G. It usually occurs in children ages 5-10 with peak incidence in the first few years of school. The transmission is through direct contact via respiratory or nasal secretions. There can be food or water borne outbreaks and the incubation period is 2-4 days. We have a great deal of strep throat in the Delta as well as peritonsillar abscesses.

Clinical onset in older children and adults is abrupt onset of ST, HA, malaise and feverish.

The pharynx is usually red and edematous with hyperic/hyperplastic tonsils with white exudate, tender lymphadenopathy, and T>101. Symptoms usually last 3-5 days. It may develop into a peritonsillar abscess – with a enlarged asymmetrical tonsil – exquisitely tender. This may need to be drained by needle aspiration. Exudative pharyngitis in children less than 3 is rarely streptococcal. Type specific antibodies are seen in 4-8 weeks and protect against infection with organisms of the same M-type.

Treatment

Positive strep in a patient with no allergies can be treated with LA bicillin x 1 – with age appropriate dosing. If the family requests PO treatment – it is now recommended to give penicillin – 750mg po Q day x 10 days. You can use the daily dosing to increase compliance.

Evaluate for dehydration – as some of our severely ill patients require IV fluids – as they are so dehydrated due to decreased oral intake from the pain. If a peritonsillar abscess looks likely – it will need to be drained with needle aspiration – using hurricane spray for numbing. Ask for assistance with this as it can be tricky. Be aware that there can many complications from strep – and a review of common complications and management is important.