Category:SRC Clinic Provider Orientation
Overview/Clinic Description
We have five subregional clinics (SRCs): Aniak, Emmonak, Hooper Bay, St. Mary’s, and Toksook Bay. See Map. Each clinic has enhanced resources and capabilities compared to regular village clinics. Each clinic has radiological imaging, lab facilities and limited ER/Urgent Care equipment.
In terms of staffing, the goal is to have two midlevel providers plus behavioral and dental health aides to provide care to patients in the SRC village as well as those villages in close proximity. At times the SRC may be the staging area for emergent transports that are not able to make it to Bethel, en route to Anchorage. Midlevel providers care for patients during regular clinic hours as well as provide nighttime and weekend call for emergencies.
Midlevel providers function like specialists in the region. They are called upon to provide care involving many different disciplines such as orthopedics, women’s health, acute pediatric issues, and trauma resuscitation. We have medical specialists such as cardiology, neurology, internal medicine, etc. in Anchorage, which can be contacted for consults. Pediatric, Emergency and Family medicine providers are available in Bethel for consults. Please don’t hesitate to call for any acute issues in which you need assistance.
Remember there are YKHC Clinical Guidelines for reference on many clinical situations. They lay out specific medical plans based on our population's challenging illnesses and our specific antibiotic resistance patterns.
Remember that health aides in villages may have already prescreened 50 percent of the patients we see and only the sicker ones have been sent on to the SRC. Therefore at times you need to be more aggressive with our sick patients.
Job Description/Duties
ON CALL
You will be seeing patients during the day, but on call on nights and weekends for emergencies. Our health aides will be on first call but will call you if they need additional help or approval of their plan. You may not have to come in but you need to be available to talk to them. Some SRCs have working cell phones to make this easier. Some villages (Aniak at this point) have a working ambulance that will bring patients directly to the clinic for you to see.
If you are the only provider at a SRC you will be on call Monday, Thursday with the weekends off except for dire emergencies.
It is important for the Health Aides to take first call and to fully assess the patient, then give you a call unless there is a dire emergency. That is their duty. Please encourage the health aides to do the initial assessments. When there is a seriously ill patient all health aides and staff may be called in to assist with that patient.
Required and Recommended Meetings
Note: Meetings can be arranged via teleconferencing from the SRCs
General Clinic Information For SRC Reference
Preparing For and Navigating Daily Clinics
Clinic Appointments/Encounters
SRC Specific Information
Admissions/ER Management/Need To Transfer
If you are seeing a patient you feel needs to be admitted to Bethel or is too sick for SRC management, the patient will need to be Medevaced from the SRC to either Bethel or Anchorage for a higher of level of care.
- Contact either Inpatient Provider Yukon /Kusko or ED Physician, depending on case and decide on the medevac plan.
- Determine where the patient needs to be transferred- Bethel or Anchorage.
- Determine who will activate LifeMed .
- Obtain Medevac Packet which contains consent forms which need to be completed
- Complete your RAVEN documentation
Some things to keep in mind:
Escorts can fly with the patient if there is room, but YKHC will not pay for them to fly home, so their travel home will be out of their own pocket.
Any time you initiate a Medevac know that you will be talking to several different people and making several different calls.
If they are flying directly to Anchorage from a SRC, the SRC provider will be the one calling for a direct accepting physician in the receiving hospital. You will call either the ER of Providence or Alaska Regional if it is a non-beneficiary patient or at ANMC the ortho or surgery or internal medicine physician. Explain the case to them and why you're medevacing the patient. Once they accept, you place their name and the place of transfer on the PTO Patient order form. You need to notify the YKHC ER just so they know that a medevac is coming from Anchorage to your village, but you can do all the communication, etc. yourself.
If flying to Bethel, usually the accepting physician is the Ward doctor, or the ER doctor will fill out the PTO and be the accepting.
If the patient is going to Anchorage you will then get two more calls. One is from the house supervisor at the accepting hospital, usually a nurse who wants to verify the patients name and diagnosis.
You will also receive a call from the LifeMed medical control, which is based in Anchorage to ask about the patient's condition, etc. before the paramedics who pick up the patient take over control.
Bethel has an OR that can be used for emergencies, but no ICU and no general surgeon or neurosurgeon. Bethel has a CT scan but no MRI. Depending on which village you are in, you may be able to call for an ANMC medevac, if immediate surgery or a vent is needed, but talk to the Bethel doc to help you make that call.
The types of admissions for YKHC hospital are mainly large abscesses and/or cellulitis that have failed outpatient treatment, large lower extremity cellulitis/abscesses that have not yet had outpatient treatment, pneumonia, bronchiolitis, suicidal ideation, COPD exacerbation, fever in a neonate and labor.
If you have a child that is not a Chronic Peds Patient (which you can tell by looking at the banner on the first page of the patient’s health summary) he or she can be admitted to the Family Medicine Ward doctor. If it is a complicated child and/or it is a Chronic Peds Patient, the child should be discussed and possibly admitted to the Pediatrician on Call. Page On Call Peds using the pager sytem on Raven. The pediatricians always help with the treatment and plan of care for the Chronic Peds Patients.
Medevacs SRC Paperwork and Process
At times you will have a patient arrive who is too sick to stay at the SRC. You will need to care for the patient and initiate a medevac. Evaluate the patient, have the health aide start your treatment plan—i.e. start an IV and bolus fluids, and call the ER to consult and initiate the medevac. Once the ER agrees, you can call the Anchorage dispatch center, 1-888-???? and they will call the Bethel crew to get ready and come, or the ER can do that for you. If there are weather delays, the dispatch center will let you know. You will have to handle the patient until the Medevac comes, which is a plane with two paramedics and much equipment.
There is a consent form, and a Patient Transfer Order Form you will need to fill out. I really recommend that you use your PCC, but then document all vitals , your secondary exam on extra pages and the flow sheet. If you are able to write a transfer summary, that is helpful, but not essential. All meds need to be documented. Before the patient is handed off to the Medevac crew you need to do a second exam and document how the patient is doing. You also need to document the time that the medevac is initiated and that the physician was consulted with, what time the team arrived and what time they left.
At times the patient is so severely ill or damaged that you know that they will need to go directly to Anchorage if possible. If you are in St. Mary’s, Aniak, or Emmonak, that may be possible. If the patient is going to need surgery, i.e. a gunshot wound, or is already intubated it may make more sense for them to go straight to ANMC. Discuss it with the Bethel ER and they or you can contact ANMC directly, talk to the Surgeon or Internal Medicine MD and get it initiated. If that happens, the nurse supervisor from ANMC should call you within 10-30 minutes to say they have sent the medevac. If that doesn’t happen, call ANMC back to make sure it is on its way.
Sometimes the patient has been stabilized and time is of the essence and the medevac team may ask you to do a Runway transfer, bringing the patient to the runway for quicker turnaround time. If this is the case, get a copy of all paperwork to give the team and get them to the runway.
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