Category:Pediatrician Specific Practice

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Introduction to Pediatric Practice at YKHC

YKHC is an unusual and wonderful place to practice medicine and especially pediatrics. Pediatricians at YKHC act as subspecialist extenders for all pediatric specialties that are not available in Bethel and often not in Alaska. There are many unique and interesting challenges (and frustrations) with practicing medicine in a remote region with travel and communication issues that are unique to our area. It is a lot like practicing third world medicine with much better support and infrastructure. The medicine is interesting and spans from primary care to pediatric subspecialty management to critical care with NICU/PICU patient stabilization and transport. Pediatricians at YKHC are primarily responsible for Chronic Peds Patients or complex and chronically ill kids, but we also do a variety of other patient care as well.

Pediatricians manage approximately 1200 chronically ill patients of mainly Yup’ik Alaskan descent with significant respiratory, genetic, metabolic, cardiac, endocrine, neuro and infectious disease issues. They act as pediatric subspecialty extenders and consultants for family medicine, emergency medicine and village health aide providers. Pediatricians manage ADHD, fetal alcohol syndrome, cerebral palsy, seizure disorders, congenital heart disease, congenital adrenal hyperplasia, asthma, aspiration syndrome, chronic lung disease, and issues related to prematurity. In clinic, pediatricians see complex care pediatric patients, urgent, acute and well child care patients as well as ER follow up patients. On call pediatricians need to be able to stabilize, manage, and transport critical care and neonatal emergency patients. Occasionally the pediatrician ‘on-call’ will fly on medevacs to villages for potential preterm or high risk term infant deliveries. The pediatricians assist and collaborate with pediatric sub-specialists when they visit YK. Occasionally pediatricians make visits to village clinics or subregional centers.

Hospitalist pediatricians work on the inpatient ward and manage hospitalized children with chronic and/or complicated issues. They are also responsible for providing consultation to family practitioners, emergency medicine physicians, midlevels and village health aides; attending all high-risk deliveries and pediatric codes; and providing intensive care while patients are awaiting transport. Sometimes a pediatrician will need to run or help run a code long distance via telephone or video conference.

Outpatient pediatricians work in clinics providing care for routine, acute and complex care pediatric patients. They also provide consultative services to family medicine clinic providers and liaison with sub specialists plus behavioral health, developmental, educational service providers Some pediatricians do both clinic and hospitalist shifts and all pediatricians share night, weekend and holiday call. Call consists of consults, care of hospitalized pediatric patients, medevacs and care/stabilization/transport of pediatric patients in the ER and newborns as required.

At YKHC, our pediatric patients get more invasive disease than children in the lower 48. We have therefore adapted standard lower 48 guidelines and created some of our own for more conservative evaluation and treatment of our patients. In most places you would not do as many labs and Xrays as we do here, but oten pneumonia, bacteremia and serious infections are missed if we do not check. Kids can be running around the ER with a little cough and no significant lung exam findings and then have a significant pleural effusion on CXR. Or a well looking 2 month old with a low grade temp will have 230 WBCs in their CSF. We also have invasive Hflu A infections with either indolent or aggressive presentations. It pays to be very, conservative, vigilant and to watch kids closely before sending them back to a village where they might get worse and not be able to return due to weather. ***Please see the following power point to get a better idea of some of the medical ad logistical challenges we face. We are often asked what defines a Chronic Pediatric Patient. There are a few absolute criteria and then some softer calls.

Definition of a Chronic Peds Patient (CPP):

1. Premies delivered less than 36 wks

2. Pediatric patients that are followed by a pediatric specialty such as neurology, cardiology, endocrinology, etc. (Peds does not need to follow patients seen by the adult ENT, ortho, Behavioral Health or surgery)

3. All pediatric patients that require close pediatric care management and village RMT follow up

4. Any young infants that have had recurrent lung infections or significant/chronic lung disease less than 6 months of age as these have a tendency to be much sicker until they get older

5. Any infant or child that a provider, in collaboration with a pediatrician, feels warrants peds only clinic, RMT and inpatient care and care management.

Once a pediatric patient has been added to the CPP registry, they are seen in clinic only by the pediatricians (unless none is available), the health aides report them to peds ‘on-call’ and they are managed by the pediatricians and our peds care manager. Sometime the CPP kids get graduated as they get older and their lung disease or other problems improve or resolve. The chronic kids will stay with peds until they are 18 or they stop seeing a pediatric specialist at YKHC.

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