Outpatient: Detailed Information
Pediatric outpatient providers see patients Monday-Friday from 9 a.m. – 5 p.m. We are responsible for the care of the approximately 1200 chronic pediatric patients on our Chronic Pediatrics Patient Registry (CPP), as well as for the routine care of children in our assigned villages. Outpatient providers are assigned panel villages based on number of patients as well as locations of villages in the area. The goal of scheduling is to have continuity of care within the villages providers serve. Ultimately, providers will attempt to do village trips to assigned villages. Family practice providers, village health aides and the State of Alaska Public Health Nurses who give immunizations and check-ups also do well child visits in the remote villages. All infants who are six – eight weeks of age will have their well child visit and immunizations with a provider in Bethel. This coincides with the maternal 6-week post partum visit.
Pediatric providers perform six-week checks of high risk, chronically ill infants and infants from assigned villages. We provide primary care for the children in assigned villages; family medicine and Emergency Room patients that require pediatric follow up; and cross cover for other pediatricians as our schedule allows or if a parent requests a pediatrician.
Pediatricians provide clinic follow up of patients recently discharged from Alaska Native Medical Center (ANMC) and Providence Hospitals in Anchorage from the NICU, inpatient or PICU services. We evaluate patients en route back to their home villages and provide additional information and prescriptions if needed.
Since some of the well care and routine pediatric illnesses are handled elsewhere, you will find that your clinic patients are usually more complicated and sicker than the patients you would see in a lower forty-eight general pediatrics practice.
Some of the pathology and diseases that you are likely to encounter in the delta are: Seizures, Congenital Adrenal Hyperplasia, Asthma, Bronchiolitis Chronic Lung Disease, Cardiac Lesions, Meningitis, Sepsis, Prematurity, CPT -1 Deficiency, ADHD, Developmental Delay and FASD. It is not unusual for you to contact various subspecialists during a clinic day. If you have a question regarding one of your patients, do not hesitate to contact a specialist for guidance. We are blessed with a whole range of providers who are familiar with our unique patient population available for consult by phone/email that are happy to answer your questions. If you cannot find the subspecialty you need, ask an “old timer” for help.
We are responsible for helping to support Pediatric subspecialty field clinics in Bethel within the following areas: Pediatric Cardiology, Pulmonology, Endocrinology, ENT, Orthopedics, Surgery and Neurology.
If you have a patient that requires one of these specialties you can check to see when the next field clinic is scheduled and place a referral in RAVEN.
If the patient requires an appointment sooner than is available in Bethel you can also send patients to Anchorage to see Pediatric Cardiology, ENT, Urology, Pediatric Gastroenterology, Pediatric Endocrinology, Allergy/Immunology, and Genetics. For patients requiring procedures such as EEG, MRI, swallow study, hip ultrasounds etc. that are not available in Bethel.
Order a referral in RAVEN and send a communication to pediatric case manager who can coordinate the appt., travel, etc. for the patient. Be thorough in filling out the referral form to provide enough information to the consultant. To ensure adequate care for complicated cases, it may be helpful to write a letter summarizing the case and/or have the case manager assistant include a copy of lab and radiology reports with the referral information.
Surgical referrals require an accepting physician. You must consult a surgeon at ANMC via phone if urgent and via telemedicine if non urgent.
All clinic notes should be completed in RAVEN within 24 hours of encounter. Include a brief past medical history and review of systems. Medications and drug allergies should be reconciled on the patient’s chart at every visit. Labs should be clearly documented as well as treatment plan and follow-up instructions. All chronic pediatric patients should have some sort of follow up plan at the bottom. Documentation of parent/patient education should be given as well as the level of education and level of receptivity; it need not be specific but can be more general such as “asthma education provided.” Every note should include documentation of instructions for returning to the clinic or health aide i.e. difficulty breathing in a patient with bronchiolitis.
Medication refills: are a part of your daily responsibilities in the clinic. Some of these will be refills for ADHD meds. Controlled meds (stimulants and pain medications) should be printed, signed and brought to pharmacy directly. We have an ADHD Guideline that all children on stimulant medications should have a clinic visit at least every 6 months. Once it is time for their follow up we will not fill their meds until they are seen. Refills are for a maximum of 30 days and you will need to include your DEA # (automatically done though the computer system) every time you refill a med. Non-schedule meds (seizure meds, asthma meds, etc.) will be refilled from a pharmacy or case management request.
You will see several cases in the Delta that are unique and/or more severe than those encountered in children in non-Eskimo cultures. Examples are:
Wheezing: Wheezing is a common complaint on radio traffic. In infants, wheezing is most likely due to bronchiolitis or asthma. Listen carefully for a history of recurrent wheezing in the past as a clue toward asthma. For infants presenting for the first time or with associated stridor, think foreign body. Wheezing in older children should not be diagnosed as “bronchitis” as this is not a disease seen in children. Older wheezing children have asthma, a viral process or pneumonia. Be tuned in to a reported past history that points to undiagnosed bronchiectasis (productive cough greater than 3 months). These children should be seen in Pediatric Clinic for an evaluation.
Febrile Infants: We follow the generally accepted policy that infants under 3 months of age with a fever of 100.4° or greater should be evaluated in Bethel for severe bacterial infection and sepsis work up as appropriate. The CHA’s are not allowed to give infants less than 3 months of age antibiotics in the village without a physician’s order, and these infants should be evaluated in Bethel before being started on any antibiotic therapy. Infants with fevers 100.4° or greater that have a normal exam and are clinically stable do not need to be medevaced, but they do need to come to Bethel on the first plane in the morning. Infants with fever who appear ill, have respiratory distress, or are toxic in appearance should have a medevac arranged, and IM ceftriaxone should be given in the village if any delay is expected. A blood culture should be obtained prior to Ceftriaxone if the patient is in a SRC. Our guideline on management of fever in infants better details our usual management style. If you have questions upon starting at YKHC, feel free to consult another pediatrician.
Otitis Media: This is the most frequent and the most frustrating outpatient problem we have. Please see the pediatric guidelines for managing recurrent otitis media, persistent effusions, and chronically draining ears. 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.
Strep Pharyngitis: There is a high rate of streptococcal complications here, including peritonsillar abscess and rheumatic heart disease. Rapid strep tests are available in the village and clinics, and are routinely done (often as a nurse-only visit) when a patient complains of throat symptoms. Two RST swabs (preferably at the same time) should be obtained. If the RST is negative the second swab should be sent to Bethel lab for culture confirmation to ensure that false negatives are not missed. We do not strep screen children <3 yo routinely. If indicated, patients with recurrent RST+ pharyngitis may be direct referred to ENT for tonsillectomy (even via RMT).
Septic Joints: 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.
Skin & Soft Tissue Infections: Here in the Delta, even the simplest laceration or hangnail is much more likely to get infected. We also have very high rates of infected eczema, varicella and insect bites. Be extremely aggressive about cleaning, debriding and close follow-up, with a low threshold for using oral antibiotics. Boils are usually managed with I&D, although small pustules can be managed with frequent hot-packing and close follow-up, especially if spontaneously draining. Follow up care can be provided by our wound care specialist or physical therapy. See our boil management guideline for details and for antibiotic choices.
Congenital Adrenal Hyperplasia: The Yup’ik Eskimos have the highest incidence of CAH in the world (1 in 300). CAH is caused by a deficiency of one of the enzymes in the cortisol pathway (most commonly 21 hydroxylase). In females, it presents with ambiguous genitalia and salt wasting. In males, it presents as salt wasting in infancy, and less commonly as precocious puberty in older males. These children are followed very closely by the pediatricians and are chronically treated with hydrocortisone or dexamethasone and fludrocortisone. Children with CAH need to stress-dose or double-dose their glucocorticoids (but not mineralocorticoids) with fevers, and triple-dose if having a severe illness or vomiting. If they are unable to take po steroids, most have IM hydrocortisone available in the village; when doing “CAH check-ups”, be sure to check their meds rec forms to make sure that prescriptions are up-to-date, and that the parents are familiar with stress dosing plans. Routine labs for CAH kids include 17-OHP, androstenedione and renin activity levels; we also do bone age films frequently on pre-pubertal children. The latest endocrine clinic note usually details the desired frequency of labs/films for that particular patient, and when they are due for endocrine follow-up.
Child Advocacy Center (CAC) Well Child/SART follow up: These are 60 minute appointments for evaluation of cases of child sexual abuse which are non-acute greater than 96 hours. Often these patients have been interviewed at the CAC and are presenting for physical exam. Acute exams less than 96 hours are often completed in the SART room in conjunction with the SART nurse who assists in collecting forensic data including photographs with colposcope. See guidelines for details on the process.