Now I Remember...I Have a Job
In the haste to put down memories of my first few weeks at the Pole, I’ve kind of forgotten to tell you what I’m actually doing to pay the mortgage and feed the dogs. I’m the over-winter physician here at the station, and a background player at best. That sounds self-obvious…it’s a station built for science, and most of us are simply here to support that…but for a physician it’s a very strange feeling. In my Universe of the Small Rural Emergency Department, I’m the center of attention and everything has to go through me. I see the patient, order labs and x-rays, talk to consultants, make medical decisions for admission or discharge, write prescriptions, and provide patient education. I’m not the only one doing this, of course. Nurses and other providers are partners in this effort, and once there’s rapport with a certain core team they can anticipate what I do and what I might say, and often add valuable insights of their own. But there’s no ignoring the fact that the health care system in the United States still runs through doctors. Without doctors to see the patients and write the orders, you don’t need an Electronic Medical Records nor an IT Department to support it. No doctors ordering tests means you don’t need lab or x-ray techs; no one prescribing medications means pharmacies are out of business. No doctors admitting patients means no nurses are needed to provide care. Nobody making diagnoses means no billings and no payments. You don’t need facilities management nor housekeeping because there’s no facilities to manage, and certainly no administrators would be needed to remind doctors of everything they’ve done wrong.
According
the BGFE, the “doctor-centric” world of health care feeds right into my basic
personality characteristic, which is called “Notice Me!” Apparently if I don’t get any attention after
about fifteen minutes, I’ll do or say something to get recognition. This is sometimes a bid for affection, like
coming near where she sits at her desk to give her a pat on the shoulder or a
kiss on the head and telling her she’s the Most Wonderful Thing in the
World. But to be honest, it’s more often
something like saying, “Hey, look at this!” and making her gaze at an internet
meme on my phone, or perhaps bounding about the bedroom where she works with
the “Look at Me” song:
“Look at me,
I’m your boyfriend!
And I like
to laugh and dance and prance and sing.
Look at me,
I’m your boyfriend!
And you know
that I am cuter than anything.
I’m your
boyfriend, so look at me!”
(One of her
gifts to me before I came to the Pole was a t-shirt with a meth-addled cat on it
screaming “Pay Attention to MEEEEEEE! MEOW
MEOW MEOW MEOW!” I think there’s a
message there.)
Relationship
experts at the Gottman Institute would call these “notice me” moment “bids” for
affection and affirmation, and couples who turn toward these bids rather than
turn away are more successful over time.
Given that after a decade she has yet to run screaming after the next
bad Dad Joke I’ve found online, we’ll probably do okay. But I’m not the best in the house at this
game. Once when both her son and I were
trying to get her attention, he picked up a dog and stood directly in front of
her, saying, “Notice ME. I have a
puppy.” You can’t fight that.
Being a physician at the Pole is different. While I might be the center of attention in a
hospital ED, here I’m just part of the supporting cast behind the scientists. The place has reason to be in my absence and
will run just fine without me. While I’m
sure there’s a certain level of reassurance that comes with having a physician
onsite with 24/7 all, the Station needs facilities engineers and satellite
technicians and heavy vehicle mechanics and galley staff to operate. You realize quickly that you’re an accessory
and not part of the main effort. There’s
a certain humility that happens when you’re out of the clinic setting and you
realize that not only are the people you never see at the hospital constantly
by your side, but that they know a hell of a lot about things you’ve never even
thought about; when Nuclear Winter comes, the guy who can fix the generator is
higher on the totem pole than you. If it’s
true that one of the lessons of a career in medicine is learning how much you
really don’t know, living and working in close proximity to people outside of
medicine and being dependent on them for your own health and welfare reproduces
that lesson logarithmically.
**********
Let’s take a quick tour of the clinic itself. You enter off the main hallway on the second floor through a set of metal double doors crowned by a Club Med sign. The sign is a leftover from the previous 1975-2008 version of the Amundsen-Scott Station, which was essentially a Buckminster Fuller Geodesic Dome erected over a set of portable classroom buildings that served as offices, berthing units, science and communications facilities, the galley, and the medical clinic Rumor has it that the moniker “Club Med” arose because the clinic was the only heated building with a self-contained bathroom. Luxury, indeed.
Immediately
off to your left is a locked door that leads to our lab and pharmacy. It’s also the province of the Physician
Assistant, whose counter and desk share the space. The lab is a long, narrow, windowless room
that turns at right angles and meets another locked door that hides the
pharmacy from view. We stock a goodly
supply of most common outpatient pharmaceuticals, as well as injectable
medications to mix into intravenous solutions.
It’s a fairly impressive range of drugs for such a small cache. Our autoclave also lives with the pharmacy
stores.
Our
laboratory capacity is surprising in its’ range, but quite limited in it’s
depth. Still, it seems to be enough to
get by for most acute care work. Most of
our resources are self-contained “Point-of-Care” tests that can be done at the
bedside or nearly so. (A home urine
pregnancy test is an example of a POC test that can be done by the
layperson.) These POC tests include
those for Covid, influenza, HIV, strep throat, urine, and pregnancy. We also have a few lab machines to do basic
blood counts and chemistry profiles, and a few specialized tests such as drug
screens and cardiac panels (looking at enzymes released when the heart is
damaged, as in a heart attack).
Here’s an
example of the use and limits of our lab capabilities. In my short tenure here, we’ve evaluated a
few younger folks for new-onset high blood pressure, or hypertension. (In Doctor World, “younger” means less than
40, which is why when I had my first cataract surgery at age 56 the
ophthalmologist said I was one of his pediatric patients.) The first steps in the evaluation of a
patient with high blood pressure is simply to take the pressure regularly to
see if, in fact, the blood pressure is consistently up and needs care or if the
reading was simply high on that given day.
Once you confirm the diagnosis, you want to try to find out if there’s a
specific underlying cause. Those causes
often include kidney issues, and we can do a basic screen for protein in the
urine and for BUN and creatinine, two blood indicators of kidney function. But if these are abnormal, we have no way
to follow them up with other measures
such as 24-hour urine collections and chemical analysis of the urine; nor can
we examine levels of hormones such as renin or aldosterone to look for signs of
issues which may result in hypertension and require specific evaluation and
treatment strategies.
The other issue
here with lab tests is if you get an adverse result, what do you do with
it? This is not a unique issue at the
Pole…one of the old adages in Emergency Medicine has always been don’t get a
test if you don’t know what you’re going to do with the result. In the real world, abnormal labs can be
followed by more in-depth evaluation.
Here, there’s no such option, and our limited lab capabilities in some
way actually help us avoid this conundrum.
You can’t find things to investigate if you don’t have a way to look for
them; as noted in the Tenth Law of the House of God, “You can’t find a fever if
you don’t take a temperature.” Or, as the internal medicine specialists…known
as “fleas,” during residency, because they’ll stick to a dying dog until it’s
time to jump ship… might say, “Health is only the absence of a sufficient
work-up.”
(The House
of God is the best book ever written about medical training. I’ve read it three times. First, as a medical student, in total
disbelief. Second, just after my
internship year, when I recognized it was all true. And once more two years
ago, just to find it still is. Highly
recommended, whether you’re medical or not.)
Sometimes
what you do with the result of a test is different than you might do back
home. For example, in a patient with
shortness of breath we might do a test called a d-dimer to look for evidence of
a blood clot in the lung. (The test
doesn’t prove there’s a blood clot in the lung but, in combination with a
clinical history and exam, the test can be used to estimate the risk of a blood
clot being present and needing care. (The
official term for a blood clot in the lung is a pulmonary embolism. Now you know.)
Up North, a
positive test would most likely prompt a CT angiogram, a study in which dye is
used to visualize the blood vessels of the lung to look for clots or other
abnormalities. However, a CT scan is not
an option at the Pole. So you’re forced
to rely on clinical intuition (supplemented by risk scoring systems) to
determine whether or not you truly believe a blood clot is present and it needs
acute care. You can quite properly make
the case that we should always be in the practice of providing cost-efficient,
evidence-based medicine no matter where we practice, but that’s not how the
outside world works. The threat of
lawsuits for the missed diagnosis, the extended face time required for informed
shared decision-making on a chaotic environment, and the simple hassle of
dealing with unhappy or disgruntled patients (most of whom claim either a
relative who’s a lawyer or to personally know the CEO) is always there, so most
days it’s just easier to order the CT, know for sure, and be done with it. At the Pole you have to use circumstantial
evidence to determine your course of action.
The
discerning reader (which of course you are) might then ask if it’s possible to
put someone at risk for a missed diagnosis, or the provision of unneeded
care? And perhaps more importantly, what
happens when there’s a case you simply don’t have the resources or expertise to
handle? This is where we begin to dance
around the edges of nihilism in clinical care in remote environments, be it the
Pole, frontier and expedition settings, or in earth orbit and beyond.
When I work
at rural hospitals in the US, difficult and complex cases are most often
referred and transferred to a medical center offering a higher level of
care. During winter at the Pole, that’s simply
not possible. In a prior post I
mentioned difficulties with aircraft operations in winter related to darkness,
cold, and weather. In addition, the
aircraft used in the MedEvac process are located in Canada during summer in the
Northern Hemisphere. To get an aircraft
down to the Pole requires mobilization of both aircraft and crew from their
other duties and flying south via the West Coast of the Americas. To add further problems, at the end of the summer
season we also take away the skiway markers so they aren’t lost by drifting
snow and ice during winter. To
facilitate a Medevac, not only will the markers need to be replaced but the
skiway will need to be reconstructed as well. (This is something that’s done at
the start of summer to welcome the flights back in, but it’s clearly a
different project in total darkness and -100 F cold.) A MedEvac mission to the Pole requires the
cooperative efforts of scores of people across four continents. As a reflection of the difficulty of the
flight itself, the last time a winter Medevac occurred at the Pole the flight
crew received awards for achievement and heroism from the Smithsonian
institution and Aviation Week & Space
Technology magazine.
(I was
taught long ago that heroes are people who do stupid things and get away with
it, while martyrs are those who do stupid things and don’t. I have no desire to turn anyone into either
one this winter. Including me.)
Time also
works against the idea of a mid-winter Medevac from the bottom of the
earth. Once the MedEvac decision is
made, it can take up to a month for everything to be in place to send an
aircraft to us. Clinically, that month
may resolve the original need, one way or the other. And in a cruel perversion of Catch-22, if you
delay the MedEvac effort until the patient is stable for transport, that time
in and of itself delays the eventual MedEvac flight, and the improving patient
may not require transport after all.
While the clinic
is fairly well equipped for its’ size, in no way does it resemble a
hospital. We’re not set up to act as an
operating theater or an Intensive Care Unit, and we can’t anything more than
basic diagnostic or radiologic procedures.
And while I’ll put an Emergency Physician up against anyone in managing the
spectrum of acute illness and injury, there are things we simply can’t do and
seeking specialty care is not an option.
So you find yourself tacitly accepting a certain amount of defeatism,
knowing that some things are simply not going to go well and will inevitably
lead to a bad result. If you have a
heart attack I can give you clot-busting medication to try and dissolve any
blood clots blocking the arteries of the heart, but if you need an emergency cardiac
catheterization or bypass surgery to save your life there’s nothing I can
do. I can diagnose a stroke, but without
a CT scan I have no good way to tell if the cause is narrowed vessels going to
the head or bleeding within the brain tissue itself. I can make an educated guess, but it is a
guess, and if it’s the latter there’s really nothing I can do. If you have a severe open fracture of the
leg, I can try to line up the pieces, wash out the wound, close whatever skin
remains, and get you on antibiotics to prevent a wound infection. I can put you in a splint or a cast as
well. But I can’t actually fix a
fracture requiring surgery, nor deal with the more severe complications of
incomplete care.
The easy
response to this conundrum would simply be to say, “Well, get them a CT scan,”
or “Maybe they need an orthopedic surgeon” or some other reflexive answer. But nothing gets here without cost, and the
cost includes staffing, maintenance, and the impact on other resources. How often would that scan be used, is it
worth the infrastructure required for that relatively rare use, and do you know
what you would do with the results? The
same questions you ask with a single POC lab test apply to the larger picture. If you add a specialist, is the expected
incidence of that truly life-threatening injury that requires specialty care
worth not only the cost of the surgeon, but of the specialty equipment required
for state-of-the-art care? And if you
add one specialist, do you need more to provide the full spectrum of care? At some point it becomes an exercise in
diminishing returns.
(In many
ways, our situation is analogous to the issue of how much medical are you can
provide on the International Space Station.
You can put an AED on the ISS, but after that what’s next? If the patient’s not immediately better, they
may require further advanced airway care, intravenous fluids and medications,
and close monitoring and attendance. (At
least at the Pole I have the benefit of gravity to keep things in one place.) While the Soyuz spacecraft is readily
available for a MedEvac, how do you keep the care going in the small confines
of the re-entry module and what are the clinical impacts of the G-forces on
descent? And how much medical equipment
do you really need on the ISS given the health status of the astronauts, the
rare incidence of true medical emergencies, and the cost of getting the
supplies to orbit?)
I don’t know
that I would term this problem as any kind of “open secret,” because there’s
nothing secret about it. I do think that
all of us are extremely conscious of the risks of our environment and our
isolation, in a way the outside word with their embarrassment of riches simply
cannot understand. But when the
opportunity arises, I do try to mention our unique conditions in order to
promote realistic expectations for care.
Here’s an
example. There was a discussion the other day in the galley about why pregnancy
tests might be required for all females on Station before closing for
winter. Clinically, the last third of
pregnancy is when disasters happen. If
someone happens to get pregnant during the winter, I can handle both the
routine prenatal care and the most likely complications of the first six months
of pregnancy. But the last three months
is when the more dreaded problems arise; and even with a normal pregnancy and
you want resources available to you in case of a complicated delivery. We have neither the resources nor the
expertise to deal with these complications of late pregnancy, so the best way
to prevent these issues is to ensure that all women over-winter have negative
pregnancy tests in February; a positive test would send the woman home on the
last flight out, as the start of her last three months of pregnancy would fall
into August, before we have the availability of MedEvac transports for
specialty care.
(For the record,
we have no knowledge of any children being born at the Pole. We do
have a couple staying over-winter, but so far they seem disinclined to be the
first. I’m personally discouraging
anyone on my watch from making the attempt, because for all the miracle of
reproduction childbirth is kind of awful…everyone’s screaming, fluids are
everyplace, newborns are slimy, and nobody’s happy in the moment. If it
happens, I’ll do all I can to use Miss Prissy’s dodge and loudly exclaim, “Gee,
Miss Scarlett, I don’t know nothin’ ‘bout birthin’ babies!”)
Both The
University of Texas Medical Branch in Galveston (UTMB, the medical contractor
for the United States Antarctic Program) and the National Science Foundation
(NSF) are well aware of the limits of care in the remote environments. As a result, they require that everyone who
participates in their polar programs has
to be cleared through a Physical Qualification (PQ) process. The process includes a complete health
history, physical and dental examinations, and selected laboratory tests. Age and job status may introduce additional
requirements; in addition to the standard labs, chest film, and abdominal
ultrasound exam (looking for signs of gall bladder disease which might flare as
a surgical problem), I was of the age where I needed a cardiac stress test. Depending upon the findings, UTMB and NSF
physicians may require additional specialty evaluation for specific concerns or
require that certain procedures (especially dental) be performed prior to
clearance. (There is no truth to the
common belief that one has to have their appendix and gall bladder taken out
before going to the Pole. Perhaps
there’s already been an auto-lobotomy in those of us who decide to spend our
year this way, but we did that to ourselves.)
I personally found the process quite reasonable, perhaps because as a physician I understood their concerns. But there’s been a lot of disparagement of the process and gnashing of teeth by those who struggle with the PQ saga. I get it. Most participants make their own appointments for exams and tests, and much of it is on their own dime. The sheer volume of paperwork is impressive, the process still works mostly by fax, and I have a sense the staff is hard-pressed to keep up with the demand. There have also been accusations that the PQ process is racist, sexist, and random, institutionalizing differential treatment of applicants with similar conditions. But a larger perspective suggests that the process is done as well as it can be given the need to centralize and interpret the recommendations of physicians working with applicants from all over the world, and integrating this information with established PQ standards. Without the ability to centralize all operations of the PQ process, including physical examinations, dental evaluations, and specialty consultations in a contained system with a single set of standards, I’m not sure there’s way to do it better. And as the over-winter physician, I want the PQ process to be tighter rather than lax, to screen out everything it reasonably can, to make sure I’m starting my sojourn with a healthy population and I’m not wearing clown shoes in a mine field (one of the most colorful and accurate ways ED doctors describe their careers).
**********
Onward we go with our tour. No stopping for pictures. Please follow the yellow flag with the caduceus. We’re walking, we’re walking…
You open a
second set of metal doors and enter the Clinic itself. To the left are two small rooms, one for our
linens and laundry, the other laden with cleaning supplies for floors and (we
do out won cleaning and mopping and sweeping).
Turning right is the acute care area.
There’s stretcher in the middle of an open area framed on one side by
our portable x-ray machine and the cardiac monitor and “Crash Cart” on the
opposite wall. IV poles with pumps and
oxygen tanks stand at the ready. Two
mounted supply cabinets watch over the head of the cot. The cabinets stock what you might expect at a
reasonably suppled rural ED, including oxygen masks and nebulizers, syringes,
needles, suction catheters, and intravenous supplies and fluids. Flanking the similarly well-equipped Crash
Cart and the neighboring oxygen tank is a small steel surgical stand with drawers
jammed full of sterilized instruments; adjoining on the same wall is another
set of mounted cabinets with ENT, urologic (urine catheters), orthopedic
(splinting and casting materials), and wound care supplies
Standing
next to the television cart, and taking out another third of the view, is a
large structural pillar. But behind this
lies our dental office, consisting of a dental chair, a set of cabinets
containing gums and fillers and pastes and picks and mirrors (and lions and
tigers and bears, oh my!), and a small dental cart hooked to a motor and water
that operates a drill, the suctioning thing, and the water gun. It turns out that when there’s no dentist
involved, the dental chair plus a comforter is a pretty relaxing place for a
nap.
(One of the benefits…and I use that term loosely…of living
with a Dental Empress is that I now know what they call some of their dental
tools, and what that really means. The
suction thing is a “water ejector,” the pick is an “explorer,” and the thing
they wedge between your tooth and the jawbone to remove the molar is called an
“extractor.” Doesn’t that sound
nice? But since I know, I’m even more
terrified at the office when I hear one of these words being used in
conjunction with me. It’s kind of like
when I had sinus surgery in medical school and the doctor said, “We usually do
this under local, but since you know exactly what you’ll be hearing we’re going
to put you all the way out.” Smart
move.)
Keep in
line, don’t stray from the group…and now you’re at my office. Just before the door on the left you’ll see
stretcher fully loaded with First Responder medical gear. This is a great thing as long at the patient
is on the same floor as the clinic. We do have one elevator at the Station, bit
it’s for cargo only and not certified for passengers; and it’s in the unheated vestibule
known as the “Beer Can” where temperatures in winter are a constant -60 F or
less. So as you can’t really use the
stretcher for most patient transport if the patient is coming from the first
floor or the outer parts of the Station, the alternative is to use a rigid
wooden backboard for the patient who cannot walk or sit up. You would immobilize the patient on the board
with straps, and very carefully coordinate with at least six others to carry
the patient up the stairwell, trying to keep the patient level and not dislodge
any tubes, IV’s, splints, or dressings started prior to movement. It’s a tricky number to choreograph, which is
why the medical ERT (Emergency Response Team) practices just these situations with
the ERT responsible for logistics and transport. There’s also an open face cabinet full of
additional EMS bags and supplies, including some specific to our environment
such as Bair Hugger (a warming blanket that fills with hot air) and a Gamow Bag,
which is a portable recompression chamber for treating severe altitude
illness).
Off to your
left you see our two-bed inpatient ward.
These beds are the best on site, and compared to our in-room mattresses
I don’t know why more people don’t feign illness just to sleep in them. (Lord knows they see my sleeping body often
enough. Have you noticed finding places
to nap as a recurrent theme?) The ward
is also equipped with cardiac monitors, IV pumps, and oxygen tanks. There’s
also a TV screen and a DVD player for the enjoyment of patients, friends, and
staff. Rumor has it that deeper into there
may be plans for a mid-winter weekday afternoon James Bond Film Festival at this very
site.
Speaking of
films, there are two lounges on Station where you can watch movies from a
surprisingly large collection of films and TV series. I mention this now because right next to one
of the lounges is a coatroom that’s used during the summer by the Fuelies…the
folks who move and transport fuel. In
that room is our industrial-strength movie popcorn machine, the use of which is
another skill I’ve acquired on post.
(You don’t want to know what the “butter flavoring” looks like coming
out of the bottle.) What I cannot do,
however, is remove the fuel smell from the room, nor from the popcorn. Which brings us to today, when we’re sitting
at lunch and I mentioned that I really didn’t have anything planned for the
afternoon, prompting one of our scientists (from MIT, no less) to inquire that
maybe to keep me busy he should drink some fuel, and what kind would give the
best results? You know, because science.
And read I
do, for the office has a small but well-stocked library for reference and
relaxation. Most of the books are older
editions and somewhat out-of-date, but medicine in this environment is pretty
basic so most of the texts remain relevant.
My favorite for gazing is a 1964 tome called “Atlas of Techniques in
Surgery” by John L. Madden, MD FACS. It
was written back when doctors knew how to write and weren’t afraid to fill a
book with personal opinions based on their own experience rather than simply
disgorging the world’s citations. There
are only two things highlighted in the Table of Contents: The McBurney Incision and the Operation for
Appendectomy. I wonder if this was the
guide for an appendectomy I’ve heard was done here a decade ago. History in my hands.
The question
that usually comes up at this point is if you can, in fact, do some surgery at
the Pole. The answer is yes, but until I
get back to the states I’m not going to tell you how, nor will I tell you about
those potential disasters that keep me up at night. The reason I will not is because every
Emergency Physician knows if he mentions a patient, condition, or situation out
loud, it will happen. I suspect I should
take some comfort in thinking that those cases that scare me would probably
scare anyone in this setting; and that if you’re not frightened by something in
medical practice, you probably haven’t
been at it long enough. But check
this space when I get home for what I’m really
thinking.
I noted that
our clinic is equipped with the usual things you might find in a small rural
ED, but that’s only a snapshot of the overall portrait. Finding medical equipment here on Station is
like a scavenger hunt if you know what you’re looking for, and like searching
for buried treasure if you’re not quite sure what you’ll find. Just in my office alone we’ve found a vintage
straitjacket, a Power Ear Washer, and what I believe to be a therapeutic
ultrasound machine used in physical therapy.
Our small cleaning room cleaning room which holds our linens and laundry
is also home to a metal tub that currently holds a large plastic bin full of
heating pads, but what I think is actually a whirlpool. The large Medical Supply Room on the first
floor is even more fun. Not only did we
find a US Navy Embalming Kit that we think dates back to the 1950’s and the
original Operation Deep Freeze, supply but there are also bizarre finds like
hundreds of rigid sigmoidoscopes, which sounds exactly as much fun as it would
be.
The clinic
is not the only place on station with a medical presence; our outposts reach
throughout the South Pole Complex like tentacles on a benevolent squid. There’s the previously mentioned Supply Room
on the first floor, Mass Casualty Incident (MCI) gear in a storage area near
the gymnasium, and a protected cache of further medical resources near the
Lifeboat (a hardened berthing area with its’ own generator should the station
experience catastrophic structural or mechanical failure). In addition, there are seven Automatic
External Defibrillators (AED’s) placed within the Station and outlying
buildings, and nearly 50 first aid kits scattered throughout the campus. One of our duties is to round on the AED’s monthly
and check the first aid kits at the beginning of each season. It gets us out of the house.
Our tour is
over. Of all the group’s I’ve had the
pleasure to know, you’re certainly one of them.
If it’s between 6 and 7 PM on a Monday, Wednesday, or Friday, you can
exit through the gift shop on the Lower Level.
Drive home safely, and have a nice day.
(Are they
gone yet?)
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