• Loving Frontier Medicine

    Family Physicians Earn Respect in Remote Valdez, Alaska

    June 06, 2018 08:55 am Sheri Porter Valdez, Alaska – (Editor's note: Family physicians provide 42 percent of care in rural communities. AAFP News will highlight some of these FPs over the next few months. The series will focus on why some family docs choose to practice in small towns off the beaten path and how they provide high-quality, comprehensive care to patients of all ages -- often with far fewer resources than their urban and suburban colleagues.)

    According to 2016 U.S. Census estimates, 3,862 people call Valdez, Alaska, home, although the population in and around Valdez swells by several thousand each summer when the tourists and seasonal salmon cannery workers arrive.

    This town, located in South Central Alaska on the northeast tip of Prince William Sound, has earned a frontier community designation based on its population density per square mile in the Valdez-Cordova census area, as well as the distance in miles and travel time to a tertiary hospital.

    "There are 105 points possible for those three things, and we score 105. We pegged the meter," said AAFP President-elect John Cullen, M.D., one of four family physicians who provide health care for this population.

    They serve patients in three adjoining buildings that share a parking lot -- the Valdez Medical Clinic LLC; Providence Valdez Medical Center, an 11-bed critical-access hospital and ER; and a 10-bed long-term care facility.

    When AAFP News traveled here in early May, Cullen said he's been doctoring in the community for nearly 25 years. "We've saved a lot of lives and dealt with a lot of challenging situations."

    Cullen recalled an incident involving two brothers who were hiking on Worthington Glacier, 28 miles north of Valdez, when one boy fell into a crevasse and disappeared. Rescuers identified the hikers' location from a cell phone photo of the surrounding terrain snapped by the younger brother.

    Story Highlights

    The Valdez Medical Clinic LLC serves some 4,000 patients year-round in a frontier community in South Central Alaska.

    A team of four family physicians staffs the clinic, an 11-bed critical access hospital and ER, and a long-term care facility.

    The team also provides full obstetrical services, which has improved the staff's ability to handle other trauma cases and helps to grow the community.

    "It took eight hours to get the kid out -- he was 40 feet down and stuck like a cork in a bottle," said Cullen. "The problem when you're that cold is you can go into ventricular fibrillation just by being bumped hard."

    Cullen credited the rescue team with getting the teen off the glacier and down the mountain in an ambulance without further incident. He had a head injury and a core temperature of 74 degrees on arrival at the ER.

    "Once they got him here it took eight hours to warm him up to at least 86 degrees," said Cullen, who eventually transported the patient to Anchorage for surgery -- despite the neurosurgeon's long-distance opinion that, with a core temperature that low, the patient was already dead.

    "I hung up on him," said Cullen, who grinned at the story's conclusion, and pointed to a photo of the brothers taken later that hangs on his office wall. Both were smiling into the camera.

    Full-scope Family Medicine

    In 2013, Samuel Shirk, M.D., came to Valdez for a one-month residency rotation -- or, as he tells it, a prolonged four-week interview in a setting he'd already pegged as perfect for him and his family.

    One year later, fresh out of residency, he returned and jumped onboard full time.

    Shirk recalled thinking during that one-month rotation, "I can't practice medicine like this anywhere else." And he has not been disappointed.

    "Just practicing the full scope of medicine intermixed with hospital care is amazing," said Shirk.

    He likes being able to walk from the clinic to the hospital to check on a patient he admitted, do an ultrasound or deliver a baby.

    And in Valdez, Shirk routinely makes decisions he never had to consider in residency.

    "Every patient who's in the hospital here is different than any patient I'd see in Iowa, because we're five hours away from a bigger and better-equipped hospital," said Shirk. Patients are flown to Anchorage for any severe trauma, orthopedic surgeries, all kinds of small bowel obstructions and more.

    Keep in mind it's 300 miles from Valdez to Providence Alaska Medical Center in Anchorage, a distance emergency patients travel on small fixed-wing medical evacuation planes -- when the weather allows. It's more than a five-hour road trip -- when the roads are passable.

    Sometimes, when the weather closes in, physicians have to be creative, said Shirk. "I've done an appendectomy with both Dr. Cullen and with Dr. Todd; those are surgeries that can happen here with caution."

    Recruiting Challenges

    The Valdez clinic is ready to add another family physician to the staff, said Kathleen Todd, M.D., who's been practicing family medicine here since 1980.

    "We want five doctors so we don't get burned out. We need to have enough people to handle all of the services and procedures we provide, she said.

    Small wonder, then, that there was much excitement the previous night when the Valdez City Council voted to offer a $60,000 sign-on bonus to the town's next family physician recruit.

    In addition, the city will pay that physician another $60,000 annually in $15,000 quarterly payments for the four years following. It's a five-year package deal that Todd hopes will be extended.

    "The point is that we have to be competitive," said Todd. "We don't want people who are only here for the money. You have to be here because you love rural practice. But on the other hand, you can love rural practice and go to Nome (Alaska) and get a sign-on bonus of $200,000. And we just don't have that to offer."

    Todd and Cullen agree that it takes three to four years to train a physician to be fully comfortable with the rigors of frontier medicine.

    "For whatever reason, people are a little bit nervous about practicing here. I've heard residents talk about this being the 'big leagues,'" said Cullen. "We've pushed people a little bit too fast in the past and that doesn't work."

    A few promising recruits have moved on because there was a lack of employment opportunities for their spouse or partner. "We've lost residents because spouses were engineers or lawyers and there weren't any jobs here for them," he added.

    Enhancing Communities With OB

    The family physicians in Valdez deliver a lot of babies -- in fact, three healthy babies were born during AAFP News' visit May 7-10. "Being able to provide obstetrical services leads to a really vibrant and young community," said Cullen.

    He referenced a small study published in the September-October 2014 issue of the Journal of the American Board of Family Medicine that shows a rural family physician in Alabama generates $1 million in economic benefit to the community, and the addition of obstetrics bumps that figure another $488,560.

    Offering obstetrical services helps the practice, as well.

    "It increases our capability for emergency medicine," said Cullen. "Because we can do C-sections, we can do the anesthesia, so we've raised that bar in terms of capability. Our nurses are better trained and more confident, and that means when we have a trauma, we have better outcomes."

    It's like building blocks, and it all leads to the economic health of the community, he added.

    He contrasted Valdez with another community of the same size and with similar geography. Physicians in that town stopped delivering babies and stopped doing long-term admissions.

    "There was a feeling that you couldn't be born or die in the community, and it was very difficult," said Cullen.

    Cowboy Doctors

    Megan Rayman, M.D., is the newest member of the physician team at the Valdez clinic, but after three years she's a seasoned veteran of frontier medicine. Like Shirk, she spent a month in Alaska as a resident and was exposed to the amazing scope of practice that's routine in such a setting.

    Even so, "it takes the right person to come here," said Rayman. "In Anchorage, they call us the 'cowboy doctors,' because sometimes you have to do things that are uncomfortable and that you don't feel qualified doing.

    "But you have to remember that you may be the most qualified person available. It's not for the faint of heart."

    Rayman recalled diagnosing a 14-year-old boy with compartment syndrome -- a condition she'd only read about -- after he rolled a snow machine. She was preparing to perform her first fasciotomy to save the boy's leg before she convinced a reluctant Anchorage surgeon to accept the teen.

    "I rode to the airstrip with this patient in a blizzard, and we got him out of here," said Rayman.

    Another tense diagnosis involved a patient with an aortic dissection, and Rayman argued with the Anchorage surgeon who refused to accept the patient. "I said, 'I can't fix this here; he's going to die if we don't treat this right away.'"

    Rayman managed the patient in Valdez for eight hours before getting him evacuated to the much more distant Harborview Medical Center in Seattle for surgery. He survived "and loves to tell his story to our visiting medical students," she said.

    Getting It Done

    These frontier physicians have countless stories to illustrate the miraculous medicine that occurs in such a remote location.

    But Todd sees things somewhat differently.

    "We can all tell bear stories and kayak stories. But the best stories are about the things we managed to do with practically nothing," she said.

    Todd described a local businessman in the end stage of arterial lateral sclerosis who needed a few more days on earth -- specifically, a few more days in Valdez -- to sign legal papers and get his affairs in order.

    But the ventilator and intubation equipment he likely would need soon were in Anchorage.

    Todd and other staff members made a few phone calls and figured out how to create a mask of sorts -- a glued-and-duct-taped apparatus that helped the patient breathe. "If that wasn't working for him, we'd go bag him until he could be back on that makeshift machine again," said Todd.

    "We bought him his week. That's small town. That's rural remote."