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Neurocritical Care in the Last Frontier – a Pharmacist’s Perspective

By Currents Editor posted 04-24-2021 15:47

  

Dyan Fleming, PharmD, BCPS, BCCCPS

Treating neurocritical care patients in Alaska, land of the midnight sun, comes with unique geographical, environmental, and seasonal challenges. Navigating these challenges requires careful planning coupled with complex coordination of medical care to minimize delays and optimize patient outcomes as much as possible through all transitions and levels of care. 

Alaskans are resilient when it comes to dealing with crises in the harsh elements and sometimes “wild” remoteness.  Can you imagine for a minute- it’s January and 15° F.  You only have 4 hours of daylight, and you live in Akun, Alaska, an island which has no real road access. You begin to have right-sided weakness and slurred speech. You struggle to pull yourself onto your snow machine (“snow mobile” to those in the lower 48 states) and somehow manage to drive it to the nearest village health aide center for triage that is located miles away. 

Village health aides are rural community members armed with comprehensive manuals and guides, developed and certified for use by Native Tribal leaders and Native Health Service officials. Health aides participate in 4 sessions of training each lasting 3 to 4 weeks, and they may obtain certification by the Community Health Aide Program Certification Board. They are critical to ensuring appropriate patient care and referral in remote parts of Alaska.  Health aides are tasked with not only managing chronic issues, but also emergent conditions in their rural communities.  They connect natives to medical care by filling the gaps when traditional medical centers are unavailable.

Imagine again - at the urgency of the village health aide, it is recommended that you transfer by flight more than 700 miles away to Anchorage, Alaska for escalated neurocritical care.  However, there is a winter storm moving in. You are now in a holding pattern due to a weather delay, as the aircraft is unable to land. 

Weather delays in rural Alaska can often last upwards of hours to days. With no other means of nearby transport, you’re at the weather’s mercy.  Other environmental-related harshness leading to delays include powerful earthquakes.  Large seismic shifts in the frozen tundra can cause erosion or instability of common “roadways” and trails used by residents. Such destruction can lead to significant delays in medical evacuations and care. Environmental challenges in Alaska often lead to delays in accessing acute medical care, which in the case of an acute ischemic stroke diminishes a patient’s eligibility for reperfusion therapies.

And imagine again - as the weather delay lifts, you manage to drive your snow machine to the nearest airstrip, approximately 50 miles away, where aerial medical transport can safely land and then transport you to Anchorage for stroke treatment. Fortunately there is a neurocritical care bed available for you. Anchorage hospitals have a limited number of neurocritical care beds available amongst all area hospitals, and at certain times of the year, beds are limited.

The tourist season brings additional challenges for neurocritical care in Alaska. Tourism remains a quintessential part of an Alaskan summer- Fishing excursions, wildlife adventures, cycling / ATV riding and hiking adventures are all frequented tourist activities, but these activities remain potential sources for traumas that fill local ICU’s. Tourists participating in these outdoor activities are at risk for neurotraumas. Patient care coordination in these circumstances involves medical evacuations and transport to our mainstream area hospitals from the accident site, which might be in a rural town, mountain range or coastal region.

Another large source of tourism in Alaska are cruise ship patrons, a population for whom it is challenging to coordinate ongoing care.  Can you imagine for a minute – you are on a family vacation aboard your dream cruise through Alaska when you begin to have the worst headache of your life.  All the usual measures for relief aren’t working, and your wife is even more concerned because you seem less “with it” then you were before.  You just left Skagway, AK headed for Whittier, AK when your family brings you to the ship doctor for evaluation.       


Turnagain Pass, part of the Chugach Mountain range

Medical emergencies can occur in the middle of the ocean, and cruise ships are prepared for this.  When a severe medical emergency happens, patient medical evacuations via air, sea and land are critical.  Imagine again – you arrive at an Anchorage hospital.  After being quickly triaged in the ED, you are whisked away to the interventional suite where you receive a stabilizing procedure, and then are transferred to the neurocritical care unit.  After a week of ICU care, your doctor tells your family you are going to be discharged soon, but will need rehabilitation.  The option of local rehabilitation is considered but may be too far away from your loved ones for support.  Hometown area rehabilitation is considered, but depending on the ongoing care needed, medical transportation preparation would need advanced planning.  Either of these rehabilitation options poses a challenge for patient care coordination within or from Alaska.   

As a critical care pharmacist in Alaska, I am poised in a unique position to appreciate the challenges of harsh environments and the added complexities of patient care. During multi-disciplinary rounds, patients’ ongoing care is thoroughly discussed and planned, and pharmacists have an important role in assisting with emergent drug needs, providing pharmacotherapy recommendations and planning for advanced medical transports of complex patients. We also help to anticipate and supply medications necessary to sustain long transports.  Ensuring appropriate alternatives during drug shortages is equally important, because overnight restocking may not be feasible in Alaska.  As a clinical pharmacist, the work itself is rewarding by seeing a critically ill patient improve, but as a clinical pharmacist in Alaska I count myself lucky to be able to help treat neurocritical patients in The Land of the Far North.    

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