Friday, February 13, 2009

When Providers Become Patients

"Everybody was healthy then. Gee, we'd come down from spring camp in the hills and we'd get to Akiak and we'd look at the people who stayed in Akiak and they'd look pale. I asked one of my uncles if he was sick all spring. 'Nope,' he said. All the rest of us were sunburned and weather-beaten--healthy."
--Carl Kawagley, Bethel, Alaska

Respiratory issues are not uncommon, particularly in cold areas. Frostbite doesn't just occur outside the body. When the temperature drops low enough and the conditions are right, the tiny alveoli in the lungs can freeze, leading to infection, COPD, and other respiratory issues. I'd seen a few cases of it since I had arrived in Bethel.

Of course, one of the potential problems with traveling to a far away place is first time exposure to new pathogens. This barrage of primarily cold virions leads to what has been called "The Bethel Crud." I was not surprised when I started showing minor cold symptoms several days after arriving, but I rapidly improved to a near base-line condition as the days progressed.

Until several days ago, when I had suddenly found myself feeling very sore, weak, and cold. I didn't have a thermometer available at the house I was staying in, but shivering in an environment that is room temperature is a sign the body is trying to increase its temperature more than normal. I bundled up and crawled in to bed, hoping the soreness would subside by morning, as I knew it would be a busy day.

I didn't have to wait until morning to wake up. At 02:12, I found myself tossing and turning, sore, and feeling very feverish. After a few minutes of struggling, I pushed the blankets off, crawled out of bed, and stood up--and nearly fell over. Bracing myself against the wall, I assessed what was going on. Difficulty forming thoughts. Not entirely unusual, but something seemed amiss. Sweating, yet freezing. That was definitely unusual. I hurt all over. Had I been in an accident? No. Did I just return from a hard practice or was I recently knocked unconscious during kumite? No. Definitely unusual. Head pounding. I rarely get headaches. Any new medicines? No. Sign and symptom identified: FEVER. Letting a fever run for a while isn't necessarily a bad idea in some cases, but since I was having obvious nervous system impairment, I decided it was time to halt the process my body had deemed necessary.

Leaving my primary diagnosis undiagnosed for the moment, I found my way to the cupboard and removed a bottle of tylenol that had been stashed there. I wondered which temporary clinician had brought and left it--had it been one of my fellow pharmacy students? I wasn't sure, but I took 1000mg and gulped a glass of cool water, sitting myself down on the couch. It was definitely difficult to think, uncomfortable to move (or sit still), and my head throbbed. I dipped my finger in the water glass and ran it around my neck, feeling the evaporation cool my body. I sat there for an hour, tried to read Pharmacy Times, found it impossible, and resulted to watching bad late night TV. An hour and fifteen minutes later the symptoms had diminished somewhat, but where not completely gone. Okay, I thought. Plan B time. I pushed myself up, turned the shower to cold, and hopped in. I alternated between warm and cold water until I felt the fever had broken, and got out of the shower. I toweled off, felt better but not great, and went back to bed.

The next morning I felt like my head was heavy but made it in to work. As the day progressed, I became more symptomatic--headache demanded I acquire some of my preceptor's tylenol.

"There's both acetaminophen and ibuprofen," she said, handing me a bottle. "It's all in the same one." I stared at the bottle. Tylenol and ibuprofen both in the same tablet? I was having trouble thinking straight again.

"What, together?" I asked. She looked up at me and shook her head. I popped open the bottle and clearly saw two different kinds of tablets, a pharmacy faux pas. "Oh. Together as in you put them both in the same bottle." She asked if I was going to make it and I assured her I would.

Later that day I decided to go home early and rest. I felt more rested the next day, but my symptoms had not improved. I increased my hand washing regimen to its highest alert status to ensure I wouldn't contaminate anyone while on rounds. My voice quickly degraded, until I was barely squeaking. I soon began a non-speaking role. At the end, a physician asked me why I hadn't gotten antibiotics and for the first time, I took the time to put all the pieces together:

Fever. Headache. Pressure on sinuses. Heaviness, especially when leaning forward. Phlegm, color: greenish. Post nasal drip.

Probable diagnosis: Bacterial sinusitis
Practical Treatment: Augmentin 875mg/125mg 1 PO Q12H x 10 days

I found myself creating a chart (with the help of the people up at reception) and soon picked up my prescription, where Steve, a pharmacist with a sense of humor, had thought it funny to place the "Antibiotics may decrease the effectiveness of oral contraceptives. Use an alternate form of contraception." sticker on the bottle.

Though my voice hasn't totally returned, I am finding myself feeling much better and plan to be tip-top on Tuesday. I'm reminded how easily it is for care providers to let themselves go untreated. It was interesting to see myself "in the system" at YK and to have a reminder to look at things from the patient perspective.

This weekend is the open market, which I am going to attend after watching a local karate club practice.

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