Category Archives: Alaska

Soldotna or Bust!

I had the pleasure of rotating in Soldotna in late September-October 2017 and it has been a dream! One of the best experiences of residency by far. I came to UW hoping that I would be able to do a WWAMI rotation in Alaska and it has vastly surpassed my expectations.

Like other residents have mentioned, your work in Soldotna is at an internal medicine clinic that functions like a referral center.  You see an incredible breadth  of primary care. In my month, I’ve diagnosed myasthenia gravis, carcinoid syndrome, in addition to managing pulmonary hypertension and post-CVA care after a 30 year old had an embolic event from an atrial myxoma.  It has been quite the learning experience and has solidified my decision to go into primary care!

The doctors here have incredible work/life balance. Dr. Bramante and I would often go on long runs together after work and go dog-sledding. Like other residents have written, there’s a ton of outdoor activities to do on your three days off per week! My favorites included hiking on glaciers, watching sea otters in Seward harbor, and seeing grizzly bears fishing in the wild (though also terrifying!).

For those of you lucky enough to come to Soldotna, good luck exploring the 49th state!

Courtney Tuegel (R3)

 

Soldotna

I am writing this from Soldotna, where I am wrapping up a really great month here. This is a great rotation, which I would sum up as a superb and unique primary care experience with plenty of time to explore one of the most beautiful places on earth.

Clinically you work primarily with Dr. John Bramante, a former UW resident and chief, and see patients with him at a private group practice affiliated with the major hospital for the Kenai Peninsula. He is great to work with, and extremely knowledgeable and supportive. Because this is a rural site with limited access to specialists, you get to manage a very wide range of medical conditions and often patients are referred from PAs/NPs or family medicine doctors with interesting problems or diagnoses. There are also plenty of people with bread and  butter medical issues who are presenting for their annual visit and need someone to work with them on their DM, HTN, CAD, etc and tweak their medicines. The best part is that the schedule is set up so that you can usually take your time to really talk to the patients to get to know them a bit and do good counseling and education.

The hours are very reasonable and flexible, leaving lots of time to explore. My month here has been in September, and the days are still really long. On the weekends I went to nearby Homer (1st picture), kayaked to and hiked on a glacier (2nd picture), went white water rafting on class IV and V rapids, and did lots of superb hikes. The third picture below is of a beach that is 20 minutes from the apartment here, and on nice days the sunsets are amazing and there are firepits to have bonfires.

This is a special place with really good doctors, warm and welcoming people, and stunning scenery. Check it out!

ICU at ANMC in Anchorage in June

Anchorage, Alaska. Home to bears, moose, liver dialysis and abundant subclavian central venous access. I chose to spend all 4 weeks of the rotation in the ICU and would definitely recommend the experience (although I hear that residents enjoy their time with all specialties up here).

At ANMC all critically ill patients end up in one unit under the care of the ICU team, so you will see patients admitted with trauma and other “surgical problems” (NSTI, ICH requiring craniectomy etc.) in addition to the things we are more used to managing. If the variety doesn’t interest you it’s possible to pick up only the more classic medicine patients, but you will at least have the opportunity to manage a broader spectrum of critical illness. You will probably get to do lots of procedures (all manner of central lines, bronchoscopy) and intubate relatively often if you are so inclined. A more unique thing you will see here is MARS “liver dialysis” which gets used for acute liver failure and Tylenol overdose. The attendings and other hospital staff are very friendly and a lot of fun to work with.

At least in the summer there is lots to do here, four weekends is just not enough time to see all the cool stuff in the area. The hiking/wildlife is incredible. Homer and Seward make great weekend trips. This also seems like the place to be if you like fishing.

real sign at Kenai Fjords National Park
if this kind of bear attacks you, fight back
If this kind of bear attacks you, only fight back if it literally starts to eat you
seriously though, get bear mace if you are going to be hiking here in the summer
moose chowin’ down at Kincaid park

ANMC/Anchorage!

I spent May 2017 in Anchorage and had a great experience at ANMC. I ended up only having 3 weeks there and did 1 week in the ICU, 1 week in a mix of clinics (Rheum, Endo, Pall Care) and 1 week of ID consults. In general if there for 4 weeks I’d recommend 2 weeks in the ICU to get the hang of it and a range of experiences and I think the staff there prefer it for some continuity. Schedule in the ICU was M-F 7am to 7pm for sign out (able to leave early some days). I worked with Dr. Worth who is great and trained at UW! I also really enjoyed the clinic experience – great way to learn more about the native health system and how subspecialty care is delivered to such a broad geographic area. Great teaching too and pretty relaxed schedule. Lastly ID consults was great with really interesting cases and fun attendings who love to teach. I was initially given a pretty short list of options of what to do but when I got there but I found that people were happy to have me in most clinics and if you ask they will make most things work.

As far as Anchorage itself it’s a very livable small city and easy to adapt to quickly. People at the hospital were all really welcoming and eager to provide recommendations for what to do and see. May was a fun time of year there as spring was really just starting but days are long. Be sure to check if hikes in the area are still icy/snowy! For housing AirBnB worked well to find a spot – midtown isn’t the most attractive part of town but halfway between downtown and ANMC. Start housing search early if you want to do a monthlong rental especiall in summer/spring. Enterprise renal car through UW also very easy to do.

I loved visits to homer (halibut fishing!), seward (kenai fjords tour/kayaking), hikes around anchorage (power line trail, eagle river nature park, flat top).

Portage Glacier Hike, at end of Whittier Tunnel
View of Anchorage from Earthquake Park
Otter enjoying Seward!

 

 

 

Get Sold on Soldotna!

Spent an incredible 4 weeks here in September/October, and can’t recommend it enough!

You work 4-5 days a week at Peninsula Internal Medicine, an independent practice with 5 MDs and 2NPs but right across the street from Central Peninsula Hospital where you’ll go for some procedures, ECHO reading, and of course, free lunch. You work predominantly with the legendary Dr. Bramante who is an incredible internist and even more incredible human being. Most of my experience was outpatient, alternating seeing patients with him on one of his normally scheduled clinic days. The patients are super interesting from both a social and a medical perspective (you see a fair amount of the standard T2DM, HTN, CAD, COPD/combo of the above but I also diagnosed/helped manage things like IPF, polymyositis, HIV, CML, aldosteronoma and a host of others).  I also spent time working with some of the other physicians in the group including Dr. Kelley, Dr. Pokorney and Dr. Mitchell and even got to do some outpatient clin ed with the med student who was there at the same time. Overall everyone is super awesome, friendly, and smart and all are supportive of you doing the things you want to do and having the experience you want to have. This includes doing a week or two of inpatient if you are so inclined.

Soldotna itself is awesome, as is the Kenai Peninsula in general. Your drive down is breathtaking and just the beginning – activities are limitless! Make sure to spend at least a day if not a weekend in Homer, a beautiful town surrounded by magnificent mountains and nonstop views, good food, and cool art shops. Also journey over to Seward, where they have a nice little aquarium, kayaking in the summer, and you can take a short hike right up to the edge of Exit Glacier. So many amazing hikes and areas to explore like the Skilak wildlife refuge, North Beach in Kenai, and Cooper’s landing.  I was also lucky enough to be there at the right time to go Halibut fishing with the Kelley’s and no doubt JB will invite you over to run with the pups. Truly a once in a lifetime experience to be pulled on the back of a 4 wheeler by a pack of dogs while clutching your attending for dear life. Incredible!

You’re also provided with a cozy apartment right on the Kenai river and a short drive from the clinic. Everyone takes care of you and is more than excited to have you over for dinner and show you all the amazing things Soldotna has to offer. I also had the opportunity to present a grand rounds style lecture for local providers. Definitely prioritize a rotation up here, you won’t regret it!


Black bear at the Alaska wildlife conservation center


Kenai river in your backyard (literally!)


Halibut fishing with the Kelleys!


View from the Homer spit


North beach at Kenai with relaxed resident feet included as proof of ample down time


Exit glacier near Seward


Ready for a run!

ICU at ANMC in Anchorage, AK!

Let me start by saying that if you’re reading this and are already scheduled to do your WWAMI rotation at ANMC though haven’t yet submitted your Alaska resident license application…stop reading and go do it. For real, you’ll thank me later. Getting that beast of an application out of the way about 4-6 months ahead of time will allow you to cruise on up to Anchorage stress-free knowing that you’ll be all set for your rotation!

Anyway, with that said, I spent my entire month of March in the ICU at ANMC and as those before me have already said, this was absolutely one of the best experiences that I’ve had in residency! As the only resident in the ICU, everyone is super willing to give you procedures and the attendings are all excellent teachers. By the end of the rotation I had done about 10 central lines (mix of IJs and subclavians), 2 intubations, 3 bronchoscopies, many arterial lines, and even a handful of chest tubes! Overall, you get a ton of autonomy and really feel like you are the primary provider for your patients, while the attendings are always available for guidance. The staff at ANMC are awesome and the ICU nurses in particular are very knowledgeable and always willing to help. From a cultural and systems perspective, working at ANMC is also really interesting as it serves the Native population not only in Anchorage but from all around Alaska. Many patients are flown in from various parts of the state, including Little Diomede, which is the westernmost island of 110 people that is right on the US/Russia border in the Bering Sea! The ICU itself is about 20ish beds, and they’re actually in the middle  of some construction to expand it. The acuity of patients ranged quite a bit, and we certainly had some sick folks with interesting pathologies.

As far as Anchorage goes, it’s not a very big place but definitely has a lot going on! If you’re heading out in March, I would recommend catching the start of the Iditarod. Overall it was pretty darn chilly with temps in the negatives most of the month until late March and snow/ice pretty much everywhere. I stayed in an apartment close to the hospital and got around just fine in my trusty Ford Focus rental car, though there were a couple of hefty snow storms and those not used to driving in the snow might feel better with a 4WD. Otherwise it was awesome exploring the city and surrounding area. Check out the pics below!

Start of the Iditarod!
Resting up before the big race.
The Diphtheria antitoxin is on its way!
I thought the thermometer would stop at 0, but apparently it goes into the negatives…
Flattop mountain just outside of Anchorage. ‘Murica!
Skiing at Alyeska in Girdwood, just 45 minutes outside of Anchorage.
Denali on a rare, clear day.
Walking across Portage Lake to Portage Glacier.
Portage Glacier
Found some old skates at a thrift shop and got in on some pond hockey!
Pond hockey after work.

 

Soldotna. Do it.

Literally one of the best months of residency… literally.   I recommend using two wishes.  I think you can do that.   The clinical experience is diverse.  A sample day can include EGDs, colonoscopies, stress tests, reading echos, and doing primary care with limited resources for subspecialty care.  The physicians at PIM are fantastic educators.  You’ll spend most of your time with #GHITKU legend, John Bramante.  If he or Dr. Mitchell have inpatient responsibilities spend a few days seeing what the hospital is like.  There is so much to do in the evenings/weekends.  Seriously, this month is the best.

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ANMC, Anchorage

I highly recommend the ANMC rotation, as so many others before me have! It’s a fantastic clinical experience, and there are endless outdoor activities in and around Anchorage. Amiko Uchida and I did this rotation in April at the same time, which made it extra fun.  Spring in Alaska can be unpredictable (it’s historically rainy, muddy, and cold), but we lucked out and had snow in the mountains during our vacation week at the beginning of the month, and mostly clear, warm weather (~50 degrees) while in Anchorage.

I spent two weeks in the ICU, which is a very hands-on, procedure-heavy rotation. The critical care docs are great teachers, they give you tons of autonomy, and you’ll take care of very sick patients flown in from remote parts of the state. In my two weeks here, I did 4 central lines, multiple bronchoscopies, an intubation, arterial line, and more.

I worked in GI clinic with Dr. Bowers for my third week, and I had a cafeteria-style ambulatory block my fourth week. Dr. Bowers is a phenomenal teacher – you’ll see clinic patients in the morning and then he’ll teach you how to do EGDs and colonoscopies in the afternoon (I did at least 5 EGDs and helped with biopsies for multiple colonoscopies). There were multiple days in GI clinic when I was able to go home at 3PM, which gave me lots of time to explore Anchorage.

Overall, you can’t really beat this rotation!

Hiking near Portage Glacier, an hour south of Anchorage
Hiking near Portage Glacier, an hour south of Anchorage
Portage Glacier
Portage Glacier
Seward, AK - a rare sunny day!
Seward, AK – a rare sunny day!
Visiting the Alaska Wildlife Conservation Center
Visiting the Alaska Wildlife Conservation Center
Snowshoeing in Hatcher's Pass, AK - north of Anchorage
Snowshoeing in Hatcher’s Pass, AK – north of Anchorage
10PM sunsets in April!
10PM sunsets in April!
Co-resident bonding in the mountains
Hiking Flattop Trail after work
Eklutna Lake
Eklutna Lake
Amiko and I getting some perspective...
Amiko and I getting some perspective…

Soldotna so awesome

Reading back further into this blog, it’s apparent that plenty has already been said about how wonderful the clinical [and natural!] environment in Soldotna is. I’ll just confirm that every bit of praise lavished at this WWAMI site is justly deserved.

No Virginia, there is no Santa Claus, but what does exist is a magical primary care practice called Peninsula Internal Medicine where you can find in abundance those qualities of being a doctor – the independence, the impact, the close relationships with patients and other providers alike – that we all crave yet find oh so elusive in residency.

Personally, as someone interested in health care systems, a month at PIM gave me the opportunity to step outside the academic bubble and see first-hand how things work in the private practice world. Whether you want to gain procedural skills, experience different models of health care delivery, or just spot some moose, this rotation is not to be missed.

Welcome to nirvana.
What awaits you on the drive out of Anchorage.
Nirvana.
Nirvana.
Denali.
Denali.
Mountains beyond mountains.
Mountains beyond mountains.
Great name for a boat.
Great name for a boat.
Bush flying.
Bush flying.
Annual migration of the common Winnebago species.
Annual migration of the common Winnebago species.
Playing in paradise.
Playing in paradise.

5 star review of the ANMC rotation!

The WWAMI rotations are a big part of what make our residency program special, and I recommend prioritizing at least one of these experiences during training. The ANMC rotation is an incredible experience that I would recommend to all comers, particularly those interested in specialty medicine. The people who work at ANMC are delightful, and the attendings (particularly Dr. Lovely and Dr. Gitomer) are so fabulous that they alone make the experience worth the trip. It was a fantastic month, both for my medical training and for my life experience. Since so many of the other posts go into detail about the rotation structure, amenities, etc., I’ll spend more time her talking about my personal experiences.

In the hospital: I spent my first two weeks at ANMC in the ICU and my second two weeks in outpatient specialty medicine. The ICU is a general critical care unit, so you take care of a combination of medical and neuro patients with all sorts of different pathology. This rotation is a great opportunity to do procedures (including subclavian lines); the attendings knew that I wanted to do as many procedures as possible, so even after I had gone over to the outpatient part of my month, the attending would come get me to place non-urgent lines. You see a lot of advanced pathology, and it’s a great way to start feeling comfortable with independence in the ICU setting. The outpatient specialty rotation was also tremendous. I rotated cafeteria style with several different specialties over the two weeks, but if you have a particular area of interest in mind, you have the freedom to focus your time. Alaska is tricky for delivery of specialty care, as the population is so spread out and sparse, so patients often fly 700 miles to come to Anchorage to see their specialists. This experience enriched my medical training profoundly, and I hope as many of you as possible choose to take advantage of it.

Outside the hospital: There is a lot to do in and around Anchorage, and I really enjoyed getting out of the hospital and going hiking, halibut fishing, sea kayaking, and getting to know the city. I was there during September of 2013, which is the rainy season in Anchorage. That time of year it was generally overcast/rainy and in the mid-50s, not unlike a slightly warmer version of a Seattle winter. Anchorage is a wild place, and I saw a lot of wildlife. Kinkaid park is a great place to see moose, but I also saw one in my attending’s neighbor’s yard one night. University Lake right next to the hospital has a nice walking trail around it and is home to a lot of beavers.  Potter Marsh on the south edge of town is a must-see, and you can frequently spot swans there. Alyeska ski resort is a short drive south of town if you like beautiful views of glaciers and the off-chance of seeing a bear.

Moose are everywhere in Kinkaid Park!
Moose are everywhere in Kinkaid Park!
This is Eklutna Lake, the water reservoir north of Anchorage, in late September, 2013, the day after the first snow was dusting the mountains.
This is Eklutna Lake the day after the first snow dusted the mountains.
I took this picture while sea kayaking in Kenai Fjords national park in late September, at the very end of sea kayaking season.
I took this picture while sea kayaking in Kenai Fjords National Park at the very end of kayaking season.

In short: go to Anchorage! Please feel free to contact me if you have any questions. I love talking about all the things I got to do and see in Alaska!