I spent october of 2012 in anchorage at the ANMC MICU. I had originally set it up as a split block: half MICU, half wards, but decided to just extend my ICU time once I was there.
It’s a very interesting ICU to work in. As always, spectacular nursing staff and respiratory therapists make ICU rotations some of my favorite. They use pressure control instead of AC style ventilation as a default up there, which is a transition that was definitely useful if a bit challenging at first.
There’s an incredible variety of patients, ranging from the worst hyponatremia I’ve ever seen (Na of 98, a combination of beer potomania and schizophrenic polydipsia, wowza), to intense alcohol withdrawal, to the usual mix of sepsis and stroke management.
The opportunity to do procedures varies a bit based on the pathology mix, but even on slow days I would head across the hall to the OR and do scheduled intubations. There was a nice mix of bronchoscopy, intubations, central lines, LP’s, and art lines otherwise. Some people had much more procedural months than I did, I only did 3 or 4 of each of our internal medicine procedures.
The attendings come from all over, as they rely on a fair number of locums. Dr. Madhani-Lovely is spectacular, and will force the residents to really justify decision making with an evidence base when she is on service.
The hospital itself is great, and the sheer splendor of alaska is literally breathtaking at times. When I would leave the parking lot near sunset, I’d sometimes find myself waxing poetic and wishing for paints. The logistics of licenses and such can be a bit of a drag, so try to get started on those things way in advance. In general, the people in the hospital are pretty motivated to help you out.
I spent this last October in Anchorage which was a great experience. You are provided lodging in a modest apartment and a rental car. October was a great time of the year to go, as it wasn’t too cold and there was no snow on the ground so exploring the surrounding areas was not particularly difficult.
I split my time between the hospitalist rotation and the outpatient clinic. The hospitalist I was paired with was none other than Ted Wright, former UW Boise track graduate. I carried about 7-8 patients and admitted every weekday. The hours were not bad. The case mix was bread and butter medicine (pneumonia, urinary tract infection, chest pain, DKA). One of the more interesting parts was discharge planning as the patients you take care of come from some very remote areas in AK. In fact, they have a hotel in the hospital to stay at while you get outpatient follow up if needed.
The outpatient clinic experience was subspecialty medicine (renal, ID, pulm, rheum). The paired faculty are great and there was a lot of teaching.
I had the opportunity to spend four weeks in Livingston this November and it was great! I was expecting to have bad weather, but it was mostly sunny and the snow was just starting to fall. The hospital and clinic experience was so enlightening. My first day there in the ED, I saw a woman with a femur fracture, a child with urinary retention and another child with a BB up the nose– all things I had not seen in my first two years of residency! In all of these cases, you take the lead on evaluating and figuring out how you are going to treat it. Thankfully, the nurses are kind and helpful! The ER was busy, but it was so much fun.
My schedule was similar to that described previously– a couple of hours of hospital medicine in the morning and then clinic afterward. I did more general primary care this month than in all of my residency! It was exciting and refreshing. The patients really wanted to hear your advice and were happy with your care. I realized how much I had to learn. Dr. Wadle and his nurse are fun and cheerful. I would recommend this rotation to anyone who wants to see the complete spectrum of general internal medicine.
I can’t say enough positive things about my experience in Livingston, MT! It gave me a great taste for rural medicine and was a nice balance between the inpatient and clinic worlds.
Livingston Health Center is a small hospital with about 25 medical beds and 4 ICU beds. The physicians and staff are a close knit group who are all extremely friendly and supportive. I worked closely with Dr. Wadle during my 4 weeks and had an amazing experience! UW trained, he is passionate about his work, extremely knowledgeable, and eager to teach. He clearly loves practicing rural medicine and is generous and welcoming.
On an average day, I showed up at the hospital around 7:30 or 8 to round on any patients on the floor or in the ICU. The number of patients varied, but ranged between 2-5 on any given day. The mornings might be filled with procedures like colonoscopies or stress tests. And then, clinic started around 9:30. The clinic is right next door to the hospital and during lunch, we sometimes ran over to check on patients. Most afternoons were filled with clinic, but once a month you accompany Dr. Wadle on nursing home rounds or rehabilitation center rounds. Every Tuesday, Dr. Wadle takes a 2 hour lunch to make time for a 5 mile run through the town to his favorite lunch spots, which I’d recommend definitely joining! Clinic offers ample learning opportunities and procedures (joint injections, biopsies, etc). As a rural medicine physician, Dr. Wadle often fills in where we would typically refer to a specialist.
One of the great things about the Livingston experience is that it is very flexible. Because there are a number of internal medicine doctors working in a group, you are free to do as little or as much inpatient work as you are interested in. I only worked one ER shift (essentially 28 hour call), but I saw everything from COPD exacerbation, symptomatic bradycardia, broken bones, screaming babies, and on and on. Working in the ER is a great experience because it is just you and the ER nurse covering 6 beds. Livingston is well situated in the sense that it is the biggest medical center to the North entrance of Yellowstone, so you end up seeing patients from around the world with a variety of medical issues.
Livingston Health Center rents a 3 bedroom vacation home for you, which is 1 block from the hospital and clinic and is very convenient.
Livingston is driving distance to Jackson Hole, Grand Teton National Park, Gallatin National Forest, and Yellowstone National Park. With most weekends off, there is ample opportunity for outdoor fun!
Livingston is a small town, but there are cute cafes and restaurants, as well as a farmer’s market. Also, Bozeman is only 25 minutes away and has a Portland feel with fun festivals, ethnic food and shopping.
I didn’t expect anything life-changing by doing a WWAMI rotation, but that’s what I got out of my time in Montesano, WA with Drs. Ki and Clara Shin.
They are a husband and wife duo, UW grads from 16 years ago, who have a fantastic tiny practice in a town of 4000. The experience changed my life because it opened my eyes to a completely different model of primary care than I’ve experienced at the VA (where I have my continuity clinic).
Thanks to Ki’s focus on “the big picture”, I had a chance to learn about the nitty gritty of how his clinic stays afloat (by looking at his quarterly financial reports, hearing about his business decisions regarding hiring PAs, how he handles billing for patients on medicare, how he designed the floor plan of his clinic to improve communication between staff) as well as some exposure to small town medicine (he does his own treadmill tests and places acupuncture needles in some patients with musckuloskeletal pain).
Ki hand-picked patients on his schedule who I would benefit from seeing. Specifically, he grabbed me for any procedure or interesting rash, and consulted me on the most interesting medical mysteries he faced. I have tremendous respect for the Drs. Shin with regards to fund of knowledge, patient rapport and interest in teaching.
I also had a chance to work for a few days in the local hospital and at another IM clinic in Aberdeen. Both of those experiences served to reinforce that Dr. Shin has set up an amazingly high functioning and rewarding clinic.
Ki and Clara are also remarkably generous. They lent me a car for the month, took me mountain biking and gave me eggs from their chickens.
So how was this life-changing? I’m actually thinking of going into private practice. Think that’s crazy? You won’t after seeing how rewarding the practice that Ki and Clara have set up for themselves. It’s a completely different career than I had been considering previously, and I’m excited to have Ki as a mentor to help guide me through it.
I can’t recommend Montesano highly enough for anyone who is into Primary Care.
No surprise here – I had an incredible time in Soldotna. The rotation exceeded my expectations and I checked more than a few things off of my clinical and life bucket list (snare a colonic polyp, see the northern lights, etc).
Peninsula Internal Medicine
PIM is a practice of 6+ attendings who are passionate about primary care and know way more about medicine than I can ever hope to know. By the end of the rotation I was still surprised when I could ask questions about everything from central hypothyroidism to treatment of metastatic esophageal cancer to echocardiograms and get detailed answers backed by the latest evidence. Most people have traditionally worked with John Bramante, a UW grad and former chief, who will welcome you to the PIM and his own family with enthusiasm. He’ll be spending most of the 2013-2014 academic year in Florence on sabbatical though, which means you’ll work with Bill Kelley, one of the original founders of the practice, who is equally experienced and devoted to his patients and teaching.
Most mornings there are colonoscopies/EGDs to be done – after you’ve tried your hand at the controls a few times, you can sit these out and prepare for the patients that are mixed in between cases. Afternoons are filled with more clinic. Lots of general internal medicine but many interesting cases too. I initiated one of Bramante’s UC patients on infliximab/azathioprine, took care of a patient with leprosy, had a discussion re:sorafenib with a stage IV HCC patient, and also saw a patient with MAI. I also was involved in a few stress tests and TEE cardioversions.
In and Around Soldotna
March was a perfect time to be in Soldotna – there was an abundance of snow and sunshine. Among the things I did:
rented XC Skate skis for a week ($80) at Beemun’s True Value/Variety store and skied at Tsalteshi Trails, just 5 min from the apt
hiked Hideout Trail at Skilak Lake, perfect on a clear day, 45 min from Soldotna
snowshoed Homestead Trail just outside Homer, and more locally at Kenai National Wildlife Refuge in Soldotna where moose can be found
watched a Kenai Bears hockey game
dog sledded with Bramante
went to Homer a bunch of times and: explored around the Wynn Nature Center, went to the Two Sisters Bakery which has amazing things called Boca bites which are perfect with coffee, wandered around art galleries. Make sure you go to Homer on a clear day because it’s one of the most beautiful places you’ll ever see. also in Homer checked out Pratt Museum and Alaska Islands and Oceans Visitor Center both of which are worth the visit
Free lunch every day at Central Peninsula Hospital – pretty tasty. Halibut, jumbo shrimp and ribs are just a couple of my favorites. Get the mozzarella sticks too. Cookies are addictive (just squish them a little first to make sure they’re chewy…)
PIM will arrange housing for you in a 1-BR apartment right on the Kenai river. Sue and Dale Cain take good care of you if there are any issues that arise.
PIM also provides a sweet 2008 Subaru Outback with studded tires.
Still cold, but an amazing four weeks. I highly recommend rotating at the Alaska Native Medical Center in Anchorage!
You will be given a choice of (1) outpatient clinic, (2) inpatient medicine, or (3) ICU. You can pick 2 of 3 if you want to mix/match. I chose a mix of outpatient clinic (and requested a GI focus) and inpatient medicine.
For outpatient clinic, you can work with a general internist and see everything, but you can also request to work with the specialists, assuming they are available. There are two infectious disease docs, a gastroenterologist, a rheumatologist, a neurologist, a dermatologist, nephrology PA, pulmonary, etc. Many of the specialists see patients in the clinic, but also perform inpatient consults. You get more weekend time off.
For inpatient medicine, I was assigned to an Attending (who rotates weekly). I carried about 5 patients of a 12-15 pt service. Rounds are pretty informal and you have independence, but still have opportunity to discuss the plan with the Attending. I admitted from the ED. There is good support for PT/OT, social work, etc.
ICU is a busy service, generally. Less weekend time off, but a lot of procedure opportunities.
Alaska Native Medical Center:
Beautiful facility. Very modern. The patients are also amazing, mostly Native and from villages hundreds of miles away requiring travel in by a bush plane. I learned so much about Alaska geography and native culture throughout the month. The patients are very warm and friendly. I really enjoyed interacting with them.
A big city. Plenty of supermarkets, coffee shops (Kaladi Bros!), restaurants, gyms, museums, etc. Even in March, snow can be challenging and I would recommend considering upgrading to a slightly nicer car with all-wheel or 4-wheel drive, especially if you plan to take some road trips.
If you have time off, consider going to:
Drive 2.5 hrs south to meet up with the Soldotna resident and then continue on south to Homer, AK
Seward (I never made it here)
Fairbanks is quite far and unless you have a lot of time, you would probably need to fly. You can also take the Alaska Railroad
In winter, plenty of downhill skiing, cross-country, snowshoeing. You can even organize dog-sledding/mushing, ice fishing, snowmobiling or a flight over Denali if you want.
If in March, try and see the start of the Iditarod (pretty amazing!) and the Northern Lights.
Despite the negative five degree weather, snow, and a highly functional Kia Forte… this was an absolutely amazing rotation. I spent 4 weeks in the ICU working as a fairly independent entity with my own patients and responsibilities. The highlights of this were close interactions with the attending, making vent changes on your own, and the procedures. I did somewhere around 13 subclavians, 5 IJ, 1 tunneled line, 2 broncs, and helped with an EGD. The staff are great and they are interested in you and your education. I would get in around 7:30, round at 8:30 and usually leave around 7 pm unless it got busy. Overall a great rotation. Anchorage is nice, but cold. Although I did do a fair amount of running which was spectacular! I would totally recommend this to anyone interested!
To be honest, I was nervous about Soldotna in the winter, but it was one of the best months I’ve had yet in my whole medical education. The clinic is amazing, as others have explained. The docs up there are top notch, I think I saw more complex patients up in a day there than I would in a week in Seattle, and all being completely managed by internists! It’s awesome. I have prescribed triple-therapy for a patient with MAI pneumonia, high dose steroids for a UC flare, and amio-loaded someone for refractory a-fib in clinic without any specialist help. The clinic runs smoothly, they have a fully functioning EMR and laptops for everyone. The support staff is wonderful and I became friends with several of the nurses and MAs.
There is still plenty to do in Soldotna wintertime, though I will say it’s the coldest weather I’ve ever been in. The scenery is just incredible. We went to Homer and Seward, like others have posted about, but it was a cool different feel to be there in the dead of winter with only the locals and the awe-inspiring views. We went cross country skiing (right out of the backyard if you want!), snowshoing, dogsledding, and ate wonderful meals at all of the doctors houses.
Don’t pass this rotation up!!
I spent mid August through early September in Soldotna. My wife, Tiffany (pediatrics), joined me to work in Katy Sheradon’s Family Practice during that time. I think plenty has been said about the quality of the rotation, but I’ll add my perspective. John Bramante is the main doc with whom residents work. He is in a practice with ~5 other docs called Peninsula Internal Medicine. They are a private practice across the street from the hospital, but also provide hospitalist coverage. During my month, that actually stopped, as the hospital hired some hospitalists, but things may change again. I spent 3 weeks mostly in clinic. I worked closely with John Bramante and also Bill Kelley. They are both excellent docs (UW and UCSF trained, respectively) and do a surprising amount of speciality care (cardiac stress tests, EGDs, colonoscopies, HCV treatment, chemotherapy, rheumatology). Their patients were also quite interesting and wonderful to treat. I spent one week working as a hospitalist as well.
The most memorable part of the month was my time away from work. There is quite a bit to do in the area, particularly if you like the outdoors. August on the Kenai Peninsula is popular with many of the locals, as the weather is still nice but the tourists are gone. By the end of my month, fall was in full swing (with a pretty brilliant color change). I went out fishing with Bill Kelley on various stretches of the Kenai on multiple occasions. He took me drift boat fishing down the upper Kenai for rainbow trout, where we saw several brown bear fishing from the shores. We also fished the lower river for silver salmon and trolled the middle river/Skilak lake for rainbows. I have been to a lot of rivers and this one is one of the most beautiful anywhere. The fishing is also excellent, if that’s your thing.
On weekends, Tiff and I did a lot of the usual trips to Homer and Seward. Homer is a quirky town SW on Soldotna on the coast. There are some good restaurants and great hikes – see the Grace Ridge photos below. Seward is a smaller town with not as much going on, but nearby Kenai Fjords National Park is amazing. All of the glacier shots are from that area.
We didn’t make it to Denali, given the distance, but I know some others have made the trek. I think the experience is highly weather dependent, as the mountain is only out 1/3 of the time.
The best part of this rotation were the people. We were invited to dinner and fun activities with so many docs and their families. Indeed we were made to feel part of their families. Tiffany got to eat moose heart once too!
John Bramante was kind enough to let me help him harvest honey from his bee hive. Here’s his daughter helping out too.
This is a pink or humpback salmon I caught. They run in large numbers on even numbered years. Locals don’t fish for them much here as they’re not great for sport fishing and don’t taste as good as sockeye, but they’re easy to catch and fun for kids. This one is a male I caught from the shore while fishing for silvers (Coho salmon).
The top of Exit Glacier, with the Harding Ice Field beyond.
Exit Glacier, as seen from the hike up to the Harding Ice Field.
A beautiful tidal glacier flowing into the fjord.
This is a sockeye salmon, aka “red.” They come up the Kenai and head into the Russian River to spawn.
Tiffany and I hiking along the lake, which flows as glacial run off from the Kenai Mountains, shown in the background.
Glacial silt gives the river its characteristic color. The silt is called “stone flour” because it is incredibly fine, leaving the river unusually cloudy.
A shot of crow berries at the top of the ridge line.
The ridgeline at Grace Ridge. This hike requires a water taxi to get to. We were dropped off at Kayak Beach and picked up at the other end, back at sea level. I think the winds were ~40 mph sustained.
Glacial silt gives the river its characteristic color. The silt is called “stone flour” because it is incredibly fine, leaving the river unusually cloudy.
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