Category Archives: Alaska

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!

Halloween in Soldotna

I had to pick a holiday to identify the season rather than saying that I spent a month in Alaska in that awkward in-between time after summer and before the first snows. A sort of weather that shouldn’t feel foreign after a year in Seattle. But that said, there was no lack of activity. It was perfect weather for jogs through local parks. Dr. Bramante’s sled dogs seemed just as happy to be hooked up to an ATV for a trot down the beach. (And I can’t help think pleased to cover me in mud in the process.) There were some beautiful views of the mountains from Dr. Kelly’s bush plane. Not to forget the title, the halloween celebration included my being pulled out of clinic to crawl through the local hay maze. Incidentally also teaching me why the docs tend to wear clinic casual.

I spent that clinic time mostly with Dr. Kelly and McDonald during a year when Dr. Bramante has been living the dream in Italy with his family. The patients were a representative sampling of the town and surrounding region ranging in age and background, but if I had to compare, remind me of the VA population. Living in Alaska takes a sturdiness that sometimes causes people to present late with disease. Young guys came straight from the “slope” oil drill, middle-aged folks boast about living without power in the wilderness, professional fisherman come with stories (and sometimes fish), and I was surprised at the number of zebras that showed up with them. While some are sent to Anchorage or Seattle for further work up, the majority are evaluated by the very capable crew of docs in town. Dr. Kelly reads all of the cardiac echos for the hospital and does a fair share of the colonoscopies and EGDs (I decided they’re just like playing video games).

All this I could have taken as a great experience making me more aware of the docs that practice “out there” far from where I might ever find myself. The more surprising and wonderful part was that I would love to go back. The practice in Soldotna is unique in that the docs there have trained and worked in big cities – most with stints at UW and UCSF – and made the thoughtful decision to continue an intellectual and progressive practice in a small town far from home. Whether by instinct related to living in relative isolation or just out of goodness of heart, the community is the most welcoming I’ve ever experienced. I got to know and spent time with the docs, clinic staff, their kids, friends of the family and even was on a first name basis with one of the grocers. It was hard to leave that kind of connection and even more amazing to think that these folks make it over and over with generations of residents.

Please drop me a line with any thoughts or questions about the rotation. Clearly happy to talk about one of my favorite experiences of residency.

Anchorage in the Summer!

Doesn’t get much better than Alaska in July/August when I was in Anchorage.  You get a sweet apartment that comes with a bed INCLUDED AND a rental car.  When I was there I split time between the hospitalists and the outpatient world.  My recommendation to people going there would be to skip the inpatient side of things (can’t speak for MICU) and do all four weeks in the ambulatory setting.  The hospitalists are all really cool but you will mostly be dealing with alcohol withdrawal, some CHF and CVAs.  The ambulatory setting on the other hand has AWESOME pathology and really super interesting medicine since people come from all over Alaska.  The general internal medicine model is super interesting there as patients are primarily followed by ARNPs, PAs, family med, etc for there general primary care needs and are referred to an outpatient internist for interesting/difficult cases.  You also have the opportunity to work with an Endocrinologist (who is awesome), nephrologist, dermatologist, GI doc, etc.  I spent a lot of time in GI and by the end he wasn’t even dressing up for the EGDs and I was doing them independently as they are mostly diagnostic scopes in patients who arguably don’t need them.

You will also get more time off and have earlier days to enjoy the endless sunshine.  Everyone gets a 5 day weekend and that’s the one I used to go to Denali where it was in the mid 70s, the mountain was out every day and I saw tons of grizzly bears, moose, and other creatures of the wild.  Do the coastal trail, climb flat top, go fishing, get a kayak and bike from one of the hospitalists and cruise around.  Let me know if you questions or need advice on what to do.

It should definitely be #1 on your schedule wish list.

ANMC MICU

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.

October in Anchorage

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.

All in all, a great month.

March in Soldotna

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

The Perks

  • 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.

Northern Lights from Soldotna Dogsledding with John Bramante! Kenai River right in your backyard! Bishop Beach at Homer Hike at Skilak Lake Moose up close and personal at the Kenai Wildlife Refuge Bald Eagles outside your apartment Peninsula Internal Medicine

March in Anchorage

Still cold, but an amazing four weeks.  I highly recommend rotating at the Alaska Native Medical Center in Anchorage!

Clinical rotation:

  • 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.

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Anchorage:

  • 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:

  • Anchorage museum
  • Drive 2.5 hrs south to meet up with the Soldotna resident and then continue on south to Homer, AK
  • Hatcher’s Pass
  • Talkeetna
  • 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.IMG_0986

 

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Steve Vindigni

December in Alaska

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!

Andrew Prouse

December in Soldotna

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!!

August in Soldotna

 

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! 

Glacial silt gives the river its characteristic color. The silt is called “stone flour” because it is incredibly fine, leaving the river unusually cloudy.