The Last Frontier
Alaska. License plates proudly display: The Last Frontier. If you live in Skagway or visit the region, the E.A. and Jenny Rasmussen Community Health Center is the only healthcare facility in this part of the frontier. Whatever malady or injury that may befall you will be diagnosed, treated and might be referred by this outpost to Juneau, Anchorage, or Seattle. None of these cities are close by and all of them must be reached by ferry (7 hours to Juneau, the closest city with secondary and tertiary medical services) or by single engine air ambulance. Of course, this is Alaska. In summer the ferry runs pretty much everyday and small planes dot the sky, moving Alaskans and visitors alike all over the state. But in the middle of winter, moving patients to other cities is not always easy or even possible.
Unlike any other community health center I’ve ever visited, this one has three Urgent Care Rooms that look suspiciously like trauma rooms found in every hospital emergency department. There is an x-ray suite (films are read over the internet by radiologists in Juneau) and an ultrasound room (a licensed ultrasonographer retired to Skagway and is on call for the clinic). What’s missing are physicians–in this town of 800 residents and thousands of summer visitors, there simply aren’t any. The family nurse practitioners (3 of them) and physicians’ assistants (2 in summer; 1 in winter) are required to undergo and maintain advanced training in trauma life support, cardiac support and pediatric life support. Their continuing education profiles resemble those of critical care and emergency personnel. These amazing clinicians must be ready for any kind of emergency that rolls through their door in addition to providing primary and preventive care for thousands of locals and visitors who come to Southeast Alaska.
The clinic has an infant isolette for emergency deliveries–local women receive prenatal care at the clinic but travel to Juneau at 38 weeks to await the birth of their baby so routine deliveries are not part of health center’s mission. However you can never predict with 100% accuracy when birth will occur. In the past year the clinic had a patient in active labor at 29 weeks, with twins. The very well trained clinicians worked furiously to slow down or stop her labor with medication (consulting by phone with physicians in Juneau and beyond) because Skagway was “weathered out”, an Alaskan expression meaning no planes could fly in/out and the ferry was not able to traverse the Inside Passage either. Even the US Coast Guard could not get into Skagway, a rare situation. This patient had to move to a perinatal center STAT and the clinic medical director–Carol Borg, MSN, FNP–called the emergency room physician in White Horse, Canada, to say they were bringing the woman up by ground ambulance. White Horse does not take transferred American patients and the border is not always open but this was an extreme emergency so Carol made the call, climbed in the ambulance with her patient and undertook a treacherous ride under bad weather conditions. Fortunately for the patient and her babies the weather had cleared somewhat at White Horse and they were evacuated by Lear jet to Seattle where high risk OB services were waiting. The patient delivered 48 hours later. Mom and babies are doing well today. Without the knowledge, skills and determination of the nurses in Skagway this story could have had a very different ending.
This is a challenging and remarkable practice site where nurse practitioners and PAs must be very confident and comfortable with the level of responsibility they assume. It is a place that does not appeal to everyone; it’s remote and particularly isolating during the long, dark winters. I was privileged to witness the work and commitment of these frontier clinicians. Their services are clearly vital to the region.