Since 1929, Yosemite National Park has had a medical clinic. For most of its existence, the clinic was operated by private-sector entities (most recently, Tenet Healthcare) through concessions contracts with the federal government. But in recent years, the clinic has not been financially viable for a for-profit corporation. When Tenet indicated that it would not seek to renew its contract with the government, and no workable bids for a replacement came in, park officials faced a decision: Find an alternate solution or risk closure of the clinic.
Losing Yosemite Medical Clinic would have been problematic, if not disastrous, for park employees, local residents, and the park’s 4.1 million annual visitors. While the park’s emergency services still would have operated, it would have been much more difficult for primary and acute care needs—those that require attention but not an airlift to another facility—to be met.
Since closing the clinic was not an option (figuratively, anyway), park officials decided to explore partnerships with nonprofit entities. As a result, Yosemite Medical Clinic is now owned and operated by the National Park Service, with a clinical staff comprised of commissioned officers in the US Public Health Service (PHS).
“This is the first model of its kind,” says clinic manager David J. Pope, who is also Deputy Chief of Emergency Services at Yosemite. “Others that are similar to it exist, but not in national parks.”
SERVING THE COMMUNITY
Yosemite Medical Clinic serves about 7,500 patients per year. Of those, primary care visits by many of the 4,000 local and seasonal residents of the park and surrounding area account for 70%. The other 30% represents the urgent care needs of visitors.
The nearest emergency department (ED) is more than an hour away by car. Without a medical clinic in the park, obtaining primary or acute care would be, at the very least, inconvenient.
“There are a lot of families living here, many with young children,” Pope says. “Having the clinic allows those families to feel comfortable and have their medical needs met in a local manner, instead of having to travel well outside the valley in order to see a clinician.”
The clinic was temporarily closed for the first few months of 2011 (emergency services remained available) while the building was rehabilitated. Yosemite Medical Clinic reopened on April 22 and is currently staffed by Ralph J. Groves, MD, Brian Burt, PA-C, senior nurse manager Jennifer Leggett, and senior staff nurse Timothy Yett. There is also an ambulance operated from the clinic (in addition to five others throughout the park), so paramedics and EMTs are available to assist in the clinic between calls.
NO TYPICAL DAY AT THE OFFICE
In addition to providing primary care services to employees and residents, the clinic staff also addresses the acute and urgent needs of visitors who pass through the gates of the almost 1,200-square-mile park. The clinic reopened just in time for the peak summer season (May-October), when Pope says two-thirds of the daily patients are walk-ins with complaints that run the gamut from strep throat, fever, and allergies to dehydration, hypernatremia, broken bones, and wounds that need suturing.
“Sometimes a quick visit to the clinic can fix a problem that will save someone’s vacation,” Pope says, “or address problems that might have become critical in the event that they couldn’t access health care quickly.”
Working at Yosemite Medical Clinic has been an interesting change for Burt, a lieutenant commander in the PHS. For almost eight years, he was assigned to the Federal Bureau of Prisons in North Carolina. After applying and being selected for the PA position at Yosemite, he relocated with his wife and two children.
“I expected to see an occasional bump or bruise and do mostly primary care for residents of the park,” he says after three months on the job. “But I’m amazed at the magnitude and the sheer number of injuries that occur daily.”
During the summer, the clinic is open from 9 am to 7 pm. In the morning, people are waiting at the door with relatively minor complaints, such as cuts, sprains, and respiratory issues; scheduled appointments follow. But it is the 4-to-6–pm block that Burt calls “the witching hour,” when hikers returning from their excursions start trickling in for assessment of any orthopedic injuries they have developed along the way.
It turns out that there is a wide variety of incidents that can occur in a national park: motor vehicle accidents, near-drownings, rock-climbing falls, rattlesnake bites. The last actually occurred this summer; antivenom was administered in the clinic before the patient was transferred to another facility.
“Your guard seems to be down when you’re on vacation; you do things you probably don’t do every day,” Burt observes. While there are proper warnings, “it’s an easy place to take risks. Most of them end favorably, but some of them obviously don’t, and those folks end up requiring us.”
GOING ABOVE AND BEYOND
The physical and mental challenges of the job keep Burt and his colleagues on their toes. Yosemite may be “absolutely beautiful,” but it’s also “in the middle of nowhere,” as Burt says. The rural setting was obviously a huge change for him: “I’m used to working in a prison, where the patient is there 24/7. You can be conservative in their management because if they’re not getting better, you’ll see them tomorrow.”
Clinicians at Yosemite may have to make decisions quickly and think ahead to provide the most appropriate care. In cases of emergency, patients might be transported to the clinic for stabilization before they are transferred elsewhere by helicopter. “Any heart attack, stroke, multisystem trauma—anything that is time-critical—has to go by helicopter, which is at most a 40-minute ride, compared to a two-and-a-half-hour transport by ground,” Burt says. “You have to be two or three steps ahead to get everything ready.”
For Burt, this plays out most dramatically in his additional role as a Search and Rescue (SAR) trainee in one of the busiest SAR operations within the National Park Service (about 250 missions per year, according to Pope, an experienced SAR technician). “There’s a physical aspect of this job that most PA positions don’t have,” Burt notes, citing 10-mile hikes into the wilderness for rescue operations as one example.
If the SAR team responds to a call from someone injured out in the “back country,” they have several options: staying with the patient overnight (providing medication, food, and water), then reassessing in the morning to see if he or she can hike out; transporting the patient via horse; or doing a “short haul” (flying over and lowering a basket to collect the patient for transport to the clinic).
“You have to think about the risks of staying versus the risks to the rescuers, as well as transporting the patient by helicopter,” Burt says. “That’s definitely an interesting part of this job, and it’s taken a lot of getting used to.”
Adaptation and improvisation are part of the job, even within the clinic. If there has been an abundance of broken limbs, the supply of crutches can run out. But even given these occasional issues, Burt says, “Our toy box is full. We have everything we need to stabilize critically ill patients and appropriately transfer them. Now, we don’t have enough supplies to keep them here for three days, of course, but….”
Yosemite Medical Clinic is one of the rare non-ED facilities that can provide thrombolytic therapy. And while it is not a pharmacy, it stocks a limited supply of convenient prescription medications for patients who might need them. “If we prescribed antibiotics and didn’t have them here, the patient would have to drive an hour and a half to the closest pharmacy,” Burt points out.
For residents and park guests alike, the most important thing is knowing that when illness or injury strikes, there is a team of dedicated professionals ready to help. “At the end of the day, our goal is to serve the community and the visitors of Yosemite National Park,” Pope says. “There was a lot of interest [during the transition] in what a government health care operation would look like in comparison with a private-sector one. A lot of the residents didn’t know what to expect, but I think they’ve been pleasantly surprised.”