PRINCEVILLE, Kauai — Dorothy Tse and her husband were trying to change a shower head in their new house here one day in late November when he felt a pain in his back and what he called “malaise.”
She and her husband had recently bought the house and intended to divide their time between the San Francisco Bay Area and Kauai. They were so new to the island that they didn’t even know the names of any of Kauai’s three hospitals.
The pain didn’t relent, so Tse and her husband went online and found a website for the Makana North Shore Urgent Care Center, which happens to be right behind the firehouse that serves Princeville.
They didn’t know that Makana represents a radical new model in providing community urgent care services. Its physicians are on staff of the University of Utah Hospital in Salt Lake City and the doctors and some of the nurses fly to Kauai from the mainland for rotations lasting several weeks.
The physicians are all board certified in emergency medicine and some, like Dr. Ted Kimball, the medical director, are further certified in subspecialties. Other nurses, physician’s assistants and the facility’s X-ray technician live on Kauai full time.
The system, which is believed to be unique in the United States, gives Kauai emergency medicine providers who are based at a large urban medical center and are current on the most recent innovations in the field. It also gives the Utah medical staff members several opportunities a year to spend time on Kauai. Many bring their families and give their stints on island a vacation-like flavor.
As it happened, Kimball was on duty when Tse and her husband arrived. As he questioned his patient, Kimball said he started to realize he was looking at an unusual — and potentially catastrophic — situation.
The man had suffered a rare dissection of the aorta, the body’s largest artery, a condition in which the vessel tears, allowing blood to start to rush out and destroy the remaining arterial tissue. He might die at any time.
“After talking to him for about 20 minutes, I believed he had what he was ultimately diagnosed with,” Kimball recalled in a phone interview. “He likely would have died in the next 24 to 36 hours had he not come in and had we not been open. It could have been a very sad day for the family.”
Kimball and the Makana staff stabilized the patient. They told Tse they needed to order an ambulance to take her husband to Wilcox Memorial Hospital in Lihue, from which he would be transferred by air almost immediately for emergency surgery in Honolulu. Many doctors who lack Kimball’s experience might have missed the diagnosis or underestimated the situation and advised Tse and her husband to go home and wait it out.
Tse, her husband and two daughters had been planning a day trip to a stable. “We had the whole day planned out,” Tse said by phone from her home in California. “I couldn’t even absorb the information.”
Within 12 hours, Tse and her family had flown to Straub Medical Center in Honolulu, where emergency surgery was performed. Her husband was put on a ventilator and hospitalized for two weeks. But he survived — though he is still recovering.
“It was a reminder of the fragility of life,” Tse said. “It could have been so much worse.”
The New Model Proves Successful — Until COVID-19
Makana opened about three years ago. It was a nearly instant hit in a community accustomed to having few options for emergency care without driving all the way to Lihue, almost 30 miles away. Getting treatment for minor fractures, flu and childhood diseases, surfing injuries and even serious cuts and bruises could be daunting.
The clinic, Kimball said, was seeing 700 to 900 patients per month. The operation was on the cusp of exceeding its original financial projections, he said.
“And then COVID hit,” he said.
Kauai’s early approach to the pandemic involved an islandwide lockdown and even an overnight curfew for a few weeks. The visitor industry collapsed. Hundreds of local families had to confront disappearing jobs and financial ruin.
Though Makana’s existence is predicated on providing services for local people, Kimball said, it is as dependent as the rest of the island on visitor spending. Tourists, said Kimball, “don’t know how to drive in the rain, how to avoid falling off rocks or crashing their cars.”
Patient volumes started to drop dramatically. The clinic started to hemorrhage cash. Not only that, but the risks of traveling during the pandemic threatened the model of providing expert medical staffing by doctors and others flying from Utah.
“We as a group made a very firm decision that we just weren’t going to shut down,” Kimball said. Even with COVID-19 slamming Kauai’s economy, the clinic, he said, still saw 4,000 patients between the onset of the pandemic in March and December.
Service modifications had to be made. Operating hours were cut from 7 a.m. to 10 p.m. so the facility closed at 5. Staffing was reduced so there was no x-ray technician available on Sundays — the day, he said, when the fewest x-rays are typically ordered. An in-house pharmacy closed.
“There are many businesses that have just gone under,” Kimball said, “but if you’re dealing with people’s medical conditions and lives, it’s another level of concern.”
“I’d say 50% of our patients are visitors,” said Ashley Ilustre, a nurse at the clinic. “But a lot of people just moved here.”
It’s a remark that mirrors a widely acknowledged bump in Kauai’s population as mainland people take refuge from COVID-19. Whether they stay remains to be seen.
“I think it’s mostly waiting for this pandemic to subside,” she said. “We definitely had to invent a COVID protocol. It would be a problem if even one of us got sick.”
Kaitlin Szekalski, a physician’s assistant, said she thinks there has been an increase in primary care patients.
“Not as many slip and falls,” she said. “Somewhat fewer surfing lacerations. Much fewer accidents at Queen’s Bath,” a notorious tourist destination that, in many years, sees drownings as visitors are swept off its rocks.
Ilustre said she has received her COVID-19 shots.
But like many pregnant women, Szekalski said she has not because available vaccines have still not been tested for effectiveness and potential side effects in pregnant women and infants. “I’m going to wait until I’m no longer pregnant. I think on Kauai that we’re fairly safe.”
“I’ve had to postpone my wedding twice,” Ilustre said, “and we’re having to pare down the guest list.”
Ironically, the situation in which Makana was trying to stabilize its bottom line led to a decision by Kimball to bring a full-time dermatology practice to the clinic — something that was never envisioned when the clinic was designed and built. Nevertheless, dermatology has long been a specialty seriously underrepresented on the island.
Previously, a single physician and a nurse practitioner had provided all dermatology care services on island and neither was based on the North Shore. “It’s been gangbusters,” said Kimball of the patient volumes the dermatology practice has attracted.
Kimball hopes to add Makana to Kauai’s roster of COVID-19 vaccination sites and said he hopes the arrival of vaccines will make a difference to island health. He is aware, however, that people on Kauai are often even more vaccine-averse than residents of other locations.
“In my medical career, I have never seen anything so completely stump every doctor’s ability to predict what’s going to happen,” Kimball said. “If the vaccines kick in, there’s hope, but I don’t see any need now to further reduce hours.”
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