American Academy of Physician Assistants Newsletter Article

Life Is a Tropical Paradise for PA on Midway Atoll


By Doug Scott

On Midway Atoll, the primary species in residence is not the human,
but the gooney bird. In season, as many as one million gooneys mate,
build nests, and make the 2.4-square-mile atoll their home.
There are no native inhabitants on the atoll, but about 100 people
live and work at the bird and marine mammal sanctuary, the Battle
for Midway Monument, and the airport runway. Since Medcor became
the subcontractor responsible for hiring Midway’s medical staff
about five years ago, it has hired exclusively PAs as health
care providers.
A tropical island in the Pacific Ocean, with plenty of beach,
crystal-clear blue water, and warm year-round weather — it must
be the perfect place to live and practice medicine.
“I don’t have any complaints at all,” said PA Jim Cassell,
clinical director of the Midway Atoll National Wildlife Refuge
Medical Clinic. “The population here is just like any small town.
You get to know all the people very well. And the people here
work hard, play hard, are very conscientious, and they are very
appreciative of anything that I do.
“The workload is not what you are going to see in a hospital in
the middle of Los Angeles or a busy clinical practice. But then
again, I can take all the time I need with a patient. We can
talk about lifestyle, and I get into a lot more issues than I
ever would in any other kind of facility, just because I have
the time to do it. And I have a captive audience. They can’t
go anywhere. “I see them all the time on the atoll, so I can
frown on them if they are doing something that we talked about,
like smoking or alcohol.”
And don’t forget the gooney birds.
“It’s their island,” said Cassell, laughing. “This place is
all about the birds, and we are here to support them. It
becomes problematic because the gooney birds will stand in
the middle of the road, and they don’t respect vehicles
at all. Every time you move your vehicle a few feet,
they just fill in behind you.”
Midway Environment
Most of us think of the Midway Islands, or what today is
called Midway Atoll,
as the site of one of the most important naval battles
of World War II. Less than 140 nautical miles east of the
International Date Line and one-third of the way between
Honolulu and Tokyo, the islands — Sand Island, Eastern Island,
and microscopic Spit Island — were on June 4, 1942, the site
of the U.S. Navy’s devastating defeat of the Japanese Navy,
considered the turning point in the war in the Pacific.
Today, peaceful Midway Atoll is an unincorporated territory
of the United States, designated as an “insular area” under
the authority of the U.S. Department of the Interior. After
decades as a U.S. Navy base, the atoll in 1996 became a
National Wildlife Refuge administered by the U.S. Fish and
Wildlife Service. The federal government subcontracts the
employment of the support staff to Chugach Industries, which,
in turn, subcontracts medical care to Medcor.
Cassell found his position through The PA Job Link, AAPA’s
on-line job matching service. “This is one of the nicest
clinics that I have ever been in because the Navy built this
for 5,000 people and it is huge,” he said. “While some of the
space has been taken over as office space for Chugach, I have
an emergency room with two beds, which used to be the operating
room and still has the big surgical lights in it. I have an
x-ray room with a fairly old x-ray machine that is manual, and
a dark room where you actually have to develop the film in
the tanks. I also have a very small lab, two dental surgery rooms,
and a room that at one time was set up to do optometry, that
even has all the devices for doing refraction tests.”
Island Challenges
With flights coming in from Hawaii only three times a month,
Cassell has to make do with whatever medications or equipment
are kept on the atoll. Only in emergency cases, in which life,
limb, or eyesight are at risk, will the U.S. Coast Guard
immediately fly in and medevac a patient to a hospital in Hawaii.
“There is no drug store where people can run to get medications,
so the trick on Midway is to develop a formulary that is large
enough to meet the emergency requirements without going to the
expense of constantly throwing meds away,” explained Cassell.
“My job is not to be everybody’s primary care PA. What I am
is strictly a professional health care provider who can provide
emergency medical care and monitor our patient population’s
health and stabilize them until they can go to Hawaii. But the
problem is that sometimes that’s up to 10 days that I have
to keep somebody here. So I keep enough medication, equipment,
and materials to be able to take care of somebody for a
period of time.” Besides the wonderful climate, what makes
it a true paradise is that Cassell does not have to deal with
insurance forms or reimbursement, because all the health care
is administered for free. “That’s really nice,” said Cassell,
who served as a nurse and a public health officer in the U.S.
Air Force before becoming a PA.
“Jim has a really nice way of attending to detail and
completing tasks in an organized and timely fashion while
possessing a laid-back personality,” said Cassell’s supervising
physician, Luanne Freer, M.D., medical director for Medcor
at Yellowstone National Park and the Midway Atoll National
Wildlife Refuge. “He is capable of seeing two patients a day
with minor complaints or managing a critically ill patient
demanding constant attention. Jim seems to do just fine with
whatever the island has to throw at him.”
Each PA works for only six months on Midway, so Cassell will
be leaving in December. “I am going to miss the people and the
incredible wildlife,” said Cassell, who hopes to return for
another six month stint. “There are occasions when it is a
little terrifying, where you are here alone, somebody is
grabbing their chest and having trouble breathing, and help
is 1,200 miles away. But once the patient is stabilized and
transferred to Hawaii, you can go back to enjoying this
incredible environment.”
(PHOTOS)Aerial view of Midway Atoll (top), part of a chain of volcanic
islands, atolls, and seamounts extending from Hawaii up to
the tip of the Aleutian Islands in the Pacific Ocean. PA Jim
Cassell (left) is the sole health provider on Midway Atoll in
the middle of the Pacific Ocean. Below, Cassell treats one of
the gooney birds on Midway Atoll.