Wednesday, May 31, 2006

Tapping the Inner Surgeon

{Author's note: before I snatch myself bald and start screaming in frustration, I will now stop trying to upload photos on Blogger. It just ain't working!}

{Imagine here a lovely photo of a handsome caribou bull with very impressive rack. Go to if you'd like to see one.}

This morning’s task always brings out the anatomist in me. It was time to get the caribou forequarter that Sinka gifted us into the stew pot. Caribou is a lean, dark red meat that turns out most tender and flavorful when cooked by a long, slow, wet process. The Crock Pot is perfect.

{Here should be a photo of the skinned, intact forequarter on the newspaper-covered kitchen table with my very impressive large butcher knife.}

There are two ways to go about this. I could just start hacking down to the bone in any sort of haphazard fashion, and it would come out fine. But I just can’t resist carefully dissecting each major muscle group off of the scapula, humerus, and single forearm bone (ulna? Radulna? Any vets out there?). It takes a bit longer, but is lots more fun. The comparison to human anatomy is fascinating.

{Here should be a great shot of my clean dissection with the muscles of the posterior scapula reflected.}

Caribou are not large animals. A full grown male weighs about 500 pounds, and both male and female have antlers. They are herd animals, and congregate in large numbers, sometimes in the thousands. A huge herd is resident in the area east of here, a large tundra plain between the Kuskokwim River and the Kuskokwim Mountains about 75 miles away. The herd has historically numbered around thirty thousand animals. They periodically migrate into areas close to Bethel or one of the many villages along the river, and then they are hunted pretty heavily.

Caribou skin is prized by Native skin sewers; the fur is very soft and warm, and the hide is not difficult to pierce with a needle. It is also very lightweight. The individual hairs of a caribou are not solid, they are like tiny straws; this holds an insulating layer of warm air within the fur. A whole caribou skin makes a wonderful addition to a bedroll; it both cushions and protects the sleeper from the cold ground. The thicker parts of the fur are often used to make mukluks, knee-high fur boots that are very warm in winter.

My caribou forequarter started out weighing about ten pounds. Out of that I got about four pounds of meat. I chopped it into cubes, floured and browned them in an iron skillet, and now they are marrying the potatoes, carrots, and onions I put on top of them.

Anybody hungry?


Tuesday, May 30, 2006

Grand Rounds Up

Yes, this is old news, it's been up all day over at Kidney Notes, and most of my visitors today have come from there. Thank you for stopping in. And a great big thank you to Kidney Doc for choosing my post for Editor's Pick! I'm very honored, especially to be in such lofty blogging company. There is some great blogging in this week's collection, which I think that Kidney Doc did an excellent job of organizing. Both pathways he provided were easy to follow. Head over, if you haven't yet, and enjoy some good reading.


Monday, May 29, 2006

Tobacco Use in Bush Alaska

As both a PA and a health educator, I have been involved in efforts to help people quit tobacco use for over twenty years. When I was a graduate student in Public Health, I worked part time doing research in smoking prevention in teens. I taught both small-group and large-lecture type classes in smoking cessation. As a family practice PA, I have always felt that encouraging people to make healthy choices can help them begin to make changes in behavior.

One of the things I was careful to include in most patient visits when I practiced in the Lower 48 was a question regarding smoking, and a recommendation to consider quitting when the response was positive. I didn’t nag, or trot out horror-story photos of blackened lungs, or go on and on about the incidence and prevalence of lung disease directly attributable to first and second hand smoke. I just asked. Every time. And encouraged cessation.

I taught smoking cessation courses as a health educator for several years before becoming a PA. I also was a smoker for five years back in my intemperate youth; I quit on January 18, 1977, when cigarettes cost 50 cents a pack. As a teacher of smoking cessation courses, having quit oneself was a crucial component of credibility among those taking the course. Participants felt that if you haven’t been there, then you don’t know… Tobacco addiction is intense, and quitting is one of the hardest things most people will ever do. And one of the most important.

The year I spent working in Montana before coming to Alaska also taught me that asking about smoking was not enough. Especially when the cowboy pacing uneasily in the exam room has a positive “circle sign”—a worn-through spot on his rear jeans pocket the exact size of a Copenhagen tin. So I started asking about chewing tobacco, as well as smoking it. But my thinking on the subject was still not quite ready for the Alaskan shift; I was still only asking males over the age of 15 about chewing, though both genders about smoking.

When I first came to bush Alaska, I continued asking my usual questions in history-taking, and was surprised by some of the differences I noted. For the most part, in the Lower 48, people either smoke or they don’t. The most common smoking habit is a pack a day; light-weights smoke a half pack a day (small percentage of all smokers), really light-weights smoke only on weekends or when having cocktails (very small percentage), and heavy-weights smoke two plus packs per day. But I found when asking Eskimos about smoking, the answer quite commonly would be some variation of “not much, maybe two sticks a day or less.” Is that all? Two cigarettes a day? That’s not much. You’d breathe more air pollution than that just living in a big city. But really, how can they do that? The demon that is tobacco addiction can only very rarely keep such a tiny hook in someone.

The answer started to become clear one day when an elderly woman answered my question about smoking with “Don’t smoke, only chew.” Only chew?

“You chew tobacco?” I asked, hoping my surprise was not showing. My medical experience had not included women chewing tobacco, though there are some family stories about my hillbilly grannies who dipped snuff.

“No. Blackbull,” she replied. Blackbull? I was quickly losing familiar ground here. Was that a brand of chewing tobacco? Seeing my flash of puzzlement, she added, “only Eskimos can chew it.” Oh. So I recorded on my chart note “patient chews blackbull” and went on with the reason for her visit. I skipped my usual recommendation that she consider stopping; I wanted to know what she was doing before I asked her to stop.

Back in the 1990s there was very little understanding of the prevalence of tobacco use among the Eskimos, and very little cessation education effort being made by the hospital. The water fountain in the hospital lobby had a sign over it (in Yupik and in English) that said “No Spitting,” but that was about it. If I’d been paying attention, I might have wondered just how much that sign represented the tip of an iceberg.

During my first year here, an energetic health educator with a fire-burning passion to eradicate tobacco use, applied for and received grant funding to assess tobacco use among the Yupik Eskimos, and to design interventions for cessation. It was the beginning of a new era.

The first arm of the study brought a stunning realization: the prevalence of tobacco use is incredibly high, and much of it is chewed, not smoked. And most of what is chewed is blackbull, which is also known as iq’mik. A door-to-door survey in the Yukon Kuskokwim Delta in 1999 revealed that 55% of adults smoke, and 45% chew. (unpublished data, E. Provost, 1999) This compares with U.S. rates of 29% for smoking and 8% for chewing. (U.S. Behavioral Risk Factor Surveillance Survey, 2001) Even more stunning is the estimate that among pregnant women in western Alaska, 57% chew and 16% smoke. (State of Alaska Maternal and Child Health Data Book, 2003)

Iq’mik is a combination of tobacco and the ash of a tree fungus. The fungus, called “punk”, forms knobby projections on certain trees that can be broken off. These are collected in burlap sacks and brought home for burning down to an ash. The ash is then mixed (in the mouth) with tobacco and saliva and set out to dry. Often, one family member is mixing for everybody. Once the mixture dries out somewhat, each family member who chews fills a small leather pouch or tin can for personal use. Each chew is described as "dime-sized" or "quarter-sized."

The addition of punk ash to tobacco raises the alkalinity of the final product to a pH of 10.9—much higher than tobacco alone, which varies from 5 to 8. (Renner, The effect in the human body is that chewing blackbull is somewhat like “freebasing” tobacco. It hits the brain many times faster, and loads all nicotinic receptors like a power surge. Speed of onset is a primary factor in determining addictive potential of any substance. Blackbull is more addictive than chewing tobacco.

Many people who chew blackbull also smoke an occasional cigarette, which brings me back to the earlier portion of this tale. The demon has its claws in far deeper than I thought when I heard “two sticks a day” from numerous patients. One thing you must learn when you work here is that Eskimos, on the whole, are very truthful, and tend to be fairly literal. They generally answer exactly what you ask, no more, and no less. The elder who told me she only chews was actually volunteering quite a lot. I had not asked her if she chewed.

The use of “spit” tobacco—plain tobacco or blackbull—is so pervasive and widespread that I now ask every patient old enough to walk whether they smoke, chew, or do both. The youngest patient I have personally identified as a daily chewer is four years old. FOUR YEARS OLD! I am still astonished by that. A young (twentysomething) mom came to see me with her four daughters, ages 12, 10, 6, and 4; all four daughters and mom chew blackbull every day. The youngest is only chewing once or twice a day, but mom and the older girls chew six, eight, ten times a day.

When patients acknowledge chewing, my exam routine has become to ask them exactly where in their mouths they put the chew, and then use a small hand mirror to show them what that spot looks like. I ask them to take a good look at the area at least once a month and note any changes to the skin there—wrinkling, loss of natural color, ulceration, brownish discoloration—and get it checked right away if any occur. The fact that I pay attention to it gets the patient’s attention. Many say that no one ever told them that before (probably not true, many patients leave predominantly educational encounters saying “the doctor didn’t tell me anything about it”). After the oral exam seems to be the most receptive moment to add, “it really would be the best thing for your overall health if you could quit.” Sometimes, they do.

I’m not on a mission by myself on this topic. That fireball health educator who got the first grant to study tobacco use in southwest Alaska got much accomplished here before she left. We now have a very active tobacco cessation program with a strong focus on education about iq’mik. Over a thousand people have registered with the program in the past year and received at least an educational session on tobacco use. Bilingual cessation counselors are available at every patient encounter in all clinics, and patients can be started on nicotine replacement (patches or gum) or wellbutrin the moment they are ready, and at no cost to the patient. Our patient record forms include a box for tobacco use along with the vital signs, and asking every patient/every visit is the goal we strive for. Slowly, we are making inroads into the Natives’ perception of how much spit tobacco can compromise their health. We’ve come quite a way since I first arrived here eight years ago, but there is still much to be done.

Renner CC, Enoch C, Patten CA, Ebbert JO, Hurt RD, Moyer TP, and Provost EM. Iqmik: A Form of Smokeless Tobacco Used Among Alaska Natives. Am J Health Behav. 2005; 29(6):588-594.


Saturday, May 27, 2006

Full Blown Spring

In the usual rapid progression of the season that southwest Alaska can experience in late May, we’ve gone from a white-out blizzard two weeks ago to nearly summer. The weather continues to be outstanding, bright clear skies and warm sun—65 degrees today!—and warm steady winds. The tundra is drying out rapidly. Most of the birds have established their nesting spots and are settling down to that serious business of hatching a brood. The swallows are still having a few turf wars, as the photo shows. Soon the mosquitoes will be with us, and the experience of the outdoors will change a lot.

The tundra is like a huge grassy sponge, with permafrost underlying it at depths that vary from inches to feet. What’s on top of the permafrost melts in the summer, and there is standing water all over—lakes, streams, rivulets, ponds, puddles, and sloughs—surrounding hillocks and knolls of dirt and low shrub cover. You can sink to your ankles in water when walking in low spots on the tundra, even when it seems pretty dry.

What all this wet ground provides is the perfect mosquito breeding habitat. And they do it quite successfully. We jokingly refer to the mosquito as the state bird of Alaska, and that is not too much of an exaggeration. So, yeah, they are big. And right after a hatch, there will be so many of them that they boil up from the long grasses around the watery spots like a cloud. Mosquitoes are capable of actually killing large animals like caribou. The only escape for the animal is to run into a river and submerge to the nostrils. People go around wearing those dorky-looking hats with mosquito curtains, or bug shirts with full hoods and zippered mesh faces.

Dorky or not, they work. Last summer Dutch spent two days weed-wacking the long grasses in the low-lying areas of our yard, often standing for long periods in a buzzing haze of mosquitos. Without the bug shirt, he’d have been eaten alive. Anybody planning a trip to Alaska in the late spring and summer should have one. Cabela’s is a great source for good gear, and their Instant Bug Jacket does a good job of keeping the little peskers off you.

Knowing that the bugs are coming makes this brief interlude we’re having all the more sweet. A few days of warm, sunny weather with NO BUGS—ahhhhhhh. We cherish that. I can’t be outside enough right now. This week the sun is rising about 5:30 am and setting about midnight, giving us over 18 hours of actual shine, but more like 21 hours of light that is adequate to read a newspaper by. So much daylight really charges people, and lots of activity goes on until late in the evening. People are repairing their boats, cleaning their chainsaws for logging, mending their fishnets for the salmon season, airing out their houses from the long winter, and walking around town visiting with each other. The outward expansion of spring is fully upon us.

In only three weeks we will be approaching the summer solstice, the longest day of the year; and then the light will begin receding at the same rate that it is currently growing: five minutes per day. That happens before summer feels really good and started here, as June is often rainy and cool. For most of July and early August, it is a nearly imperceptible recession, and the summer days are long and hot. We’ll have temperatures in the 90s for a week or two, and may even break 100 degrees. And considering that there is no air conditioning in Bethel, that can make for an uncomfortable period, even though it is brief.

Eskimos hate to sweat—it can be life-threatening in the wintertime to do so—and the comment “It’s tooo hottt!” is often heard when the thermometer starts pushing the high 80s. Fortunately, we have a fairly low humidity rate, despite all the surrounding water, so this place is nothing like the oppressive wet heat of the Deep South in summer. The air stays cool, and getting down by the river is a guaranteed relief from the heat. And no matter what, it won’t last long. Summer in the subarctic is packed into a few short weeks. Every form of life seems to know that at the cellular level, so growth happens quickly. Winter is always just around the corner.


Friday, May 26, 2006

A Perfect Vacation

Back in early February, when I requested to have the last two weeks in May off work, I fully intended to spend it traveling. I would spend the first week visiting family in the Pacific Northwest and in the Deep South, and the second week attending the annual conference of the American Academy of Physician Assistants being held in San Francisco. But events transpired that it was not to be, and though I was disappointed at first, it has turned out to be perfect in the end. I am having the vacation that Fat Doctor longed for, and I couldn’t be happier.

I love to cook, but there never seems to be enough time or energy for doing more than basics. Today there is a big pot of moose chili bubbling on the stove, and a hot skillet of cornbread is going to go with it. It is the last of my moose meat from the fall, a gift of my friend and mushing idol, Aliy Zirkle (her real name! The only real name I use in this blog.) She stayed with Dutch and me in January for two weeks when she came to Bethel to run the Kuskokwim 300, our premier sled dog race, and we’ve been friends ever since.

Out in the mud room, there is a caribou leg thawing out to make stew with in the next few days. It was a gift from Sinka, one of Dutch’s crew who had a successful hunt in late winter. He just dropped it off one evening, with a smile, and a handshake, and a quiet “enjoy!” We shall, quyana cuk nuk!

I love bicycling, but Bethel is a challenging place for it most of the year. Especially for a former long distance rider used to really skinny tires. Distance cycling was what I missed the most when I first moved here. I rode the Seattle-to-Portland Bicycle Classic (200 miles) three times back in the 1990s, and really enjoyed thirty- or forty-mile rides regularly. Since I haven’t managed to switch to a nail-studded mountain bike, I haven’t done much cycling here.

In March Dutch bought me a new cyclocross bicycle for my birthday, and I am delighted with it! It’s been on the windtrainer for several months, but today I took her out for her first real road test and it was a blast. The roads here are always going to be fairly rough (packed gravel or very patched pavement) for a “roadie”, but just being out on a fine new machine was a total joy. I can forget how much I miss it.

And then there is writing. I love to write, and always have; but it is something I always seemed to accomplish only in spurts, with long dry spells in between. Writing is a tool that helps me clarify my thinking, and often broaden my understanding of my experiences. When I write about something, I see it differently, experience it more fully. It focuses me.

Not having the time to write is a well-worn excuse, but writing, for me, is something that takes time. Time to think, to sift, to polish. A long stretch of time, uninterrupted by commitments elsewhere, is what this two weeks has given me. It is a blessing for the awakening writer beginning to walk the path.

I can’t imagine a more perfect vacation. Unstructured time at home to write, to cook, to bicycle, and to be with my dogs and my soul mate. Life is good.


Thursday, May 25, 2006

Eskimo Foods and Botulism

Living a subsistence lifestyle—i.e., living off the land—requires a constant round of seasonal activities directed at acquiring food, heat, shelter and clothing. Most of the people living in villages, and quite a few living in Bethel, are doing exactly that. It is a constant procession of hard work with very few days off.

The Eskimos of southwest Alaska have traditionally had a nomadic hunter-gatherer culture. The tundra supports an abundance of life, and the native people are very attuned to collecting what Nature offers.

In the spring, migratory birds begin arriving from as far away as South America. They come in the millions, literally. Geese, crane, ducks, swans, plover, swallows, jagars, owls, falcons, eagles, hawks, all spend the summer here breeding. Almost all of southwest Alaska is a wildlife refuge, predominantly for birds. Some species are restricted from hunting, but most are not. The traditional native diet is heavy on bird, usually goose or duck, in early spring. A well-prepared swan or crane soup is absolutely delightful. The meat is all dark, and very juicy and tender; carrots, onions, and noodles are usually added, and a little salt. Always, a clear broth base, not thickened to a stew. It is generally served with Pilot Bread, a big semi-soft cracker, with butter and homemade berry jam.

As all these birds settle in for the business of nest building, egg laying, and brood hatching, the people begin collecting eggs. The nesting is, by necessity, on the ground, as we have almost no trees. Families travel to favorite tundra spots and spend days combing the land, collecting eggs. There is some hazard involved here, as the bird parents can be quite aggressive in their protection efforts.

The birds begin arriving before the river breaks up, and their activities are vigorous for a few weeks. Before and during the egging season, the paired activity is logging. As soon as the river is free of ice, boats start heading upriver to collect the deadfall left by the receeding ice. We don't have many trees here, and none of them are big, so a good wood supply for winter means a two-week logging trip in early spring. The logs are retrieved from the riverbank, cut to size (14 to 20 feet), rafted up and towed home by boat. Then another week of bucking, splitting, and stacking.

By late June, the earliest runs of salmon begin in the Kuskokwim and Yukon rivers. The mighty King (Chinook) come first, and are the most prized. They have the highest oil content and the finest flavor, and are the staple of the Eskimo diet year round. These are huge fish, weighing 20 to 60 pounds each. They are caught in drift nets, filleted, cut into strips or blankets, brined, dried, and then smoked. In three weeks, a family will catch and process enough fish to feed themselves until the following summer. Well made King strips are a savory delight, chewy like jerky, but oily and full of flavor (and omega 3 fatty acids).

The Kings are followed by Reds (Sockeye), Chum (Dog), Humpies (Pink), and Silvers (Coho). All are considered “people food”, but only Kings, Reds, and Silvers are prized. Around here, Chum and Humpy are dog food. If Chum is all you have, it is certainly good enough to eat, but it just can’t compare with Red or King.

By August the tundra is covered in berries, and berry-picking becomes the predominant activity. There are a half dozen different types of berries, each with a distinct flavor and peak season. Families travel together to their favorite berry picking spots and camp there for several weeks, where they will do nothing but pick berries for twelve to fourteen hours a day. With 22 hours of daylight and two hours of semi-darkness, it is an around-the-clock activity.

An Eskimo woman on a berry-picking mission can pick two 5 gallon buckets full in a day. When you consider that each berry is only about a quarter inch (half centimeter) in size, that’s a LOT of berries. Now consider that she performs this feat standing/walking completely bent over, as the berries grow on tiny ground cover no more than 3” high. And then she carries those full, 5 gallon buckets back to camp a mile or more, walking on squishy, very uneven tundra. If you are suspecting that clinic visits for back pain go up in August and September, you are quite right!

Berries are the primary source of Vitamin C in the Eskimo diet. Plenty will be eaten fresh, but most will be frozen for use throughout the winter. They are the flavor component of the dish known as agutuk, or Eskimo ice cream. Agutuk is quite a delicacy, and worthy of its own post.

By September, summer is over and fall is moving in fast. Now the focus becomes moose hunting. Every family hopes for a moose to supplement their supply of dried fish. The trick is to get one before the rut sets in. Once a bull moose is in rut, the flavor of the meat is sharply tainted. A moose hunt out of Bethel means going upriver two or three hundred miles. The moose population on this part of the river was very low until two years ago when a moratorium was instituted; now they are coming back, but it will be three more years before they can be hunted here.

Moose is one of the best game meats I have ever eaten. It is not “gamey” at all. It is very lean meat, especially compared to beef. Moose soup and baked moose roast are the primary dishes. Another dish, which I have not yet had the gumption to try, is jellied moose nose. There is a recipe for it in Cooking Alaskan, the bible of all Alaskan cooks. Somehow, I just can’t go there.

Hunting is a year-round activity, in addition to the seasonal work. Other game that I have eaten includes black bear, porcupine, beaver, and musk rat. It is all quite tasty, except for the musk rat. I have to admit to being a little squeamish on that one; can’t get over the “rat” part. Though beaver is also technically a rodent, it just doesn’t have the same effect on me.

The coastal villages are also hunting sea mammals year-round. Seal, walrus, and whale are prized for their tasty meat and fat. Seal fat is rendered into a light, clear oil which is used for cooking and dipping dried fish in. Whale fat (“blubber”) is cut into chunks and pickled; this is called muktuk. The one time I tried it, it was like chewing a rubber tire. Your teeth just bounce off it; eventually your muscles of mastication get so tired, you just swallow it whole in order to quit chewing it.

The Problem of Botulism

Fermenting is a food preservation method favored in many cultures around the world, and Eskimos are no exception. The primary fermented food in this culture is called “stinkhead”, and is definitely an acquired taste, like lutefisk and limburger cheese. Most Eskimos say that white people can’t eat stinkhead, and they are generally right. I have two friends who managed to hold their noses and swallow some, but it was quite a challenge.

Stinkhead is made from the whole head of a King salmon, which is somewhat larger than a football. The traditional method of preparation was to wrap the fish head in the long grasses which grow along rivers and streams, and then to bury it in a moss-lined pit in the ground for four to six weeks. Where it rots. And then dig it up and eat it. Yum. The bones soften up until the whole head has a mashable consistency. The dish gets its name from the smell, which is every bit as rancid as you might imagine. I can’t even be in the same room with it, much less consider putting it in my mouth.

Another fermented delicacy is “stinkeggs”. The female salmon have large roe sacks when they are caught in the summer. These are buried intact along with the heads; the surface dries out and becomes quite firm, leaving the interior soft.

As aesthetically distasteful as these dishes might seem, the health problem stems from the method of preparation, not from the dishes themselves. As long as the fish head was wrapped in grass before burial, it fermented aerobically and slowly at cool temperatures buried just on top of the permafrost. But then someone discovered that placing the fish head in a Ziplock bag, or plastic bucket with a lid, speeded up the fermenting process significantly. Stinkfood could be made in about half the time. Additionally, now the food is sometimes left unburied, so it ferments at warmer temperatures.

The result of these changes is an increased incidence of botulism. Botulism is a life-threatening disease. It is actually an intoxication, not an infection. The toxin is produced by a spore-forming obligate anaerobic bacterium, Clostridium botulinum, which is ubiquitous in Alaska. It is found in soil, ocean water, salmon and marine mammals. The most common food sources of botulism are whale, seal, and salmon. The toxin is inactivated by heat, so cooking these foods generally renders them safe to eat.

There are seven types of botulism; most human disease is caused by three of those. All cases in Alaska have been associated with consumption of traditional Alaska Native foods, including fermented foods, dried foods, and seal oil. Fermented foods are the most common source.

The toxin acts at cholinergic neuromuscular junctions by blocking the release of acetylcholine. The initial symptoms of botulism are usually gastrointestinal, and occur with 12 to 36 hours of consuming the contaminated food. Patients present with nausea, vomiting, diarrhea and abdominal pain. Neurologic symptoms are often present as well: dry mouth, blurry vision, double vision, dilated pupils, difficulty swallowing, and decreased gag reflex. Depending on the severity of the case, progressive skeletal muscle weakness may follow, including weakness of the muscles of respiration. Almost all of the early deaths from botulism in Alaska have been caused by respiratory arrest.

Laboratory testing for the toxin takes several days; in our hospital, treatment with anti-toxin is instituted before confirmation in any highly suspected case. Convalescence can be quite prolonged, even in milder cases that do not progress to respiratory collapse. And there may be periods of relapsing symptoms without new exposure up to several months after initial recovery. Also, surviving an episode of botulism does not confer immunity from future episodes resulting from new exposure.

One of the major concerns in our hospital is dealing with any large-scale outbreak of botulism. The hospital only has four ventilators, and a very small respiratory therapy department. We often have only two RTs, and they are on call all the time. Timely transfer of patients to Anchorage via medevac is crucial.

The most recent large outbreak in our area occurred a few years ago, in the coastal village of Kongiganak. A dead whale was found washed up on the beach a few miles from the village. No one knew how long it had been there. People cut away the seal bites and shark bites and obviously rotted outer portions, and proceeded to butcher the rest for human consumption. Four cases of botulism resulted from that event; three were mild, but one was medevac’d to Anchorage and maintained on a ventilator for several weeks.

Many people from the village ate the whale meat, but only a few got sick, which illustrates an interesting fact about the toxin. It is not distributed homogenously throughout the tainted food. Often only the inner portion contains toxin, so those who eat first, from the outer portions, do not become ill.

Fermented foods are an integral part of native culture in Alaska, and we, as health care providers, are not going to change that tradition. Our efforts at decreasing morbidity and mortality from botulism are focused on prevention education and early identification and treatment. We recommend hot soapy water wash of hands, containers, and utensils prior to handling foods, and cleanly washed foods prior to storage. We strongly urge the use of “the old way” to prepare fermented food—wrap the items in grass and ferment at cold temperatures, ideally less than 37 degrees F. Consider boiling the food before eating it. This suggestion is less well received; they say it changes the taste too much. And, if you don’t know how it was prepared, then don’t eat it.

If you are interested to know more about botulism in Alaska, you can Google up the Alaska Division of Public Health and search their website for botulism. Their monograph entitled “Botulism in Alaska, a guide for physicians and healthcare providers” lives on the resource shelf in both the ED and the clinic, and was the source of my more technical information here. A parenthetical footnote: in addition to being a PA, I also have a Master’s in Public Health.

So if you show up at our hospital clinic or ED complaining of a dry mouth, don’t be surprised if you get more than you bargained for! In milder cases of botulism, that can be the only presenting symptom.


Wednesday, May 24, 2006

Flood Watch Follow Up

It’s gone! Just that quickly. The ice has moved completely out and the river is flowing in front of Bethel strong and free. It only took about twelve hours this year, which is quite fast. At midnight last night, Dutch and I drove down to the river to check its condition before going to bed. The sun was just setting and lots of people were still out, watching in quiet fascination. Ice stretched from shore to shore, but was moving steadily. A lot of it was ground up into basketball size hunks, but big truck-sized plates were drifting thickly among them. Sometimes with fully-rooted trees, upright and intact, sprouting from the centers.

The grinding, tinkling, sparkling noise of all that ice moving could be heard more than a block from the river. Think of a ballroom full of a thousand people, each holding a glass with ice cubes and some water, and everyone rattling their ice cubes at once. It is an amazing noise.

By noon today, it had all gone down river, and now only a few lonely hunks are drifting along on their own. The ice pack is probably down to the village of Eek by now, about 50 miles away. Small skiffs are motoring up and down the river, and everybody is smiling around town. Break-up brings out the “friendly” in people.

We are all starting to breathe a huge sigh of relief as well. It is beginning to look like we escaped any major flooding this year (all those crossed fingers had to have helped!). Nine feet above normal is OK, we can deal with that, and so far that is what we have had. Fifteen feet is a whole other matter, and causes great problems. By mid-afternoon, when the tide went out, the water level was dropping noticeably. The dog yard at Henry’s should be out of the water by tomorrow, though it will take several more days of sun and light wind to dry it out enough to put the dogs back in their houses.

The birds continue to be a delight. Bethel has become a virtual aviary. Little titmice, robins, grosbeaks and shrikes are everywhere. Seagulls have come upriver from the Bering Sea. And swallows by the thousands. We are especially glad to see the swallows; they eat nearly their weight in mosquitoes, daily. (Not yet, thank goodness.) And lots of others that I can’t identify. I sat in the sun (briefly!) in short sleeves, barefoot, and tried to count how many distinctly different bird calls I could hear. I managed to differentiate six out of the panorama of bird sound around me.

Fortunately, the incredibly good weather we’ve had is holding. Today was another beautiful day. The sky is huge and blue, and the sun is hot. The winds are keeping up, just enough. It is the most amazing gift to have this kind of weather for break-up. It can often occur during a south storm, which is where all our warm, wet weather comes from. Low and heavy gray cloud cover and drenching rain for days are not uncommon. Then it is cold, wet, muddy and nasty. Moving dogs means lots of slipping in the soupy mud, and they are miserable out in the rain without their snug houses. Yes, folks, there is joy in River City tonight. We made it through another spring transition.


We Have Break-up!

Oh, glorious day! The Kuskokwim River officially broke up at 1:23 pm Alaska Daylight Time, Tuesday, May 23rd. The winner of the Ice Classic will be announced tomorrow. I guessed pretty close, but not close enough. I always pick May 23rd as one of my guesses, because it is my sister’s birthday (Happy Birthday, Sis!). But I chose the wrong high tide; I guessed 1:30 am instead of 1:30 pm.

The day was absolutely beautiful, with lots of warm sun and warm breezes. We actually broke 50 degrees, and the air really smelled like spring. Birds are suddenly everywhere, chirping and twerping and sounding very happy.

The level of excitement in Bethel is palpable. This is one of our biggest yearly events, charged by a certain undercurrent of danger as we go into full flood-watch mode. Some years we have a lot of flooding and some years only a little; there is no predicting which it will be. Flooding depends mainly on how the ice moves out of the river and where the ice jams will occur. The river becomes very broad and shallow not far below Bethel, and is joined by a large tributary, the Johnson River. The confluence of the two is a recurrent jam-up place, and can cause significant flooding in Bethel.

Everyone is on high alert, and the town is buzzing. People are headed for the river on bicycles, dirt bikes, four wheelers, cars, trucks and cabs. Everyone wants to see the turbulence of the ice going by; the riverbank is lined with people watching the big event.

The ice is just starting to make the grinding noises that will go on for a few days. Large blocks of ice get jammed up at the sides of the river as the center moves out. The blocks roll and tumble in the current, sometimes shooting debris out suddenly, seemingly from nowhere.

I am fortunate to be on high ground, so flooding is not likely here at our house. My friend Henry, however, is in a much lower area, and the water had started rising quickly by 4 pm. Flood waters have started encroaching the dog yard, so we had to get some dogs moved fast!

It required getting out Henry’s small boat to rescue some of the dogs and move them to higher ground. Our friend Joan, and her two teenage boys Michael and Luke showed up to help, along with Henry’s wife Betty and their niece Andrea and a friend.

It took nearly two hours, but we got a heat pen set up and a dozen dogs moved up close to the house where they are tied in the bushes. The dogs are out of their minds with excitement at all this.

The flood water rose so much while I was at Henry’s that I almost couldn’t get through in my full-size pick-up to get home. Dutch works for the city of Bethel, and he and his crews are all over town, keeping track of things and solving problems. I hope he manages to get home tonight! This state of alert may last for several days, during which he may not get much sleep. We haven’t had a big flood for almost ten years, and many are wondering if this will be the year for it.

Keep your fingers crossed for us…


Sunday, May 21, 2006

The Lion Roars

In the more temperate areas of the country, it is the month of March that comes in like the lion and goes out like the lamb. Here in the subarctic, the lion is still roaring as we dance between winter and spring. Yesterday was winter and the view from the front window looked like this.

The temperature stayed in the mid-30s and snow fell for much of the day, big wet heavy flakes that accumulated to an inch or two. Visibility was minimal and everyone was groaning that it really is time for this to quit. It is late May, for goodness sake!

Overnight the wind picked up and a high pressure cell moved in. This morning we awoke to bright sun, and today it is spring again. Temperatures are in the low 40s. The lion is still roaring, and now the view from the same window looks like this. Yes, that's a pond in front of the house, and it is frozen. What you can't tell from the photo is that the wind is really whipping. There is a steady blow at about 20 mph with gusts to 30 or more. The wind actually helps our transition by drying things out. Mud Season is upon us, and the roads become quagmires that seem impossible in places. The old joke about discovering a hat in the road and finding a guy under it, still on his horse, is not too implausible, except that we don't have horses up here. At least our mud has no clay content, so it doesn't stick to your boots, your wheels, and everything else, the way it does in Georgia. This is silty, river-bottom stuff that washes off easily. The bad roads look like a stage for a tractor-pull, and the good roads have teeth-rattling washboard surfaces with axel-breaking potholes. The road crews are working seven days a week to keep things as good as they can.

This, too, will pass, and in another month the big problem will be the dust. And the mosquitoes, but that is a story for another post. And we are still waiting for break-up. Maybe by next weekend...


Saturday, May 20, 2006

A Whole New Look

Oh Happy Day! I am dancing with excitement! Since I started this blog two weeks ago, I have not been satisfied with its appearance, and have been TOTALLY frustrated with my inability to accomplish the blog roll listing. The very idea of writing html code into the template just gave me heartburn, especially after the sad demise of The Blog That Ate Manhattan. My general computer skills rank about the level of advanced beginner.

At last to the rescue, like the cavalry riding in, comes Dutch. My Soul Mate, the Love of My Life. He has been travelling for much of the time since I started the blog, but returned a few days ago and has worked a miracle for me (in more ways than one). His computer savy is at least twice mine, and he was not intimidated by brackets and slashes. Voila! New look for the blog, complete with Blog Roll! (she does a little happy dance while looking out the window at yet more snow falling) The next big step is the addition of photos. Stay tuned!

Wednesday, May 17, 2006

Too Much Information?

Dear Readers,

Am I wearing you out with these long posts? Is it just too much information?

My internet service has been out for a full week (one of the challenges of living in bush Alaska; 21st century services with 20th century delivery), so I have been writing Word documents at home and taking them to the hospital for posting. Then I am surprised at how long they seem on the blog. Perhaps I am more of a novelist than a short story writer (I am, in fact, working on a novel about life here, but that is having a very long gestation).

Comments, suggestions, advice welcome.


Tuesday, May 16, 2006

Radio Medical Traffic

One of the more unusual aspects of practicing medicine in bush Alaska is Radio Medical Traffic, or RMT. It is integral to the concept of health care delivery via community health aides. When a patient comes into a village clinic to be seen by a health aide, there is a prescribed order to how things happen. The health aide takes vital signs and records the chief complaint on the Patient Encounter Form. She (80% of health aides are female) then consults the bible of her practice, the Community Health Aide Manual, or CHAM. The CHAM is a large, three-volume reference and cookbook of medicine, organized by presenting problem. It is extremely detailed and thorough. She fills out the encounter form with history of present illness, past health history, medications, allergies, other history (including tobacco use, immunizations, LMP/pregnancy history), physical exam, assessment, plan, medications given in clinic, medications for home, special/other care, and recheck/follow-up. Very thorough, and all by the book.

Depending on the health aide’s level of training, the encounter form may stop at assessment; more advanced and experienced health aides will include what they think the plan should be. In some well-defined instances, the higher level health aides have standing orders that they may implement. A positive rapid strep test, for instance, may be treated on the spot with an LA Bicillin injection if the patient has no penicillin allergy and no other problem.

Most of the time, however, the health aide stops at assessment, tells the patient she must confer with a hospital provider and will get back to the patient later in the day with a plan. She then faxes her encounter form to the hospital and waits to be called back. The faxed encounter forms are collectively known as RMT, from the days not so long ago when medical traffic was actually done on VHF radio.

It is the responsibility of each provider to do the traffic with their assigned villages. Faxes come in throughout the day and are placed on the provider’s clipboard in clinic. As time allows throughout the day, we call our villages and talk with the health aides about the patients they have seen, going over the encounter form, asking additional questions, sometimes requesting additional tests. Often there is a good opportunity for one-on-one teaching with the health aide. The provider’s assessment is recorded on the encounter form next to the health aide’s assessment, and a plan for the patient is agreed upon.

Each village clinic has a limited pharmacy supplied by the hospital from which the health aide can dispense medications on the order of the provider. Antibiotics available in the village are amoxicillin, penicillin, trimethoprim-sulfamethoxazole (single strength only), doxycyline, erythromycin, cephalexin, and ceftriaxone. The health aides are trained to mix suspensions as needed.

The patient returns to the clinic later in the day to pick up the medications and read (or have read to them) the CHAM’s “Education for patients” pages according to the provider’s assessment.

The whole system works pretty smoothly as long as the patient is not of high acuity and the provider is not overwhelmingly slammed in the hospital. (For urgent cases, the health aide does not have to wait for a call back; she can have the hospital operator page the physician covering the inpatient unit, or the ER physician on nights and weekends.) But on any given day, there are always “orphan” villages, those whose assigned provider is out of the hospital; and those whose provider is so slammed in clinic that he or she is not able to do RMT. So each afternoon, two providers are assigned to do nothing but RMT, calling their own villages and all the orphans.

When the traffic is not too heavy, this is a really fun assignment. You get to talk with health aides in lots of different villages, find out what the weather is doing all over the region, how the hunting or fishing is going for the different villages, how the health aides themselves are doing. You can come to know health aides fairly well that you’ve never met.

On a slow afternoon, I’ll have a stack of less than 50 patient encounter forms on which I have written my assessment and the plan I agree upon with the health aide who saw that patient. My copy then goes to medical records for inclusion in the patient’s hospital chart. The health aide’s copy goes into the patient’s village chart. On a killer afternoon, that stack will have more than 80 encounter forms; my personal record is 116. At that rate there is no time for chit-chat or amenities. We depend strongly on the health aide’s ability to know which patients are truly sick, and which ones simply don’t feel well. They are very good at that. And quite forthright about saying “I really want this patient to go in to the hospital for further evaluation.” When that is the case, the patient comes in, either by scheduled flight, charter, or medevac.

RMT is an essential part of how we provide care in the far-flung corners of this giant region. We couldn’t do it without the amazing health aides, who are truly “the eyes and hands of the doctor”. They do an incredible job.


Monday, May 15, 2006

Dog Mushing and Ice Fishing

The dog mushing season usually ends in early April. We have had such a delayed spring this year that the trails stayed good until early May, which is quite an extension to the normal season. But it is really over now. Last Wednesday we encountered so much water the dogs were swimming at times. Fortunately, I was wearing chest waders, but still. The dogs really hate it when it gets like that. Most sled dogs do not like water.

So to describe mushing to you, I’ll tell you about one of the winter’s earlier trips. First I must introduce you to my mushing partner, Henry. (As I stated in an earlier post, I will not use real names for people in this blog, only for places. Once I figure out how to do it, there will be a sidebar with this disclaimer as a permanent reminder.) Henry introduced me to mushing on my first visit to Alaska in the summer of 1998. He taught me everything I know about mushing, encouraged me to get my own dog team, showed me the trails and the ways of the river. He has been training dogs here for thirty years.

He is in his early 60s, and is in enviably good condition. Lean, fit, and flexible, he moves like a man twenty years younger. He has a warm nature, a friendly smile, and strong hands that know just how to scratch a dog's head. He grew up on a farm in the midwest and has worked with animals all his life.

Henry is one of the few non-Natives who lives a mostly subsistence lifestyle. In southwest Alaska, living by subsistence means that you do not have a job that provides you with a paycheck. Rather, you glean your living, and feed your family, from the land. There is a constant cycle of seasonal activities that are required in order to do that. The Eskimos have lived in this way, on this land, for thousands of years. Western culture (i.e., “modern” life, technology, book-based learning) is making deep inroads into the subsistence lifestyle. Some say that in a few more generations it will no longer be possible to live by subsistence. Hopefully that is not true.

Henry and I usually take our dog teams out together about twice a week. Our homes are about a mile apart, and my trail out intersects with his at the edge of Hangar Lake (so called for the float planes that are moored there in the summer). The lake is about a mile across, and can be terrifically windy and difficult. At times you can’t see the far edge, which is a particular challenge for the lead dogs. One of the more difficult tasks for a leader is to be able to maintain a straight line of travel when there are no landmarks and the wind is blowing sideways.

For much of the winter, the goal of our mushing trips is the ice fishing net. There is good fishing in the winter for pike, whitefish, and lush fish. Henry usually keeps a set net under the ice on the Kuskokwim or one of the smaller tributary rivers. The net must be hauled out and the fish removed every two to three days. It makes for a nice afternoon to hook up the teams, run the ten miles or so out to the net, gather the fish, and run back home. I’ll take you on just such a trip from late winter.

It is mid-February, and though the days have started getting longer, two months past the winter solstice we are only up to about eight hours of daylight. Much of the last six weeks has been extremely cold—twenty to forty degrees below zero. Henry took his net out shortly after the hard cold started; it is just too difficult to deal with pulling fish from the water at those temperatures. The net, the fish, and your hands freeze almost instantly on exposure. At forty below, your spit will freeze before it hits the ground.

Henry had put his net back in two days earlier, so we are heading out to check it for the first time. He is hopeful that this new spot up on the Tubungaluk River will be a good one. It is a sunny morning right at zero degrees, which feels amazingly balmy after weeks of twenty below. Part of the get-ready includes packing a lunch of sandwiches and a thermos of coffee, and a bag of frozen fish chunks for the dogs. And a bag of extra clothes, including boots, in case you get wet. Tools for chipping holes in the ice, rope for threading the net under the ice, and big burlap bags for (hopefully) bringing home lots of fish.

This is perfect weather for the dogs. Zero is ideal temperature for them, and the two inches of snow that fell yesterday will soften the snowmachine ruts in the trail, as well as give them easy bites of snow for hydration while they are running (“dipping”). As I start loading gear in the sled and laying out their harnesses, they are wildly excited, barking, jumping on and off their houses, running in circles around their posts. They truly love their work, and every dog wants to go. Since we have fairly deep snow right now, I need all nine to pull the sled; fortunately there are no females in heat at the moment, and no muscle strains or sore feet. Everybody gets to go today.

The sled is packed and the ice hook is firmly planted to anchor it. The gangline is stretched out in front, and dogs will be hooked to it in pairs; first the leader(s), then the swing dogs—collectively known as the “front end”—then the team dogs. The last pair, just in front of the sled, are the wheel dogs. Wheel is a difficult position, as those two dogs get jerked by the sled more than their teammates do.

I harness Lucky first and attach him to the gangline in lead. He is a big white-blond male with a very fast trotting gate; he responds well to gee/haw commands (“right” and “left”, respectively), and he pulls hard. His job for the rest of hook-up is to hold the line out taut while the rest of the team is harnessed and attached. He is less good at this than I would like, so a second ice hook is attached to his harness and placed in front of him to keep him from wandering.

In swing position are Lucky’s brothers, Flash and Woody. Flash is red-blond, Woody looks almost exactly like a timber wolf; both are secondary leaders, and the three together make quite a strong front end.

The first team pair behind swing are Balto and Blue. Both are almost solid black, with little brown eyebrow spots and white crosses on their chests. Blue is named for her piercingly ice-blue eyes. Balto is named for one of the most famous sled dogs of all time, a leader of the team that took diphtheria serum to Nome during the epidemic in the 1920s, saving the lives of countless children. There is a statue of the original Balto in New York City (of all places).

Next in line are Buster and Brownie. Buster looks much like Balto. He is the weakest link in the team; he is just not strong-minded, which is an essential quality in a sled dog. I keep debating whether or not to keep him. Brownie has a special place in my heart, as she is the mother of my house dog, Bear. When Brownie arrived, she was pregnant, though neither I nor the Yukon musher I bought her from knew it at the time. I came home from a two week vacation in the Lower 48 to discover a single, HUGE puppy, just opening his eyes. He became the dog yard mascot, running in and out of all the dogs’ houses, eating from their bowls, and tolerated by all his bemused aunts and uncles. When he got too big to fit in Brownie’s house with her, he moved inside with me. I’ve often wondered what kind of dog fathered Bear; he is huge, much bigger than Brownie, and weighs about 70 pounds—all lean muscle and long legs.

The pair in wheel today are Sasha and Yoda. Sasha is the mother of the whole team, and is an old leader. She is a solid white dog who never goes in her house. Ever. Doesn’t matter how cold or windy it is, she will sleep on the ground curled into a tight ball with her tail over her nose. Her circle has several saucer-like depressions where her body heat has melted the ice under her as she slept. She pulls hard and never gives up. Last year she had a hysterectomy due to pyometritis following a heat cycle. I had no idea anything was wrong, she just seemed to be off her food and moving a little stiffly. I thought she had just over done it on a hard run two days earlier. But the vet happened to be in town for his monthly visit, so I took her in. Her uterus was so full of pus, he said she would have died within the next 48 hours. The infection had been building since her heat cycle ended the week before.

Yoda is a mostly-black dog, so named for her serene disposition. When the other dogs are jumping and barking, she is sitting quietly and watching. She pulls hard, but she doesn’t have a fast gait. Her strong, stocky build makes her a good wheel dog, and she and Sasha work well together.

I pull the hook at 10 a.m., about an hour after sunrise, as Henry and I agreed on. If he is on schedule also, we should get to our meeting spot within five minutes of each other. The team leaves the yard like they were shot from a cannon. Fortunately my trail out is basically straight and flat, which minimizes disasters. I’m riding the brake the whole way (a length of snowmachine track with studs, mounted to the underside of the sled, which I can step on between the sled runners), controlling their exuberance reasonably well. After a mile or two they settle into their rhythm.

I love to watch the team working. Stretched out in front of me, they move together smoothly, many legs of a single unit. Heads down, pulling hard, tug lines taut. They know this trail well, and Lucky needs no directions.

We reach the meeting place only a moment before Henry, who doesn’t stop. My team falls in behind his and we cross the snow-blown surface of Hangar Lake with a blessed lack of wind. The trail follows several frozen sloughs, passes through stands of willow and cottonwood, and then heads up to high tundra on a bluff above the Kuskokwim River. This is one of the highest natural elevations in the area, perhaps a hundred feet above the river, and the view is magnificent. The land curves away to the horizon in all directions. It feels like the top of the world. It is also pretty windy up here, so we quickly move on.

While we are traveling, Henry wants to practice some passing exercises, so at random intervals the musher in back will yell “trail!” The musher in front will command the team off to the side, put the ice hook in and go up to stand by the lead dog, allowing the team behind to pass. This is race etiquette, as a team is required to “give trail” when being overtaken by a faster-moving team; it is also good practice for the dogs. They must learn to pay no attention to other dogs when passing or being passed by another team.

We make good time, and get to the net in under an hour. The dogs are ready for a little break, and they are used to this routine, so they all lie down quietly to wait.

A pair of sticks marks each end of the fish net, about 50 feet apart. The sticks are frozen into the ice, and look like they are growing out of it. We each take an ice chisel on a long handle and begin chip-chip-chipping a hole next to each pair of sticks. The holes must be about two feet across and have straight sides down to unfrozen water. I am working on the hole closest to the shore, and hit water after about 18 inches of ice chipping. Henry is on the deep-water end of the net and breaks through at 30 inches. He is a lot faster at it than I am, so we hit water about the same time. River water comes bubbling up cold and clear.

The net is stretched underneath the ice and attached to one of the sticks at each end; the other stick serves as a tie-off for the net stick. We free one net stick, untie it from the net, and tie a long rope to the net in its place. Back to the other side; we free the net stick from the ice and begin hauling the net up through the hole.

Right away we’ve got fish! Henry is excited; looks like his intuition was right on the money about this location. We free the fish from the net as we pull it up, tossing them wiggling and flopping on the ice off to the side of the hole. Every two or three pulls yields a few more fish, and—oh joy! They are almost all the most prized fish of winter, whitefish!

By the time the net is completely out of the water we have landed 29 fish; only a few are lush, and there are no pike at all. Two dozen whitefish is a truly great catch!

The long rope we tied to the free end of the net is now hauled back out, pulling the net back across under the ice. Henry does the pulling and I feed the net carefully into the river through the hole, then tie the net stick to the anchor stick. On the other end, Henry ties the free end of the net to his net stick and the net stick to the anchor stick; then we cover the holes with squares of plywood he brought along for the purpose and weight them with snow and ice chips. The covers will keep the ice from freezing in quite as thickly, making it easier to chip the holes out next time.

We gather fish into the burlap bags, load them in the sleds, and take a break to drink coffee and eat our sandwiches. The dogs know that snack time is coming for them too, and they remain quietly watchful.

The Tubungaluk is a small river compared to the Kuskokwim, less than half a mile across at our fishing site. We are maybe two miles upriver from where it empties into the Kusko. A tall stand of cottonwood (tall = 20 feet around here) lining the near bank breaks any wind, and a deeply blue sky arches over us. The sun is bright, and looks like it should be hot, but there is hardly any strength to it yet. Though it is noon, the sun shines on us from about 45 degrees above the horizon.

After lunch, we lounge on our sleds and rest. One of the things I enjoy about Henry is that we can spend extended periods in comfortable silence. I love lying on my back on the sled and gazing up at the sky; it is a perfect blue bowl, from horizon to horizon. We are quite a way from the main snowmachine trail between Akiachuk and Bethel. We are completely alone in a huge wilderness, and lying there looking at the sky, I become aware of the deeply profound silence. The dogs are still, the wind is still, Henry and I are still. No planes pass overhead, no snowmachines whine in the distance. There is no sound whatsoever. None. I strain my ears to catch even the slightest noise of any kind, but nothing breaks the stillness. Minutes go by, and I marvel at the luxury of total silence. It is something that hearing people do not often experience.

After a bit it is time to get moving. Even at a balmy, windless zero degrees, you start to get cold if you stay still for too long. The dogs are looking alert, as this is their cue that it is snack time. Each dog gets a thumb-joint sized piece of frozen fish, which they swallow in a gulp. We pack all the gear back in the sleds, lash it down, and pull the hooks. The dogs know we are headed home, and their pace is lively and energetic without being wild and frantic. We move along nicely at about 12 miles per hour. The only sounds now are the dogs’ panting breath, the chut-chut-chut of their feet on the snow, and the shooosh-shooosh of the sled runners. I stand on the runners, controlling the sled as it slides around corners, slowing it on the descents so it doesn’t bump the wheel dogs in the rump, pushing it up the inclines when the dogs need some help. Lucky has an amazing ability to retrace his steps, but I catch him glancing back at me occasionally, as if to say, “yeah, Boss, this way, huh?” I love him. He is a great dog, and a good leader.

Henry and I part with a wave at our usual spot and Lucky takes us home without any problem. As we pull into the yard, I “whoa” the dogs and plant the hook. They all stand quietly, in contrast to the chaos of leaving the yard. First I place a piece of meat on top of each dog’s house, then unharness and release one dog at a time. Each one races to his or her own house, gulps down the treat, and waits for me to reattach the chain. It always amazes me that the first dog doesn’t race around and grab all the treats, but they don’t. Each dog gets praise, head-rubs, and thanks. The lead dog is always first on the gangline and last off, and Lucky gets extra petting and thanks for his job well done. He leans against my legs, and licks my face when I bend down to rub his big head.

The fish and rice stew I cooked for them yesterday is only partially frozen, and it warms up quickly on the propane cooker. I do “poop rounds” while it is heating, and then serve each dog a ladle full with some extra kibble. While they eat, I hang harnesses in the shed to dry, unpack the sled and put fish in the freezer. As I head inside for a nice hot shower, Balto starts a soft low howl. He is the yard’s songleader. The other join in one by one, some standing on their houses, some lying inside with head out the door, some sitting on the ground; all have their noses pointed up, crooning a beautiful owwwwwoooooooooo-ow-ow-ow-owwwwwooooooo… Each dog’s voice is distinct, and together they have a beautiful harmony. The song goes on for about a minute, then slowly dies away. The haunting echoes linger at the edges of the dog yard, and then all is quiet. It is the most eloquent statement of contentment and happiness.


Saturday, May 13, 2006

Waiting for Break-up

Spring is often a somewhat indecisive season in the subarctic, but this year really is taking the cake. Winter seemed to go on forever, with subzero temperatures deep into April and continuing snowfall that set new records. Finally in May it began to warm up a little, at least to the point that afternoons were above freezing and the sun got a little bit more melt going than the nighttime cold could keep up with. Gradually, in the last two weeks, the land was thawing and we could watch the snow and ice receding. Mornings still required scraping ice off the windshield before driving the truck, but afternoons were almost balmy, sunny and light-jacket pleasant at nearly 50 degrees.

This morning I awoke to 30 degrees and heavy snowfall with about an inch of accumulation since I went to bed last night. Arrrrrrrrgghhh! Yesterday’s areas of bare tundra are whitened up considerably. I begin to wonder if this is the year foretold in Eskimo legend when the river never breaks.

Break-up is the big event we are all waiting for. The Kuskokwim River is 800 miles long, and for six months of the year most of it is covered in a four- to six-foot thick sheet of ice. Cars and trucks drive up and down the river for most of the winter, some years as far as the village of Aniak, 150 miles away. When spring comes, all that ice doesn’t just melt. There is no time for that.

The river will clear itself of ice in a space of about five days, in the violent and mesmerizing event known as break-up. Thawing ice and snow increase the volume of water in the river which begins rising under its cap of ice. The surface of the ice cap degrades under the longer, stronger sun exposure. The ice begins to crack, and when it does it sounds like rifle shots and sometimes canon booms. Quickly from that point, the thick sheet breaks apart and the rising torrent of water coming down from the mountains sweeps the ice out to sea in chunks the size of houses. Anything close to the river’s edge gets swept out along with the ice—lots of trees, unwary animals, boats that weren’t pulled up far enough in the fall, all kinds of things.

Bethel is only 80 miles from the Bering Sea, so by the time all that upriver stuff reaches us, it is huge. The river rages past in a constant loud grind as the ice smashes against itself, constantly shifting, rolling, floating. It is an amazing thing to watch, and most people make daily pilgrimages to the river’s edge to stand in awe of this ravaging process. It is the violent and decisive marker of the end of winter.

Break-up can occur anytime from late April to early June. Historically, the most frequently-occurring date has been May 18th. We have a lottery known as the Kuskokwim Ice Classic; you buy tickets and make your predictions of the exact day, hour and minute that break-up will happen. In early spring, a 20 foot wooden tripod is built on the river with a cable running from the top to a small building on shore, and attached to a clock. When the tripod goes down, the cable is pulled loose and stops the clock; this is the moment of break-up. The person with the closest guess wins the pot, which is usually several thousand dollars.

Break-up often causes big jam-ups of ice that last for hours to days, and which can cause huge flooding problems. The river can rise ten feet or more in a few hours. In a land as flat as this, that means an awful lot of water. People living along sloughs or near the river start moving things to high ground well before break-up, just in case. Some years it is unnecessary and we have no flooding at all. Other years, many streets in Bethel are under three to four feet of water (some with a pretty stiff current) and you need a canoe or kayak to leave your house.

Fortunately, it doesn’t last too long. In a few days the river clears itself of ice, the water recedes to high-normal level, and the land begins to dry out. Most people have some kind of small boat, and the minute the ice is gone (sometimes before) boats are cruising the river. The joy of our short-lived summer has begun. The river will be frozen again by Halloween.


Wednesday, May 10, 2006

Dog Mushing Basics

If medicine is my vocation, then dog mushing is my avocation. I love them both. I was introduced to the sport of dog mushing in the summer of 1998, when I first came to Alaska, and I was hooked immediately. It is the state sport, and lots of people are doing it. Why? Because it is fun, exciting, challenging, and rewarding.

Dog mushers fall into two very basic categories: those who race and those who don’t. I am in the latter (much smaller) group. For me, mushing is about traveling around on the land; going camping, ice fishing, or logging; and just being with my dogs, who are some of my best friends. It is fun to go fast, but racing is a whole other mentality that I am not inclined toward. It is not that I am not competitive; look out if you face me across a ping-pong table! Sled dog racing puts a different focus on mushing; if I had come to Alaska in my twenties, instead of my forties, I might have gone that way. As a non-racer, mushing is all about having fun with my dogs, getting out into the country, no pressure.

Before the introduction of the now-ubiquitous snowmachine to bush Alaska about forty years ago, sled dogs were the mainstay of transportion in the roadless arctic. Most Eskimo families kept some dogs; sleds were made from willow branches bent and lashed together with seal intestines. Truly fine sled runners were carved from the ivory tusks of walrus. With a good dog team, a family could cover long distances hunting and gathering for their subsistence.

Modern mushing has become a high-tech enterprise. Sleds are lightweight things made of aluminum and plastic. Dogs wear foam-padded harnesses with reflective tape, booties to protect their feet, warm jackets when it is cold, and sometimes small collar lights. Mushers wear the latest in polypropylene and Gore-tex. Smaller, lighter, faster is the order of the day, and that includes the dogs themselves. Old-style sled dogs were big and built for slow, heavy pulling. Hundred-pound malamutes were common. Most sled dogs these days, especially racers, are thirty to fifty pounders with thinner fur coats and longer legs.

Call me old-fashioned, but I prefer the old style. OK, not that THAT old, I don’t have walrus-ivory runners on my sled. But it is a handmade antique wooden basket sled that weighs about eighty pounds and drives like a school bus. A racing sprint sled, by comparison, weighs about twenty pounds and drives like a Porsche.

Now about the dogs. Sled dogs are an amazing breed. They are working dogs, not pets, and far less civilized than your average Fido. A sled dog has only three things on his mind: eating, procreating, and pulling. Mostly pulling. They are bred for it, and they love it. People who think dog mushing is a cruel sport just don’t get it. Sled dogs LOVE their work. As soon as the harnesses come out, the entire dog yard is jumping around, barking, excited, hopeful. They all want to go, every time. You cannot make a dog run who doesn’t want to.

My dog yard is small; I have only nine dogs. Some of the big-time professional mushers who run the Iditarod (more on our famous race in another post) have dog yards with a hundred fifty dogs or more. Of course they also have corporate sponsorship to pay for dog food and paid handlers to help with dog care and training.

My dogs come from old village stock; they were bred by an Eskimo musher on the Yukon River. I bought them from him as mostly two-year-olds who are all related—a mom and her offspring from two litters. Their names are Lucky (the main leader), Woody, Flash, Balto, Yoda, Buster, Blue, Brownie and Sasha (the mom). They are Alaskan huskies (not Siberians), about fifty pounds each, and all different colors. That is the reason the breed is not recognized by the AKC; there is no appearance-based breed standard. Alaskan huskies can look like almost anything; the only breed standard is performance based. They gotta love to pull.

Each dog has its own house and is attached to a six foot chain around a post next to the house. So each dog has a twelve foot circle and can go in, out, or on top of his house at will. The circles are as close together as they can be without allowing the dogs to actually touch each other. As most sled dogs are reproductively intact, this arrangement prevents accidental breedings. When the females come in heat, there is a 5x10 foot chain link heat pen with six foot walls that they go into for 21 days. Walt Disney’s movie Snow Dogs was cute and fun, but the idea of a dog team being housed loose in a big barn is totally unrealistic.

My dogs are fed a diet of meat, fish, and kibble in roughly equal proportions. They eat twice a day; a watery soup with some meat or fish in the morning, and a more substantial meal in the evening. The fish is predominantly chum salmon from the Kuskokwim River, caught during the summer fishing season and frozen whole. I have two large chest freezers dedicated to dogs. The meat portion of their diet comes from a variety of sources. Sometimes I buy cow hearts from the local butcher in fifty-pound boxes. They come frozen and are easy to chop into fist-sized portions with an axe. Sometimes people around town donate freezer-burned caribou, beaver, porcupine or bear. The kibble is shipped in from Fairbanks in forty pound bags. Only nine dogs means I can feed the whole yard from one five gallon bucket, which is really nice.

And then there is the other end of the feeding process. Poop scooping. It is impressive just how much poop nine dogs can produce (I can’t even deal with the image of what 150 dogs produce). Keeping up with it is a daily activity I call “poop rounds”. During the winter it is easier; hard-frozen turds don’t smell. Summer is a bit more of a challenge, but not that bad.

OK, enough of the basics. The fun is out on the trail. Let’s go mushing…


Tuesday, May 09, 2006

Grand Rounds Is Up

Welcome, cyber-travellers from the Grand Rounds Express!

Thank you for your kind comments and warm welcome. When I decided to stop gnashing and start blogging, I feared it would be akin to standing naked in a cold wind. Your generous responses have turned it to partial exposure in a warm breeze. Fertile ground to nurture the budding writer. (How many metaphors can one mix?)

And many thanks to Tara at Aetiology for including me in this week's round-up of the medical blogosphere. Nice job pulling it all together!


Sunday, May 07, 2006

A Memorable Elder

Since I wrote this story last week, spring has arrived in full force. The snow is melting rapidly, the temperatures are holding mostly in the 30s—though still below freezing many nights—and the geese are beginning to arrive in much larger numbers. More about that in a coming post.

April 29, 2006

Despite the fact that it is nearly May, southwest Alaska is still firmly embraced by the cold arms of Winter. The tundra landscape is solid white, snow continues to fall every few days, and I awaken to a thermometer hovering in single digits (positive ones, at least, since last week’s minus two degrees). The Eskimos are whispering excitedly about the first few sightings of geese returning—a sure sign of Spring—but so far the high-flying V’s are passing us over in their search for bare tundra with tender new growth. We are poised at the edge of transition, and SO ready for it to happen. After seven months of winter, my eyes long to gaze at green landscape and feel warmth from the sun.

One of the inherent dangers of transition is that the warm and sunny afternoons cause a fair amount of surface melting that refreezes overnight into a treacherous slick of ice. Walking becomes a precarious exercise known as the Eskimo Shuffle—taking small, careful steps with body weight poised directly over feet, hands out and ready to break the fall should one go down. Even with good cleats on (Stabilicers are widely considered the best here), remaining upright and in forward motion can be quite a challenge. If the wind is blowing it is twice as hard. Falls are very common this time of year, and we see a variety of upper extremity fractures in the Family Medicine Clinic as a result.

One morning last week, I paused at one of the windows in the clinic and a deep sigh escaped as I watched yet another few inches of snow falling. Time for this to be done, I thought. The pager at my waist vibrated; the health aide in my assigned village about twenty miles downriver needed to talk to me.

The lead health aide in Napaskiak, Irene, was calling me about an elder who fell outside her home a few hours earlier. Her arm was obviously broken, and Irene wanted to send her up to the hospital. The question was not about whether she needed to come, but rather about how she would get here. The small planes commonly used for village hops were flying despite the snow falling outside, but her patient hates to fly. The trail up from the village is in good shape, but it is too drifted in for trucks to be driving on the frozen river, and her patient refuses to travel by snowmachine. She is willing to let her grandson bring her up by dog team.

“Do you think that’s OK?” Irene wondered. “She seems stable, she’s alert, vitals are fine, and she’s refusing any pain meds except Tylenol.”

I quickly checked the computer, scanned her health summary for the active problem list, chronic medications, recent visits. She is an amazingly healthy elder, on no meds except occasional Tylenol. “No loss of consciousness?” I asked.

“No,” said Irene.

“Full memory of the accident?”


“Sounds like it would be OK to me. Are you comfortable with it?”

“Yeah, I am. She’s my grandmother, I wouldn’t let her go if I thought it wouldn’t be safe. My cousin Golga is a very good dog musher and his dogs are reliable.”

“OK, then. Be sure she’s well splinted, firmly swathed, and warmly dressed. And ask her not to eat anything before she gets here. I’ll be watching for her.”

Two hours later they arrived.

The trail up to the hospital from the main river comes over a small rise and emerges into the clearing around the building. I watched as a well-moving dog team cleared the rise and trotted toward the entrance somewhat away from the snowmachines. I knew this had to be my patient and her grandson. The driver was a compact, energetic Eskimo man in his 30s, but it was his sled that was a sight to behold. It was an old-style wooden basket sled (a rare sight around here anymore), about nine feet long, pulled by ten powerful-looking Alaskan huskies. Enthroned on a fur-covered seat in the sled was a tiny elder wearing the most beautiful fur parka and mittens I have ever seen.

The musher parked his team as close to the door as he could get, and then helped his passenger out of the sled. She was dressed in furs from the ruff around her face to the mukluks on her feet, but it was clear from her movement that she was injured and needed help. She moved slowly, with care and dignity, her eyes narrowed and her mouth set firmly. The two disappeared through the front door, and I headed for the nurse’s station in the clinic to order her x-rays.

In less than an hour (a minor miracle) she was registered, screened with vitals taken, imaged, and sitting in my exam room. I had never met this woman, but I had heard of her; she is one of the matriarchs of her village of 375 people. She is both loved and revered by her extensive family. She is a moving force in the village; though she doesn’t sit on the Tribal Council any more, no important decision in the village is put in place without her blessing.

The tiny woman who sits before me is a marvel. Her name is Anutka. Seventy-nine years old, she stands 4 ft. 6 inches tall and weighs less than a hundred pounds. But for all her small stature, she has a powerful presence. Her face is as brown and wrinkled as a dried apple. She has an almost regal bearing, sitting quietly in the chair with the injured arm in a sling. Her beautiful fur parka is carefully folded and placed under her chair; she wears a traditional Yupik kuspuk, an overshirt with large front pockets and a hood. Her long gray hair is contained in a handmade beaded hairnet.

I had already reviewed the x-rays before going in to see her, so I knew that she had a comminuted, angulated, displaced both-bone forearm fracture; I also knew she would be going to Anchorage for probable surgical fixation. I just needed to get the details of the story before contacting the orthopedists and teleradding her x-rays.

Sharp black eyes snapped with impatience as she endured my history-taking questions about how and when the accident occurred. Her grandson Golga, the musher, translated my questions into Yupik (not really necessary, as she understands English fairly well) and her answers into English (totally necessary, as I don’t understand Yupik at all). She had spent the night before at her granddaughter’s home next door, helping give nebulized albuterol treatments to the two babies with RSV bronchiolitis. When the sun rose about 6:30, she walked back home, avoiding the deep snow drifted between the two houses by staying on the boardwalk. She said ruefully that she should have gone through the snow.

One of her sons heard her cry when she fell and rushed to help her. She held her broken left arm to her chest with her uninjured right arm as he brought his snowmachine around to drive her to the village clinic. Eskimos, as a people, are the definition of the word stoic. She never complained about the pain as the village health aide splinted her arm and advised her that she had to go up to the hospital. She needed x-rays, maybe even surgery to fix this arm. Anutka agreed, but was adamant that she would not travel by snowmachine. “Too noisy, too smelly, too bumpy, too fast.” Her grandson smiled a little at me as he translated this. It is clear that this tiny little woman is revered by her family, and her wishes are law among them. She would travel by dog team. After talking it over with me, the health aide had called Golga and told him to start harnessing his dogs.

A well-trained dog team pulling a moderately heavy sled will travel about ten to twelve miles per hour and can go all day at that pace with intermittent breaks. The trail from her village to the hospital is mostly on the river, which is still solidly frozen with a four-foot thick sheet of ice. We have had so much snow this year (over 90”, which is a lot for us), the trail is fairly smooth and soft and easy to follow. Golga and his dogs were able to get her here in under two hours. A snowmachine could make the trip in under thirty minutes, but it is a hard, teeth-jarring ride sitting in a homemade plywood sled being pulled over river ice behind a snowmachine going 60+ miles per hour. And getting regularly smacked in the face by the ice balls kicked up by the snowmachine’s track. I did not blame her one bit, preferring the quiet beauty and slower pace of a dog team to the loud and bouncy speed of the snowmachine.

After carefully removing the sling, her arm looked as bruised and swollen as I expected it would. She had a mid-shaft fracture, displaced about 50% and only mildly angulated, so the arm didn’t look grossly deformed. Her hand was warm and the nailbeds had brisk capillary refill. She had good sensation in the hand and could move her fingers.

A quick phone consult with the orthopedist at Alaska Native Medical Center who had reviewed the images sent electronically by teleradiology. He agreed that she needed to come in, preferably this afternoon; remain NPO, as he would want to take her to surgery right away.

I explained to Anutka that she needed to go to Anchorage, her arm needed surgery to fix the broken bone. She closed her eyes briefly, then looked at me and nodded. She expected it. She truly hates going to Anchorage ("too many people!"), but she knew it was necessary.

I filled out referral forms and travel forms and sent the patient to pick up her plane ticket to Anchorage, 400 miles away. I also called her daughter who lives here in town; Golga could not escort her, he had to take his dogs home. Anutka has Medicaid, which will cover the expense of travel for her and her escort. By mid-afternoon she was boarding the Alaska Airlines jet for the one hour flight to the city. I’ll see her next week when she comes through on her way home.

Before she left the hospital, she held my hand briefly and looked closely at my face. “Quyana cuk nuk,” she said quietly. Thank you very much.


Saturday, May 06, 2006

Bush Medicine Basics

Call me The Tundra PA. I have been a family practice physician assistant for 14 years. After seven years practicing rural and suburban medicine in the Pacific Northwest, I came to southwest Alaska and immediately fell in love with the place and the people. This is the southwestern Alaskan bush, land of Eskimos, caribou, salmon, and wide-open tundra. Medicine—and just about everything else—is different here. It is The Last Frontier.

For most of my life, I have also been a writer; but I never managed to “realize my potential” in that direction. I suspect a serious lack of "bum glue" as the root cause, but closely connected is the sense that I’ve never found the story I wanted to tell. Until now. This place, these people, and my life among them is the story I will tell in this blog.

The geographical names--villages, rivers, mountains--are real. The human names are fabricated, fictionalized, anonymized, compositized. The patient stories told here are real situations, but refer to no specific patient.

I live in the small town of Bethel. There are no roads that come here from anywhere else; you arrive by flying in from Anchorage. The town has about 25 miles of road and six of them are paved. There are no traffic lights. We have no mall, no movie theatre/bowling alley/skating rink. There are a few restaurants, a video rental store, and a motel. Our only fast-food franchise is a single Subway, which opened about three years ago. We have two banks and a credit union. The two grocery stores sell everything from vegetables to furniture.

I work in the outpatient clinic of a small 20-bed hospital with no ICU, no MRI or CT scanner, and no easily accessible speciality care. Our medical staff is composed of 26 physicians, physician assistants, and nurse practitioners trained in family medicine, emergency medicine and pediatrics. And we have one internist. We are the only hospital in an area the size of Oregon, and our patients travel hundreds of miles to receive care from us. We are 400 miles from the nearest city, Anchorage, where our referral hospital, the Alaska Native Medical Center is located. Visiting specialists come to Bethel periodically to hold Field Clinics, and are usually available for telephone consults, but getting a patient seen by a specialist is logistically difficult. The use of telemedicine is in its infancy here, and holds great promise for improving the care we can offer our patients.

Bethel is situated in a vast region of nearly treeless tundra between two great rivers, the Yukon and the Kuskokwim. Most of the region is a national wildlife refuge. There are 58 villages throughout the region, which is home to the Yupik Eskimo people. Most villages have an average population of three to five hundred people; some are smaller, a few are larger.

Southwest Alaska has no road system; that is the primary definition of “living in the bush.” You can’t get here by driving. Or leave that way either, whenever you feel like it. It is kind of like living on an island; there is an undercurrent of reassurance every time you look up and see an Alaska Airlines jet taking off (three or four times a day). Travel between the villages, or from a village to Bethel, is by small plane, boat, or snowmachine. Occasionally by dog sled.

Each village has a health clinic staffed by community health aides. These are village residents who come to Bethel for five separate month-long training sessions in physical exam, history taking, first aid, and basic general medicine. They are the front-line workers in our health care delivery system, and most of them do a tough job very well. A lot of trauma and disease happens in the villages, and health aides see it all. And it is often their family members or close friends who are their patients.

One of the unique aspects of working here is that each member of the family practice portion of the medical staff is assigned two or three villages to manage medically, get to know, and be responsible for. You are that village’s “doc” and everyone who lives in that village is empanelled to you. When they come to the hospital to be seen, it is you they will see (unless they are in the ER). When their chronic meds need refilling, it is you the pharmacy will come to for refills. When they go to Anchorage for consults or procedures, it is you who will get copies of discharge summaries to coordinate their care. And twice a year, it is you who will travel to the village for a week to see patients, teach health aides, do home visits, and really get to know the people you are responsible for. It is an incredible relationship.

The Yupik are a warm and generous people who share their culture graciously. They place a high cultural value on hospitality. Spending time in a village and really learning the ways of the people there, the social and family dynamics, the hygiene challenges they face, adds a valuable facet to being their health care provider. And for me, as the provider, there developed a sense of ownership of the health status of the village that I had never experienced in the Lower 48.


Why this blog?

For three reasons:

Because Bush medicine is different. The geographical challenges and the structure of the health care delivery system are unlike anything in the rest of the United States.

Because dog mushing is exciting. The sport is incredibly fun, and the relationship between a dog team and the musher is deeply rewarding.

Because tundra life is endlessly fascinating. The land here is wide open and totally wild. The sky is huge. The rivers are untamed. The climate demands respect and attention. It is an amazing place to live.

I want to share with any of you who are interested the stories of a life and a medical practice very different from most. Both are challenging in ways I never imagined. Let me tell you about it…