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.