Thursday, June 29, 2006

Apologies and Goodbyes and Welcomes

My apology to scan man! I wanted to share your site with our visiting radiologist today and discovered to my deep chagrin that I do not have you on my blogroll. I was sure that I had placed you there ages ago (for my almost-two-month-old blog, "ages" = weeks). In my mind, you were there, but in reality, you were not. Most humble apology, my friend! You are certainly there now.

And sad farewells... First, The Blog That Ate Manhattan, then Medpundit, and now shrinkette. The medblog world will feel your departure with disappointment. Blogging can certainly become a time consuming activity, as I and many others are discovering...but must it be all or nothing? Is it not possible to cut back a little without stopping completely? Perhaps a post every week or two?

You will be sorely missed, shrinkette. Thanks for the posts! And if some time away gives you a new perspective and you want to jump back in, please do. Your voice enriches us.

As one member leaves our circle, a new member joins; a warm welcome to Doctor Anonymous. If you haven't discovered his blog yet, do drop by for a visit. He provides some thoughtful humor, and there can never be enough of that.


Wednesday, June 28, 2006

Cooking Salmon

If June is the month in which Alaskans are plagued by mosquitoes, it is also the month in which we are blessed with salmon. Right now there are three species swimming upriver towards their spawning grounds: kings, chums, and reds. The kings can be really huge, sometimes 60 to 70 pounds each. Small kings, the 15-20 pounders, are called jacks. Chums and reds are also in the 15 to 20 pound range, and all three of similar size tend to be caught in the same net. If the net has some unmended holes in it, a few big kings may be hauled in at the same time. People who are fishing for the big kings use a net with larger mesh, which the smaller fish can swim right through.

Fishing is really good this year; the Department of Fish and Game has put no restrictions on subsistence fishing days. In previous years when the run was poor, we were only allowed to fish Wednesday through Saturday, to allow sufficient escapement for subsequent years.

Henry took his boat out last night for the first fishing trip of the season. Joan and her son Michael went with him. The lower Kuskokwim is a tidally-influenced river, with two tides per day, and the best fishing is usually just as the tide turns from going out to coming in. They were putting the net into the water just at that magic moment, and the fish began hitting immediately. It is so exciting to watch the string of floats begin jumping and bobbing. They only did one drift for about half an hour and caught so many fish it was all they could do to get them in the boat. Henry estimated the catch at nearly 400 fish! Most were chum, which will be frozen whole in his trailer-sized walk-in freezer and cooked up for dog food over the next year. About 80 were reds and jacks, and there were four big kings tangled in the holes at the bottom of the net. What a catch!

Dutch and I were gifted with a king fillet for dinner, which we had on the grill within three hours of being hauled from the river. It doesn’t get much fresher than that. The photo above is actually half of the fillet, and it was from a small king. Sorry I can't show you the "after cooking" photo with the fat running; Blogger is only allowing me one photo tonight (grrr...).

I love salmon just about any way you cook it, but overall, I think simple is best. Grilled over hot coals with a little garlic salt and lemon pepper is absolutely yummy. When the fat is running out and the meat flakes easily, it is ready. Add some fresh corn and a green salad and you have a feast.

When the weather is rainy and windy and grilling outside is not an option, my second favorite way to cook salmon is on a cedar plank. I have a professionally made, store-bought one, but any two-inch thick piece of sanded cedar will work. Soak it in water for an hour or so first, coat the top with cooking oil, and slap the salmon on it (fillet or steak doesn’t matter). Cook it at 350 degrees, about 20 minutes per inch of thickness of the fish. I often make a dry rub for the fish consisting of paprika, lemon pepper, onion powder, garlic salt, tarragon, basil, and a little light brown sugar—roughly equal amounts of all, except twice as much paprika. It doesn’t mask the great salmon taste, but adds a nice little extra flavor.

My third favorite preparation is to sauté chopped scallions, halved cherry tomatoes and whole black olives in a skillet; add salmon steaks and cook until done. I think of this as “Mediterranean style” because of the olives.

And of course there are plenty of other options too. Salmon soup, salmon salad, salmon dip, salmon burgers, salmon croquettes to name a few. When you start with such a great fish, it is hard to mess it up. The key is simply not to overcook it. Ummmmm…I’m making myself hungry. Time to fire up the grill.


Sunday, June 25, 2006

Prenatal Care in Southwest Alaska

The Yukon-Kuskokwim Delta is a huge region that presents some unique challenges when it comes to providing prenatal care. Distance and weather are significant barriers to care when the need is urgent. Many villages are more than an hour’s flight to the hospital in Bethel when the weather is good; when the weather closes down, due to fog, wind, snow storms, or severe cold, a pregnant woman may be many hours or even days from the care she needs.

Routine prenatal care is provided at the hospital by family practice physicians, physician assistants, nurse practitioners, and certified nurse midwives. We have one OB/gyn specialist on staff who oversees the high risk pregnancies and coordinates care with the perinatologist in Anchorage for the very high risk patients.

There are about 400 births per year in our hospital; most are uncomplicated vaginal deliveries that require very little medical intervention. We have two nurse anesthetists, but no anesthesiologist; we don’t give spinal anesthesia for deliveries. Our rate of Cesarean section is fairly low; we do perhaps a dozen C-sections per year. Three of our 15 family practice physicians, and the obstetrician, have privileges for C-section.

Patients are designated as having a high-risk pregnancy for a number of indications, most commonly grand multiparity—more than five previous deliveries. Risk of hemorrhage at delivery increases significantly for a grand multip, and many of our moms have had more than nine or ten children. Some have had more than twelve, and a few have had more than fifteen. There is strong cultural support among the Yupik Eskimos for early and frequent childbearing. Most primips (first pregnancy) are teenagers, and many grand multips are women in their forties (advanced maternal age). We also have a fairly high rate of pregnancy-induced hypertension and gestational diabetes, as well as chronic hypertensives and diabetics who become pregnant. We have a small, but slowly-growing population of HIV positive patients in the Delta, and some of those become pregnant as well.

Genetic diseases are an area of concern for our obstetrician also. Congenital adrenal hyperplasia—known more commonly here as AGS, for adreno-genital syndrome—is frequently seen in the Delta, and many families have more than one AGS child. There is a much more rare condition known as Kuskokwim Syndrome which occasionally occurs. These patients are born with permanent hip flexion contractures which can vary from mild to severe; some will never walk at all, and the milder cases will only walk with a very hunched posture.

Most women in the Delta will present to their village health aide for a pregnancy test within two weeks of missing a menstrual period. Once a woman has a positive test, she will qualify for Medicaid and WIC, and the health aide will file that paperwork for her. The Encounter Form from that visit is faxed to the hospital as Radio Medical Traffic and she is enrolled in the Prenatal Program. She is started on daily prenatal vitamins, calcium and iron supplementation, and is scheduled in the Family Medicine clinic for a first prenatal visit (about an hour), and in Radiology for a dating ultrasound, at 8 to 10 weeks gestation. There is an extremely low rate of pregnancy termination here; undesired pregnancies are far more frequently carried to term and the infant adopted out: to the pregnant patient’s own parents, or her extended family, or to an unrelated family in another village. Infants are almost never adopted outside the culture. If a termination is desired, the patient is referred to a provider in Anchorage, or occasionally in Seattle. Elective terminations are not performed at our hospital.

After the first prenatal visit in Bethel, a woman with a normal pregnancy will remain in her village and have monthly prenatal visits with the health aides. Health aides are trained extensively in prenatal care and follow their pregnant patients closely. They know who is drinking or taking drugs, who is experiencing domestic violence, who is not taking supplements or eating well, and who is having too much morning sickness. They report their concerns to their village provider and arrange for counseling, or evacuation to the women’s shelter in Bethel, or Vitamin B supplementation. At any one time, there may be as many as a dozen pregnant women in any one village.

All pregnant women spend their last month of pregnancy in Bethel. At the first prenatal visit they are given their “Be in Bethel” date—the beginning of the 36th week. Women from the village refer to this as “going to wait” and they generally hate it. It is very difficult for them to separate from their families and their village for such a long time. They sign a paper at their first prenatal visit acknowledging their Be in Bethel date, and their understanding of the repercussions if they stay in the village past that date: that they are placing an unfair burden on the health aides of the village, and that they may be placing their own lives and the lives of their unborn children at risk by doing so. If necessary, attempts to medevac will be made, but if weather is prohibitive, the lives of the medevac team will not be risked to bring them in.

Most women do come in, on or near their Be in Bethel date. If they have family or friends in town to live with for that month, they may do so. If not, they spend the month living at the Prematernal Home. The home provides dormitory-style living for about 30 women. They are assigned a room shared with one roommate, and have regular chores to do, mostly cooking and clean-up. Partners/husbands, family members or friends may come to town to visit them, but are not allowed to stay at Prematernal Home.

The women have weekly prenatal visits (twice weekly for high-risk patients) at the hospital during their last month. Prematernal Home is just less than a mile from the hospital, and most of the women walk back and forth for the exercise, which is strongly encouraged. They may go ice fishing in the winter, or berry picking in the summer; but most are pretty bored, especially if there is no one else from their village also waiting. They are often homesick or worried about their children back home being cared for by relatives. It is a difficult time for them, and the temptation to make a quick trip back just to check on things is strong, especially for the women from nearby villages.

Despite this well-established system, village deliveries do occur about ten to twenty times per year. Most of them are premature, occurring before the 36-week Be in Bethel date; but a few are full term infants born to stubborn moms who refuse to come in, or who fly back home for a weekend. The health aides do a magnificent job in these situations. Health aides in one of my assigned villages last year delivered a double footling breech successfully, with no help except a doctor in Bethel talking them through it on the phone. That baby is now a healthy toddler known to all as “Footy.”

When a woman in the village goes into labor before 36 weeks, a big medevac ensues. The health aides get her to the village clinic by any means available (hand-carried reclining litter or dogsled pulled by four-wheeler or snowmachine), place a Hep-lock for IV fluids, and get a phone link established with the ER physician in Bethel. They have terbutaline in the village, which they can give on the order of the physician, to try to slow her contractions. Meanwhile, the on-call family practice physician and pediatrician at the hospital are paged STAT to the ambulance bay for a fast ride to the airport. The flight team (1 pilot, 1 paramedic) starts warming the plane as soon as they get the call, and take off the minute the docs jump on board. The near villages—Kwethluk, Napakiak, Akiachuk—are only a fifteen minute flight; the distant villages—Kotlik, Scammon Bay, Tununuk—take over an hour to get to. That’s in good weather with good visibility, and it often isn’t. Most of the villages now have lighted airstrips, but not all. In December we only have four to five hours of daylight, so it is a major concern. If necessary, the health aides will get on the VHF radio and ask everyone in the village with a snowmachine or four-wheeler to drive to the airstrip and line up on each side with their headlights on. Whatever it takes.

Hopefully, the team will arrive before the baby delivers. If not, it is all up to the health aides. There are no incubators in the village clinics, so they put a space heater in the smallest exam room and try to get the temperature up to 100 degrees; and they warm up bags of IV fluid in the microwave to lay next to the infant. The team brings an incubator with them for transporting the infant back to Bethel. A medevac team from Anchorage may meet them at the Bethel airport for a tarmac transfer if it is necessary to get the infant to intensive care. Our hospital has no intensive care unit at all.

More often than not, these heroic efforts end well. Dedicated staff overcome huge challenges of geography and climate to deliver state-of-the-art medical care to the people of this region. It is not easy, but it is incredibly fulfilling, and it is always appreciated.


Village Travel

As always, it is good to be home. Seems like returning to Bethel always involves a bit of culture shock for me; but the shock is different coming home to Bethel from a village than coming home to Bethel from Anchorage or the Lower 48. With the latter, the shock is how small, rural, grubby and frontier-like Bethel is; with the former, it is how big, developed, and fast-paced Bethel is. Interesting. It really helps me appreciate what my village patients go through when I tell the health aide to send them in to Bethel for further evaluation. That sense of displacement and reality distortion for them rachets up several orders of magnitude when they have to go from the village to Anchorage. They really hate it, except for the week before Christmas when it is nice to have a shopping opportunity.

Traveling in the bush is different than any kind of travel in the Lower 48. Almost all of it is done in small planes. This is the Caravan that flew Diane and me up to Pilot Station last week; it is about the largest plane doing regular bush flights. It has 11 seats. The plane we returned on was a Cessna 206, which has six seats and limited luggage capacity. We thought we would have to leave some of our luggage in the village to be sent the next day, but fortunately the other three passengers had very little, so it all fit.

Bush travel demands a lot of the traveler. The first rule is that it is really your own decision whether or not to fly at all. In the Lower 48, if the plane is going, then you can figure that you are safe to get on it; if it is not safe, then the plane won't go. Not so in bush Alaska; bush pilots are a cowboy breed to start with, willing to take on all kinds of wild weather. You can generally trust the mechanical functioning of the plane itself, but it is ultimately up to you whether you think the weather is safe enough to fly in. You could have a crazy pilot who will batter the plane ragged against a wall of wind, trying to get you there.

The second rule of bush travel is to dress like you are going to crash. Literally. Because you might. In winter that means full snow pants and parka, snow boots, fur hat, fur gloves, fleece underneath, head lamp with fresh batteries, matches, pocket knife, water bottle in an inside pocket, and protein snacks like dried fish and nuts. Most planes fly at much lower altitudes (less than a thousand feet; there is nothing to run into out here) and most crashes are survivable. You just have to be prepared to hunker down and wait for Search and Rescue.

In summer, the terrain you are flying over looks like this. There is a lot of water down there. Even the part that looks like dry land is pretty squishy. If you had to go down there, you'd want rubber knee boots and lots of bug dope. I should interject here that I don't mean to imply that crashes are frequent; they are not. But we do usually have two or three a year in the Delta, and it is best to be prepared.

The third rule of bush travel is to be prepared to have to stay in a village two to three days longer than planned, especially in winter. The weather can change fast out here. Perfectly good flying conditions on the outbound trip may crumble to zero visibility and high winds in a few hours. It is a common experience to be "weathered in" a few extra days in a village. Being prepared for this primarily means having extra food with you. When you travel to a village, one of the most important things you must take is every single bite of food you will eat for the entire stay. You cannot assume that people will invite you home for dinner, and you cannot assume that there will be anything to buy at the village store. And there sure ain't no restaurants! Careful planning beforehand is crucial, and comfort foods are essential; I always take pasta, chocolate, and fresh fruit.

I have been very lucky in doing village travel; I have only been weathered in once, and then only for one extra day. And I've never crashed (knock on wood). Fortunately, I love flying in small planes. My dad flew a Cessna 172 when I was growing up, and we made lots of trips in it. One of my small regrets in life is that I declined when he offered me the opportunity to get my pilot's license when I turned 16. At that point I was more interested in driving a car.

During our week in Pilot Station, Diane's husband Andre flew up for a visit. He is a pilot who teaches at the flight school in Bethel. He took us for a short joy ride up and down the Yukon River in his Cessna 172. It was lots of fun. We circled over the villages of St. Mary's (pop. about 500), Pitka's Point (pop. less than 100), and Mountain Village (pop. about 650). We did a touch-and-go at Mountain Village which was interesting; the airstrip is on an incline, and we landed and took off going uphill. Never done that before.

Looking straight down the Yukon River.

Village travel is fascinating, exciting, and enriching in many ways. It is also exhausting, and I am really glad to be home.


Thursday, June 22, 2006

Pilot Station Photo Album

Pilot Station, Alaska

A beautiful Yupik Eskimo village on the Yukon River. Population about 500 people.

The Russian Orthodox Church

The Catholic Church

The new clinic...

...and the old clinic, now a residence.

The village store

Mom with baby wearing a mosquito cap

Kids are playing everywhere, and pay no attention to the mosquitoes.

Life at Fish Camp

Hanging freshly cut salmon strips and blankets to dry in the breeze for four or five days...

...and then into the smokehouse for about two weeks. The fire is kept burning constantly for the entire time. Letting the fire go out is considered "lazy on the fish" and an Eskimo elder can tell by the taste if that happened.

This elder is serious about her dry fish. This is Martha's mom, known to all as "Auntie M." There are over 200 salmon hanging in the rack over her head; she and Martha were up most of the night before, doing the cutting. The forked stick leaning against the pole is used to place the fish on the high poles.

Gutting the fish by the river's edge. The large white tote was full of fish only a few hours ago. At the edge of the table in front of the fish is an ulu, the curved-edged knife used by the Yupik for everything from filleting fish to chopping vegetables.

Mending the drift net. The man is working near the lead line, the bottom of the net, which often picks up snags and debris from the bottom of the river. If holes are torn, fish can escape through them, so they must be mended regularly.

When the fishing is good, everyone is in a good mood, despite the long hours and hard work. The smells coming from the smokehouse are tantalizing.

Life at fish camp is a family affair.

Butterflying the salmon head and popping out the eyes before smoking. The eyes are a much-loved delicacy, and are crunchy after they are smoked. Ummm...

Picking wild rhubarb. The stems are peeled and eaten raw, or sometimes dipped in sugar first. They have a tangy crunch that is quite delightful. The leaves can be boiled and eaten like spinach.

The universal mode of transportation in the village. Families of six or seven will all pile on at once.

Proud grandma, proud mom...

If the hospital ever decides to place PAs in the small village clinics, I'll be the first to volunteer to move to Pilot Station. I love the people there. It is a beautiful place to live.


Tuesday, June 20, 2006

Mosquito Dance

It was a bit delayed in coming, but Mosquito Season is now here in full force. After the light rains of the past weekend, there was a huge hatch. Swarms of the little pests are everywhere. If you stand still for a minute, you are in a cloud of them. They boil up out of the long grasses, they fly circles around your face, they bite right through your clothes, they buzz in your ears. If you take a deep breath you'll get a few in your mouth. Even worse is when you get them up your nose. It is easier to spit them out than to blow them out.

Early morning and late evening are the worst times. During midday they don't seem quite as bad, but there is no escaping them completely. At least they are big and easy to see (and swat!); they average nearly an inch in wing-and-leg-span. And they actually splash blood when you score a direct hit. The walls of the clinic are littered with corpse smears where humans have triumphed. The kids around the village are on mosquito-killing missions. People are burning pik coils in their houses to repel the onslaught.

Apparently it is just as bad on the Kuskokwim as it is up here on the Yukon. I spoke with Dutch on the phone tonight and he assured me that Bethel is suffering as badly as Pilot Station. One of my patients in the clinic today said that she was in the hospital in Bethel yesterday, and the waiting room was full of them. People everywhere were doing the Mosquito Dance (also known as the Alaska Salute), a constant two-handed wave to clear the air in front of your face and around your head. I remember a bug-repellent TV ad from my childhood in which a man stuck his bare arm into an aquarium full of mosquitoes; watching it made my toes curl in disgust; in Alaska in June, it is not just your arm in that aquarium, it's your whole body. I read somewhere that if you compacted all of Alaska's mosquitoes into a solid block, it would literally weigh a ton.

There seems to be a type of immunity to the bites that is acquired over years. Adults don't seem to be bothered by them much here, but small children have huge reactions. Toddlers will often develop cellulitis and become febrile from a few bites, especially ones on the head. When I first came here, I was surprised that children would be brought to clinic for a chief complaint of "mosquito bites," but I quickly came to appreciate that it was a far more serious problem than I gave it credit for.

It is a problem in the dog yard as well. Mosquitoes swarm around the dogs' eyes and noses, where the fur is thin. Their eyes can swell nearly shut from it, and they are whimpering in misery. Black dogs suffer more than white ones, as the mosquitoes are drawn to dark colors more than light ones. Henry and I both do twice daily rounds in the dog yard, spraying Deet on their backs and bellies, and rubbing citronella oil on their faces. It helps a lot for a few hours. They hate the smell and taste, but don't struggle against the application.

A dog musher told me once about a litter of pups born in early June to one of his best females. The pups were all sleeping in the dog house, and when he looked in on them, he thought someone had thrown a burlap sack over them. When he reached in to remove it, it was a solid layer of mosquitoes on the puppies. They had so many bites, there were blood spots everywhere, and two of the eight pups died from the inoculation.

There is an old Eskimo legend about mosquitoes that a woman shared with me in the steambath last night. According to the legend, in the old days, mosquitoes didn't know that people tasted good, so they only attacked animals in their quest for a blood meal. One day an old woman went to her food cache to find that mosquitoes had eaten all her stores of moose, caribou, and fish, and drunk all her seal oil. She was so mad she took off all her clothes and stood naked in the open and said to them "Mosquitoes! You might as well eat me too, for now I have nothing!" And so they learned that not only do we taste good, our blood is a lot easier to get to without all that fur. They have been making a meal of us ever since.

If mosquito season is intense, at least the worst of it is reasonably short. June can be pretty horrific, but by mid-July the land has dried out a lot. There will be bursts of mosquito hatches following a rain, but the rest of the time will be fairly tolerable. It is always a good idea to keep the "bug dope" close at hand. You never know when it is going to rain.


Sunday, June 18, 2006

A Village on the Yukon

Note to readers:

For reasons I cannot fathom, Blogger will not upload my photos. I have many beautiful images that would illustrate this post, and I would love to share them with you. The file sizes are less than 500 kb, and each attempt to load them claims to be successful, but no photos appear. If I ever figure the problem out, I will come back and add them here, but for now the writing will have to stand alone. I am hugely disappointed by this technical failure...

Pilot Station, Alaska, is a small Yupik Eskimo village on the Yukon River, about 200 miles due north of Bethel. The population numbers a little over 500 people. The village is nestled in the cleavage between two large bluffs, a small valley that slopes gently to the river’s edge.

The village consists of about a hundred homes (mostly pre-fab HUD houses and a few log cabins); a small general store selling groceries, some clothing, gasoline, tools and hardware; a Tribal Council building, large enough to hold most of the people for village meetings; a lovely new school (K-12); a lovely new clinic; two churches, one Catholic and one Russian Orthodox; and a barn that houses the village’s road grader and dump truck.

There are no commercial enterprises other than the village store—no restaurants, no businesses. The only paying jobs in the village are at the clinic, the school, the store, or with the Tribal Council, taking care of roads and landfill. The clinic employs nine people: five health aides, a behavioral health counselor, two clerks, and a janitor. The school employs perhaps as many as 30 people (I’m guessing here, and that’s a generous estimate). The principle and all of the teachers are Outsiders who come here for a few years and leave; the local people are employed as teacher’s aides, secretary, and janitor. The store employs about five people. The Tribal Council employs perhaps a half dozen people. Overall, less than 20% of the people have a job. The rest depend completely on the traditional lifestyle of subsistence: fishing, hunting, gathering, living completely off the land. The Native people of the Yukon-Kuskokwim Delta have one of the lowest per-capita incomes in the entire United States; and they are, on the whole, among the happiest people with the richest lives that I’ve ever known.

I have been the primary care provider for Pilot Station for the last seven years. I am responsible for managing their chronic illnesses, their medications, and their specialty referrals. I spend an hour or so on the phone with the health aides every day, discussing the patients they have seen in the village clinic, and deciding on plans of care for each one. When that plan includes coming in to Bethel, the health aide and I must decide whether transportation can be by commercial flight, available twice a day; by charter, usually available within two hours; or by medevac, usually within an hour. If the patient’s destination is not the ED, then he or she will be seen by me in clinic if at all possible.

Once or twice a year the hospital sends me to Pilot Station for a week to see patients in the village clinic. This is absolutely the best part of my job; I love village trips.

The health aides know several weeks ahead of time when I am coming. They start making a list of patients I need to see while I am here; especially elders who have difficulty traveling, home-bound patients, people with no Medicaid and no way to pay for travel. Additionally, the hospital wants me to see as many as possible of the babies under one year of age, the pregnant women, the patients with diabetes and/or hypertension. One of my own goals is to do as many Pap smears as possible. There are currently 84 women in the village who are due for Paps.

The new clinic is quite spiffy and modern. It was built about two years ago, and is a huge improvement over the old one. It has hot and cold running water, flush toilets, and (oh, luxury!) a shower. There is an itinerant sleeping room with two comfortable bunk beds, a microwave, a sink, and a tiny refrigerator. There is a large waiting room with cable TV, an office, four exam rooms with working exam tables complete with stirrups, a counseling room, a dental operatory (rarely used), a lab/pharmacy room, two bathrooms and a storage room. Everything is still shiny-new, and very clean. The clinic is very well supplied with most things any clinic would need. There truly is no hardship in working here, compared to the old days of honey buckets and dipped water.

When I make a village trip, I like to go a day or so early, to have time to settle in a bit, and walk around the village visiting with people. It helps to spread the word that I am here, which gets patients coming in to see me earlier in the trip. And it is just nice to have a little relaxed time in the village before starting very busy clinic days.

For this trip I have a companion, one of the new physicians on staff, Diane. She will soon be making trips to her own villages, and this is her training trip on how to do it. She is quite as excited as I am about coming to the village.

We left Bethel yesterday morning on a Cessna Caravan operated by Hageland Air, the commercial charter company that makes scheduled daily flights to Pilot Station. Taking a small plane to the villages is more like the old (pre 9/11) days of air travel. There is no security screening; no one minds that I have a Swiss Army knife or a Bic lighter in my pocket. The Caravan is a single engine nine-seater (plus two pilots) that holds a fair amount of luggage. The flight up was reasonably smooth, and took about 50 minutes. The view of the tundra from the plane during the warm season shows what a sponge the land is; an endless spread of lakes, ponds, rivulets, and streams. What land there is, is pretty marshy. From the plane we saw several colonies of tundra swans, congregating on the larger ponds by the dozens.

The last few minutes of the flight were a bit turbulent, and my stomach was glad for a smooth touchdown at the airstrip above Pilot. We were met by the Hageland agent, who has one of the very few trucks in the village; he loaded all our gear, and the two of us, in the back of the truck and drove us down the hill to the clinic. The health aide on call for the weekend was there as planned to let us in and give us a key to the clinic.

Transportation around the village in the summer is either on foot or by four-wheeler. The clinic owns a four-wheeler, but the health aides have to buy the gas themselves ($4.75/gallon) if they want to use it, so it mostly sits around unused. I am happy to buy the gas for it; buzzing up and down the hills of the village is great fun, and Diane and I had a ball yesterday touring the place. We stopped and visited a few friends that I have known quite a while now. One friend, Agnes, was totally delighted to see us; she hadn’t heard that I was making a village trip. She hopped on her own four-wheeler with her three-year-old son Devin, and we went to visit her mom and sister.

Mom is eighty-something, a tiny little woman who was so happy to see me, she kept stroking my arm and patting my knee in disbelief that I was actually sitting on her couch. Her nearly toothless smile was ear-to-ear for the short visit. She is the mother of seven daughters and five sons; three unmarried daughters live with her, and most of the rest live in Pilot. She speaks only Yupik, so the daughters had to translate for me as she got out her medicine box and told me about her pills, then showed me her arm where it still aches occasionally since she had a Colle’s fracture a few years ago.

After the short visit we climbed back on the four-wheelers and Agnes took us down to her smokehouse, where her husband Andrew is tending the fire. Salmon are running strong on the Yukon, and the men are out drift-net fishing every day. The women “cut fish”, which means they fillet the big salmon, and then cut the fillets into long narrow strips (half inch wide by about three feet long, depending on the size of the fillet), or make “blankets” by leaving the fillet intact and making cross-wise cuts an inch apart which go down to, but not through, the skin. These are dipped in a brining solution and then hung on a covered drying rack for several days, where no rain and a good breeze will shrink and harden the surface of the meat. Then the strips and blankets go into the smokehouse, where they are hung directly over an oil-drum woodstove fired up with green cottonwood to make a really smoky fire. The fish smokes for two weeks, and the fire must be kept going constantly the entire time. It is a labor-intensive process, but the tasty product will be the staple of the family’s diet for the next year.

Some people also dry and smoke the salmon’s head (as opposed to fermenting it into “stinkhead”, as I described in an earlier post). Next door to Agnes and Andrew’s smokehouse, Bernice and her two grown daughters are cutting strips and brining them. Her younger daughter, Linda, is just learning how to butterfly the salmon head for drying. Bernice smacks her lips and says yummm, she loves the eyes the best. They are nice and crunchy when they are dried. Both daughters look at me and laugh. Linda wrinkles her nose and says, “Yeah, and she can have them all, too.”

From the smokehouses along the slough, we decided to drive up to the air strip and look for wild rhubarb. Agnes was “greedy to get some” and Diane and I were glad to help her gather it. The airstrip is up on the taller bluff and has a beautiful view of the Yukon River. The area around it has nice trees and tall grasses, and the rhubarb grows all over the place. It is early in the season for it yet, so we didn’t find too much, but Agnes was quite happy with what we did find. She will peel the stalks and eat it raw, or make rhubarb agutuk, or bake it in pies. The leaves can be boiled and eaten like spinach, or soaked in dill pickle juice and eaten raw.

On our way down from the airstrip we passed the Orthodox priest, Father Gregory, and his wife Janet, out for a stroll and stopped to greet them. She invited us to a brunch at their home following Sunday service to honor fathers on Father’s Day. We were delighted to accept.

Saturday night was a bit rainy, and by Sunday morning there was a new hatch of mosquitoes that were everywhere. They are not bad if you’re moving quickly, but if you stand still for even a moment they are all over you. Fortunately, Diane and I both brought bug shirts and Backwoods Off.

We arrived at Father Gregory’s house right on time. Janet was busily making mountains of French toast for the hungry roomful of people gathered there. I went around the room, shaking hands with each person, and introducing Diane. I was pleased to find that I knew almost all the names without prompting; I’m terrible with names (but never forget a face) and I’ve worked hard over the years to keep names and faces of people from Pilot Station filed together in the often leaky sieve of my brain. Slowly, I’m getting it. Now I’m also trying to add family connections to my internal database of each person. What I really want is a wall map, where I can graph the entire village and visually see the connections.

The brunch spread was lovely. When it was ready, Father Gregory and his assistant priest lead the large (30+) group in prayers, blessing the fathers, grandfathers, stepfathers, godfathers, and fathers-to-be. The blessing lasted a good five minutes; Orthodox are known for praying quite thoroughly.

There was much talk over brunch of fishing and fish camps. When the salmon are running, most families leave their village (or Bethel) and move to their inherited spot on the river known as fish camp. They will live at camp for two to three weeks, until all the fish they need is finished smoking and ready for storage. To have a drying rack and smokehouse in the village, like Agnes and Andrew, is unusual; there is not enough room for everyone to do that. Most families have camps on the river that are passed down for generations. Some are accessible by four-wheeler, but most require a boat.

The camps have no electricity or running water. Most have rudimentary cabins, a covered drying rack and a smokehouse. Some have a steambath, which is really a luxury. The fish are headed and gutted right at the river’s edge, where they can be easily washed and the guts disposed of in the river. The cutting table for filleting and making strips and blankets is right next to the drying racks and smokehouse. It is a family affair, and even the older children will help by carrying water and feeding small fires set around the area to cut down on mosquitoes.

Just upriver from Pilot Station is a cluster of several fish camps. I know the families who own them, and Diane and I were invited to come up after the brunch to visit. Several people at the brunch were going by boat and offered us a ride. I’d have been quite happy if the boat ride had taken an hour or so, as I have never been out on the Yukon in a boat. But it only took a few minutes to get there.

Yesterday was a very good fishing day, and there were lots of fish hanging and still being cut. One drying rack had over 200 fish hanging. It was a beautiful sight. An old woman and her daughter, Martha, had done the cutting in two days; they were up most of the night last night cutting fish. The old woman was tired, and her arthritic hands were hurting from holding the heavy fillets and keeping a tight grip on the ulu (Eskimo knife), which becomes very slippery when covered in fish blood. Diane and I sat next to the drying rack and chatted with them for a while. Martha has had some health problems lately, and I had referred her in for an MRI and a visit with the neurologist. She just got home from Anchorage two days ago and wanted to bring me up to date on the trip. I was very glad to hear that the studies had been normal.

Diane and I caught a ride back to the village and returned to our home base at the clinic. We look forward to relaxing in a relatively mosquito-free space for the evening. Janet or Agnes may call us to come take a steam bath tonight, and I will be happy to accept. Tomorrow promises to be a busy clinic day.


Friday, June 16, 2006

Logging Update

Henry and company made it safely home to Bethel after two weeks on the river logging. They arrived at the small boat harbor about 4 am, so I don't have any photos of the homecoming. The trip was very successful; they got about 80 logs. A boom wasn't necessary, all the logs were bound up into a single raft. It was large and stable enough to put all the gear on, but not to pitch a tent and sleep on, so they slept on the boat for the trip home. Exhaustion levels are high by the end of such a trip, so Henry usually gets the raft within 25 miles of Bethel and then ties it off at the river's edge and zips home for a few days of rest and recuperation. Tomorrow he will go back upriver to Akiak and bring it the rest of the way home.

I spent the afternoon with him on Wednesday, sitting on his porch swing and listening to the stories of the trip. It was a wonderful river experience with lots of wildlife. He has the faraway look in the eye and the wilderness energy flow that being on the river imparts. It is good to have him back; I've missed him.

The stories are good ones, and worth retelling, but time does not allow. My day at the hospital begins shortly, and will be busy. And tomorrow I leave for a week in Pilot Station, my village on the Yukon River. So lots to do tonight. The internet connection up there is way more tenuous and slow than in Bethel, but I will write and post as much as I can. Stay tuned for more adventures!


Wednesday, June 14, 2006

Life in Bethel

Alaska is America’s Last Frontier, and living here has all the flavor of frontier life that most people associate with movies about the Old West. Things are not as polished and genteel here as in most places in the Lower 48, especially for those who live “in the bush.”

The state of Alaska is huge on a scale that is difficult to comprehend. I particularly like this graphic, as it puts size somewhat into perspective. Alaskans like to say that if you cut Alaska in half, Texas would still be the third largest state. Alaska has 600,000 square miles and 600,000 population, which works out to one person per square mile. But considering that over half the population lives in the three urban centers of Anchorage, Fairbanks, and Juneau—less than 10% of the land—once you leave those centers the population density is more like one person per five square miles. Or something like that, math was never my strong suit. Big, open, and empty of people at any rate.

In all this land there is only a very limited road system, mostly in the central portion of the state connecting Anchorage and Fairbanks (600 miles apart) and the Kenai Peninsula. This little road tangle sprouts off the end of the Alaska Highway, which meanders a few thousand miles down through Canada and connects up with the US highway system along the northern border of the Lower 48. That is a beautiful drive, if you’re interested, but don’t go unprepared. Anyone considering it should buy The Milepost, a guide to driving the Alaska Highway, available from and many bookstores.

Once you get off the limited road system in Alaska, you are considered to be “in the bush.” And now we’re talking truly rural, and very frontier. Goods and services are far more limited, and more expensive. The focus of life is much closer to survival and much farther from elegance. Climate plays some role in that, but distance and geography are huge factors also. Bush Alaska is the edge of the planet in many ways.

Out here on the edge is the town of Bethel. With a population of about 6,000, Bethel is one of the larger towns in the bush, along with Dillingham, Nome, Kotzebue, and Barrow. Bethel is the hub of southwest Alaska, a somewhat grubby little town (I say that with the greatest affection) perched at the edge of a huge, untamed (unbridged, undammed) river, surrounded by a gazillion miles of open tundra. Truly “out there” in every possible way.

The only way to get here from the Outside World is to fly in, from Anywhere to Anchorage, and from Anchorage to Bethel. Anchorage is very much like any other small Big City in the US (pop. 250,000), only with more gorgeous scenery. Prices are a bit higher, but availability of goods and services and the general feel of life are about the same as in any urban area of the Lower 48. Those who don’t live in Anchorage consider it a suburb of Seattle, and not “living in Alaska” at all. When Bethel folks want to really shop, or see a recently released movie, or eat in a nice restaurant, they “go to town,” which means they go to Anchorage.

Going to town is not cheap. The one-hour flight (400 miles) on Alaska Airlines costs around $500 for a round trip ticket. Occasional specials may drop the price to $300 or so, but those are not frequent. Traveling on to the Lower 48 is also not cheap; round trip Bethel to Seattle is $900 and takes eight hours each way; Bethel to Orlando is $1400 and takes 18 hours. Trips are carefully planned, and most people here don’t travel all that much. We don’t just pop over to Anchorage for the weekend on a whim.

Some people say that there is a time warp between Anchorage and Bethel, and once you land here, you’ve gone back about thirty years (or fifty). The pace of life is slower. Attitudes are different. The flavor of Yupik Eskimo culture informs everything about life here.

There are four Alaska Airlines jets from and to Anchorage on most days, weather permitting. The airport has two runways. The Alaska terminal has one big room where you check in and wait for your plane; security screening happens just before you walk through the door outside onto the tarmac to board. When you fly in, baggage claim is in the same room, so while you wait for your luggage,

you can chat with people who are flying out. Turn-around time from touch down to lift off is only about 40 minutes, so it happens pretty quickly. Opportunities to come or go occur at 8 am, noon, 4 pm, and 8 pm. You can see the jet land and take off from anywhere in town, and even though you may not want to leave, there is a sense of reassurance in that visible confirmation that the lifeline is intact. A few days without a jet and the grocery store shelves are pretty bare; we are very dependent on the connection.

The airport is about three miles from the center of town, and the ride in is bumpy one. Much of the road is paved, but laying pavement on tundra is not like paving hard ground; tundra shifts, heaves, and moves with temperature variations. We are living on a permanent ice cube covered with a mud layer and topped with a thick carpet of shallow-rooted plant growth. Roads buck and pitch and don’t stay where you put them.

Houses do the same thing, and one of the odder aspects of living here is that you have to have your house leveled every year or so. Frost heaves cause the foundation to shift, and suddenly your doors and windows don’t close anymore. Houses here are all built up on pilings (no such thing as a basement in Bethel) similar to beach houses in the Lower 48. When the door won’t close right, or there is a new crack in the sheetrock, it’s time to call one of the house leveling companies. They will come over and jack your house up, stuff a few shims on the piling, and ease it back down. And charge you three to four hundred bucks, depending on how unlevel it is, how big it is, and how long it takes them.

The shifting ground is also the reason that Bethel does not have an underground water and sewer pipe system. Until about ten years ago, there was no piped water or sewer at all. In the mid 1990s, a huge construction project was begun to bring piped water and sewer to Bethel, and about a quarter of the town now has a piped system. The pipes cannot be buried, however. They are built on top of the ground, and are somewhat of an eyesore, but you sort of get used to them.

People without piped water are on the hauled water system. Each home has a large water tank, usually 500 to 1500 gallons. The town operates a fleet of trucks that deliver water to the homes

once or twice a week. (I took this photo of a water truck getting filled at the pump house last December; the driver is holding "Flat Stanley" for a project that I was helping with.) A thousand-gallon water tank is about 8 ft. long by 3 ft. wide by 7 ft. high, and most tanks are inside the home to prevent freezing. Water conservation is absolute; you do NOT want to run out of water. When you turn on a faucet, you hear the water pump start up, and you become very attuned on a subliminal level to that sound. If no one is taking a shower or doing laundry, the pump should not be running for more than a minute; if it does, start looking for the source of water loss. A leaky toilet will empty your water tank faster than you’d ever think possible. No letting the water run while you brush your teeth. No cavalier approach to doing dishes. No long, hot, 40-gallon showers. No flushing the toilet when all you did was pee.

The other half of this system is hauled sewer. Each home has a sewer tank (outside), emptied weekly by the town’s fleet of sewer trucks. Each truck evacuates three or four sewer tanks and then drives out to the sewer lagoon for emptying. We have no sewer treatment facility; ours is said to be the second largest sewer lagoon in North America.

It is the homeowner’s responsibility to keep the access pipes for water and sewer unfrozen and easily accessible to the big trucks. The last thing you want is to come home from a day’s work to find you’ve been “green tagged” by the water or sewer truck driver. Then you have to get out the propane torch, melt the ice blockage, and call the Dept. of Public Works to schedule another delivery or evacuation.

Until very recently (like only a few years ago), many homes in Bethel did not have sewer tanks or toilets. They had honey buckets. Literally, a five-gallon plastic bucket with a removable toilet seat and lid. When the bucket got full, it was set in the home’s entryway and the sewer man came into the house and picked it up, dumped it into the truck, and set it back empty. If it froze, he left it there, and you had to warm it up enough to thaw before he’d take it. Large families might fill four or five buckets between visits from the sewer man. Bethel outlawed honey buckets about five years ago, but some renegade types still have them, and empty them in trash dumpsters around town (also illegal).

Garbage removal happens only at the level of the dumpsters; there is no home pick-up. Each home in Bethel pays $12 per month for the privilege of carrying its trash to the dumpsters of choice. There is one on nearly every corner, so it isn’t that hard. Bethel only has two garbage trucks, and they work six days a week keeping the dumpsters empty. Dumpsters are “adopted” by groups, or by the neighborhood they reside in, and are painted according to the whimsy of the adopters. That is a subject for a post all its own, as a new round of adoption is coming up this summer and the new paint jobs will make great photo subjects.

There are other “common conveniences” that Bethel does not have. No home delivery of mail; everyone has a post office box. No drive-up window at the bank; everyone has to go inside. No drug store; the only pharmacy in town is at the hospital, and all prescriptions are filled there. No alcohol of any kind sold in town; Bethel is “damp,” which means it is ok to have alcohol shipped in, but none is sold legally in town. There are bootleggers selling rotgut for exorbitant prices, but most people order deliveries out of Anchorage. It is a two-day process to drive your order out to the cargo handler at the airport and then return the next day to pick up the shipment. Most of the villages are completely dry, and no alcohol of any kind is allowed. Village safety officers are authorized to confiscate any alcohol brought to the village.

Shopping in Bethel is an experience in itself. There are two locally owned (not chain) grocery stores, and both carry a far more limited selection of fresh vegetables, meat, canned goods and other supplies than the average Safeway. At far higher costs. A gallon of milk is about $8. A nice New York strip steak goes for $10.79/pound. A box of cereal costs $7 or more. Bread is $4 per loaf. It is interesting to watch people go through the check out line. The customer’s level of astonishment at the amount due is inversely proportional to the amount of time s/he has been in Bethel. After a while you get used to the fact that the weekly grocery bill for two people will run about $300. It helps a lot when your freezer is full of moose, caribou, and salmon.

There are a dozen or so restaurants in town, and all are outstandingly mediocre. They all have roughly the same menu, with Chinese food, pizza and hamburgers figuring prominently. The only franchise restaurant we have is a Subway.

The pace of life is very relaxed. Nobody really dresses up for anything. The only suits and ties you’ll see are on lawyers in court. There is nowhere to go that requires “evening dress,” and somehow the overall impression of a gown is somewhat marred by wearing it with snow boots.

Entertainment is pretty much self-made. There is no movie theatre, no bowling alley, no video arcade, no shopping mall, no pool hall, no tavern, no skating rink. Visiting friends, having potlucks and barbeques, playing games and just spending time together is the primary entertainment.

The medical staff recruiters for the hospital have an info packet which they give to newcomers; it contains a sheet called Things To Do in Bethel. The list contains the following suggestions:

Ask KYUK about volunteering on the radio
Ask someone about the medicinal uses of plants
Check out videos from the library
Clean up around your dumpster
Go Fishing (Ice Jigging in Winter; Rod & reel in summer)
Go on a bird walk
Go out for lunch
Go to a sled dog race
Go to a dance (Fiddle Dance at the Armory or Sober Dance at the alcohol treatment center)
Go to a quilt guild meeting
Go to a softball game
Go to Hangar Lake and watch the floatplanes
Have a potluck
Help clean up a dog yard
Learn how to harness dogs
Learn some Yup’ik words
Learn the names of different tundra plants
Learn to cut, dry, and smoke fish
Learn to sew fur
Learn to use an ulu (Eskimo knife)
Learn which villages are where in the Delta
Look at the graves in the cemetery
Make a basket
Make a kuspuk
Pick berries
Pick up a bag of trash off the tundra
Plan a camping trip on the tundra
Play on the playground equipment at Pinky’s Park
Read an out of town newspaper at the library
Read the editorials in the Tundra Drums or the Delta Discovery, Bethel's weekly newspapers
Ride a snow machine on the bluffs
See how many different tundra flowers you can find
See what new books are at the library
Take a Yup’ik dance class
Take a walk on the frozen river
Try agutaq (Eskimo ice cream)
Visit the Bethel History Display at the Cultural Center
Visit the displays at Fish and Wildlife
Volunteer at Bethel Health Fair
Volunteer at Cama-i, the annual dance festival
Volunteer at K300 headquarters (the annual dog sled race)
Volunteer to read to children at the library during Children’s Reading Hour
Watch the barge unload
Watch the commercial fishing boats come in and unload huge totes of salmon

Exciting, no? Like I said, we’re on the edge of the planet here, and there is no place quite like it. I truly love it.


Saturday, June 10, 2006

Blooming Tundra

Spring arrived a few weeks later than usual this year, but is moving in quickly to catch up. Snow and ice is mostly gone now, except for a few deep gullys that never see direct sunlight. And the Alaskan tundra is starting to bloom in the nearly around-the-clock daylight.

There is a huge variety of grasses, moses, lichen, and flowering plants. Cotton grass is everywhere, putting out little puffs of white that look like close cousins to the king plant of the Deep South. It looks like a carpet of white across the tundra, and Eskimo legend says that the amount of cotton grass in the summer predicts the next winter's snowfall. Small pink flowers add spots of color, and deep within the spongy ground cover are tiny little blooms on the blueberry and blackberry plants that will develop into tart and tasty berries by August. It is hard to fathom how this riot of growth can survive the severe cold of winter, but somehow it does. The earth laughs in flowers, and nowhere more so than during the brief growing season here on the subarctic tundra.

One of our most colorful flowers is fireweed. It grows along the roadsides and anywhere the tundra's protective cover has been peeled aside by big machines. It is a true chronometer of summer's progression; the two-foot stalks begin blooming at the base around the time of summer solstice, and by the time the top of the stalk has flowers, summer is about over. This photo was taken in July.

Along with the flowers, my week was gladdened by the return of a pair of Lesser Golden Plover (Pluvialis dominica) who nested successfully on the tundra right in front of our house last summer. They stayed for about six weeks and raised two offspring before departing for their winter home in South America. What an incredible distance to fly! They are rather small birds, only a little larger than robins. The two that nested in our "yard" were the only two I saw anywhere, and I was surprised and delighted to find that they had returned (of course I want to believe that it is the same pair). This morning I managed to sneak close enough to the male to snap this photo of him standing in a large patch of cotton grass; I need a better telephoto lens to capture the details of his beauty. He is very "flighty", and takes wing at the slightest movement in his surroundings. His mate has very similar coloring, with less black on the breast and underbody. They take turns tending the nest diligently. I wonder if their youngsters from last year returned with them, but so far have seen only the two. I hope they do as well this year.


Wednesday, June 07, 2006

Seeing Patients

The first two days back at work after vacation were just as hectic and busy as I expected them to be (surprise! Don’t you usually get what you expect?). Lots of patients to see, lots of radio medical traffic to do. Lots to catch up on.

My first patient Monday morning was a young man commuting to Bethel by boat. His village is not far away, and he works here in town. The weather was overcast, but not windy, so the river was reasonably calm and he was scooting along about 40 mph in his open skiff. Some thoughtless person had left an unmarked fishing net anchored just under the surface of the water, and the boat’s lower unit snagged it in passing over. The boat slammed to a halt, and then jerked backwards, sending my patient sailing forward to smash the side of his chest into the center bench seat. He was traveling alone and somehow managed to get his motor disentangled, his boat into Bethel, and himself into the clinic.

His chest showed surprisingly little evidence of trauma—small abrasion, no bruising—but his complexion was very pale and his eyes slightly squinted as he lay motionless on the exam table. I asked if he wanted a wheelchair to get to Radiology, but he said no, he could walk.

Have I mentioned recently how incredibly stoic most Eskimos are when it comes to pain? The man had five broken ribs. Each rib was only broken once, so thankfully there was no flail chest; and no significant displacement, so no punctured lungs. But he is still in for a rough ride over the next few weeks. His biggest concern is that fishing is about to start, and he is a strong young man with a large extended family to feed. This couldn’t happen at a worse time for him.

A bit later in the morning, I saw a patient that I had discussed with a health aide prior to my vacation. She had been in to the village clinic several times in the last month, and the health aide had reported her on radio medical traffic. Her complaint to the health aide had been dry mouth and constipation. Warning bells! Red flag! Could be botulism! (see my previous post here for more information) But she had denied the neurologic symptoms—blurry vision, double vision, proximal muscle weakness—and had not consumed any fermented or “stink” foods. So the health aide and I agreed on treatment for her constipation, and I told him to have her come up to see me in Bethel if her symptoms did not clear up.

As with many elders in our region, this patient’s English is halting at best, so I called in Nastasia, our main translator. Her presence makes all three of us more comfortable that the patient and I are understanding each other, but the visit will take at least twice as long. Yupik elders often have a tendency to give long and circuitous answers to simple questions when speaking in Yupik. Interestingly, the English-speaking ones don’t seem to do it nearly so much when speaking English. It is somewhat affectionately known as “going to the moon.” A question that may be answered with a simple yes or no may engender a long story; at the end of it, the translator may sort of shrug and say “basically, she said yes (or no).” When I raise my eyebrows, the translator will say “well, she had to tell me a story about the time when her daughter…” Elders are held in very high esteem in this culture, and when an elder is speaking it is rude and unacceptable to interrupt. They go to the moon if they want to, and everyone will listen and wait until they are done.

The patient said that her complaints of dry mouth and constipation had been going on for over a month, ever since she was admitted here in early May (new information) for “stomach flu.” Checking the chart, yes, there it is, a two-day admission for gastroenteritis, received IV rehydration for the diarrhea and vomiting, and was discharged home. I asked if she had had dry mouth at the time, and she said yes, but she never told anyone because they never asked.

I asked if she had eaten any fermented foods or sea mammals in the days prior to admission and she said that she had. Her son-in-law’s family is from a coastal village and had gifted her family with some seal blubber. She usually doesn’t eat blubber, because it made her sick once a few years ago, but this looked so tasty that she just had to try a little. Within 24 hours she had nausea, vomiting, diarrhea and abdominal pain. No one else in the family became ill. I asked if she had told anyone about the seal blubber when she was admitted, but she said no, they never asked.

Since the admission she has been fine, except for the ongoing problem with dry mouth and constipation. She has never had vision problems, muscle weakness, or shortness of breath. When I looked in her mouth, her mucous membranes were sticky and parched, and her tongue was reddened with central fissures. Just looking at it made me appreciate “dry mouth” on a whole new level.

I think she did have a mild case of botulism, but a month out from it, the only treatment is supportive. She is not at risk for respiratory involvement now. Her dry mouth and constipation may continue intermittently for months. I sent her off to pharmacy for some docusate sodium and psyllium powder, along with encouragement to push fluids/chew gum/suck on lozenges, and she left with a smile. I hadn’t really done anything, but she felt very reassured that her story had been heard, the right questions asked, and her complaints validated. Sometimes, just listening is enough.

The next patient was a young man with uncontrolled hypertension. Twenty-one years old and a blood pressure of 184/106. His work up started with another provider about six months ago and all lab work was normal. His EKG showed left ventricular hypertrophy by voltage, but chest x-ray was normal. He had better control two months ago on atenolol, but that was changed to a diuretic when he complained of being tired all the time.

The more interesting thing (to me) about this patient was not his hypertension. He is a thin young man who was dressed in “baggy” style sweatshirt and jeans (meaning about 4 sizes too big) which covered everything but his face and hands. When I had him lie on the exam table and lifted his shirt, I found his skin covered in the classic “fish scale” appearance of ichthyosis.

The derm books describe this as a commonly occurring condition, but in my 14 years in family practice, I had never seen it before. When I asked him about it, he said that it is not itchy, and he uses no special creams on it. It is “just there” and he ignores it.

After he left, I checked back through his chart. At 21, his chart is still a single volume, and contains every clinic/hospital visit since the day he was born. That is one of the more amazing things about working here. Most patients are born here and stay here their entire lives; their hospital chart may become five or six volumes large, but if you need to know what drug reaction they had in 1948, or what surgery they had in 1963, it is all in there. This young man was diagnosed with lamellar ichthyosis at the age of three. He had numerous visits for it in the late 1980s, but none in the last 15 years. And it has no connection to his hypertension.

The rest of that day and the next went by in a blur of prenatal visits, colds, annual exams, aching knees, well babies, toenail removal, headaches, STD checks, and lots and lots of radio medical traffic. There are quite a few “orphan” villages right now, as many permanent medical staff members are on vacation. Yesterday afternoon I was the assigned RMT person and reviewed ninety-one patients with the health aides in the villages. Anything over sixty is a lot, but over ninety is approaching crazy. I’m really glad that Wednesday is my day off. Tomorrow promises more of the same.

These patient stories are fictionalized; the photo above is not related to these accounts.


Monday, June 05, 2006

End of Vacation

Today is back-to-work day after the two most wonderful weeks off that I could possibly ask for. The time away has been completely restorative. I got plenty of sleep, despite bright daylight from 5 am to 1 am. I indulged myself in the luxury of spending hours reading the archived posts of some of my favorite bloggers. And I spent lots of time in the "zone", where the creative process of writing occurs. That process charges me, and I love the energy. You, gentle readers, are very much part of that dynamic process; you have given me positive feedback, which has contributed to the charge and encouraged me to continue. And for that I thank you, one and all.

As I turn my attention back to the hospital and the health-related events around the region, I find that I have missed it quite a bit and do feel ready to return. I've missed talking to the health aides each day, and look forward to catching up on happenings in my three villages. And I have missed seeing patients. As always, when I have been away from the practice of medicine for a couple of weeks, I have some trepidation about starting back; I'm always afraid that I've forgotten all the medicine I know. I haven't, but it feels that way at first.

It is also time to start preparing for my next village trip. I am totally excited about that; I have not been to Pilot Station for 18 months. Village trips are a low priority when we are short staffed at the hospital, and we have been for nearly a year. Fortunately, there are enough temporary medical staff coming up to work brief assignments here this summer to allow permanent staff to get out to our villages. It is the part of my job that I love the most, and I am really looking forward to going up to the Yukon River. There is quite a bit of preparation beforehand that I will get started on this week. I'll be there June 17th to the 24th. I'll be blogging from the village, with photos!

Saturday, June 03, 2006

Bethel's Bike Rodeo

Bethel's annual Bike Rodeo was held this afternoon in the big parking lot in front of the Community Health Services Building, a branch of the hospital. The rodeo is sponsored by the Bethel Parks and Rec Dept. and the hospital's Injury Prevention Program. Lots of kids show up for it, and for good reason--they have a great time. This year about 150 kids came out, and we had a beautiful sunny day. The wind was a bit nippy, but that did not bother them at all.

Registration started at noon, and within an hour there were kids and bikes everywhere. The first stop after registration was the helmet fitting station. Bethel has an ordinance requiring helmets on all cyclists under 18 years old. New helmets were given to all registered participants, along with instructions on how to wear it properly, and teaching about the importance of helmets to prevent head injuries. Non-registered participants could bring in an old helmet and trade it for a new one if they wished.

The next stop was the bicycle maintenance station. Bikes were checked for safety, bolts tightened, tires pumped up, chains cleaned, seats adjusted. This station was staffed by the local Boy Scout troop.

After bike maintenance, it was time to watch an educational video. A school bus was parked at the corner of the lot and a television monitor with VCR mounted in the driver's seat. A dozen kids at a time filled the bus seats and watched a short video on bicycle safety.

After the safety video came the most popular station: the obstacle course. Bikers had to follow a marked, unpaved course. They had to obey all signs, signal their turns and stops, do a figure 8 around barrels, go over a small jump (small riders could skip the jump), and go through a shallow sand trap. They were taught bike handling skills at each obstacle. Many kids did the obstacle course several times!

After the stations were completed, there were hot dogs, potato salad and lemonade for the hordes of hungry rodeoers. A big open course was marked on the pavement for free riding so that all who wanted to could practice their new skills.

A silent auction of bikes donated by individuals was held throughout the afternoon. These bikes had also been checked out by the Boy Scout bike mechanics to be sure they were in good working order. Some went for as little as $20.

Any conclave of kids and bikes has a high likelihood of skinned knees, so there was also a well-supplied First Aid station. I was asked to run the station again this year, with the able assistance of Iris, a former health aide. We cleaned up some minor road rash and dispensed a few band-aids, but fortunately had no serious injuries.

All in all, it was a fun afternoon. Kids in Bethel pretty much have to make their own entertainment, and they love a big organized event like this one, especially when they can race around and blow off kid energy.

Over the next month, the Injury Prevention Program will be doing an observational survey around Bethel to see how many kids are wearing helmets when they ride. As a long-distance cyclist, I have always been a proponent of bike helmets for everyone. It is all too easy to hit a patch of gravel or soft sand and go down quickly. I've done it standing still! The discouraging thing is to see a family out biking with the kids properly helmeted and the adults bare-headed. You only get one brain, don't scramble it!


Friday, June 02, 2006

Taking Steam

All the people out logging right now are laying in wood supplies to feed their wood stoves through the winter. Not so much to warm their houses, as most homes in Bethel are heated with fuel oil, though some have wood stoves as a back up. And with the cost of fuel oil up to $3.65/gallon, many people are planning to burn more wood and less oil. But most of the wood collected after spring break up goes to heat the steam bath.

The Eskimos call it muk’ee, and it is their traditional method of bathing. In a land where water is locked up in ice for the eight frozen months of the year, the people had to develop a system for bathing that required very little water. The steam bath gets you cleaner than a shower, and provides an opportunity for socializing as well.

In the villages, as well as in Bethel, most people have a steam bath. It is a small, two-room building made of logs or lumber. The smaller of the rooms has a six foot ceiling and is for changing clothes and for cooling down after coming out of the bath. The larger room is the bath itself. The ceiling is very low, usually less than four feet, so you can only sit or lie down inside. A portion of the floor is cut out to make a recessed space that holds a woodstove just below floor level. Really nice steam baths have a plywood floor coated in marine paint, which cuts down considerably on one of our dreaded-but-common problems, the BOB (boil on butt).

The traditional muk’ee is gender segregated, as this is a naked activity. The men steam together, usually first, and crank the woodstove as hot as it can get. The temperature in the bath may exceed 150 degrees F. A mark of Eskimo “machismo” is how hot you can take your steam. After the men are done, the women and children steam, usually at somewhat lower temperatures. Boys after the age of five steam with the men.

The Eskimo muk’ee is very different from the Native American sweat lodge, though both involve an intense heat source in a small space and lots of sweating. The sweat lodge is a spiritual experience, while the muk’ee is a purely social one.

When the woodstove is literally rocking from the violent forces of combustion within, and the stove pipe glows red hot nearly to the ceiling, the steam bath gets hot beyond all belief. Conversation stops. Everyone gets flat on the floor as the person hosting the steam bath pours ladles of water over the woodstove, instantly creating billows of steam. Though it is hotter with the steam, it is also easier to breathe. Sweat is rolling from every pore, and your skin is tingling all over, but especially the part facing the woodstove. By this point I am usually prone with my face to the wall, trying not to let my exhaled breath touch my skin anywhere—it burns when it does.

When you feel that you just can’t take the heat for another second, you may ask for the door to be opened. You slip out quickly, before too much heat is lost, and sit down in the dressing room to cool off and drink water. Loss of body fluids from sweating can be extreme, and dehydration headaches several hours after a steam bath are not unusual if the person hasn’t been replacing fluids adequately.

The sign that you’ve had a really hot steam is when you come out with “muk’ee skin”—a lacy pattern of redness known medically as reticularis livedo. In people who take steam infrequently, it is a temporary skin change that resolves in a few hours; but over a lifetime of frequent exposure, it becomes a permanent pigmentation pattern.

When the woodstove cools, each person brings in soap, shampoo, and a basin for water. After sweating oneself clean from the inside out, it is a small matter to “wash up,” and only requires about a gallon of water per person. And you feel so incredibly clean! The Eskimos believe our method of bathing, taking a shower or a tub bath, is only doing half the job. I have to agree; I’ve never felt cleaner than after taking steam. And it is followed by such a great night’s sleep.

One of the most memorable steams I can recall occurred on New Year’s Eve of Y2K (remember that?). I did not believe that the world would fall apart at midnight, but I wanted to be somewhere peaceful if it did. The following is what I wrote the day after:

January 1, 2000

Steaming in the New Year

It’s a quiet New Year’s Day, especially after all the hype and hoopla associated with this particular New Year’s Eve. There were parties all over town and I was invited to a couple, but chose instead to spend the evening at Henry’s taking a steam bath. He said the elders are saying that that is the best way to ring in the new year, and he agrees with them. I was thrilled; there is almost nothing I would rather do than take a steam.

Henry’s steam bath is exceptionally beautiful. It is a low log structure that he built from logs he salvaged out of the river about 25 years ago. The main room is about 6 feet by 10 feet, with a hole cut in the floor so the woodstove can sit directly on the ground. There is a small dressing room, about 6 feet by 3 feet, where you can step out if it gets too hot inside. The stove itself is a 55 gallon drum laid on its side with pipe out the roof and a square hole in front which is closed off by a big pot which holds water. River stones cover the top and sides, held in place with chicken wire. This increases the surface area to create more steam when hot water from the pot in the stove door is ladled over the hot stove. Several 5-gallon buckets of water have to be carried down to the steam house to use for drinking, washing, and making steam during the bath. The floor is plywood with an element of luxury--it is painted. This minimizes splinters in bare butts which often lead to boils.

The Eskimo tradition of steaming has more to do with hygiene than with spirituality. In a land which is frozen half the year, water is a precious resource, and conserved in all ways possible; chipping ice from the river, hauling it to the village in buckets and melting it over a fire is hard work. Some Eskimo villages in our region to this day have no running water and no sewer or septic system. They developed steam baths as a way for numerous people to bathe using minimal water. Last night there were 6 of us in the steam and we used about 10 gallons.

Generally we steam first and eat afterwards, but since we wanted to “steam in” the new year, we reversed it. After a light supper of shrimp and salad, we lit the fire in the bath house about 9:30. It was about 25 degrees below zero outside, so took some time to get the bath warmed up. Everyone else stayed up at the house during the warm up, but I was enjoying the quiet and peaceful solitude in the dark bath house with the fire crackling against the chill. It felt so good just to sit with the fire, eyes closed, and absorb the energy.

After a second wood stoking, the fire was roaring and the bath was hot. Henry and four other friends came down and we began ladling on the water. There is an art to proper ladling; if you just dump water on the stove, it splashes, which can burn people sitting close, and doesn’t make a lot of steam. Water must be slowly and carefully poured from the ladle while moving it over the surface of the stove. This produces maximum steam from each ladleful of water. The temperature in the bath goes up about 20 degrees with every ladleful. It quickly gets really hot. Some people stay in the bath the whole time and others go out to the dressing area to cool down and then come back in. It goes on for a couple of hours. The Eskimos say that in a steambath, you get clean from the inside out--much more than in a shower. After everyone has had enough, the floor is squeegied to leave it as dry as possible and any extra water in the buckets is dumped. The candles are put out, the fire is left to die, and the bath slips back into darkness until the next steam.

As I was leaving the bathhouse, the Alaska night presented me with the most awesome spectacle. The Northern Lights were flaming green across the sky. The crescent remnant of the waning moon was just rising and the stars were outrageously bright. The Big Dipper hung just over the steam house, which was a silhouette against the night sky with sparks coming from the stove pipe. It was breathtaking. I wanted to stand there forever, just looking at the majesty of it, filled with the beauty. With a start such as this, Y2K could only be good.

This is a photo from the interior of a muk'ee house in a small village on the Yukon River. It has seen almost daily use for forty years. Notice the water container sitting in the mouth of the stove--an old gasoline can! It is a common practice, but it still makes me nervous. As health care providers, we encourage the owners of the baths to clean with bleach between each use, and we encourage people using the bath to bring their own piece of clean cardboard to sit on. As this information has penetrated the culture, we have seen some reduction in boils caused by methicillin-resistant Staph. aureus (MRSA), a particularly nasty bug.