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.