Saturday, July 01, 2006

The Villages of Southwest Alaska

A gray, cold, windy Saturday and I think perhaps it would be a good time for a geography lesson. Most maps of Alaska show only a few of the villages of the southwest quarter of the state. I've mentioned several of them in previous posts, and I thought you might like to see where they are. I love maps anyway; my dad taught me how to read one when I was pretty young, and I've always enjoyed pouring over them.

When I first came to Bethel in 1998, I was fascinated by the village names. Some of them are quite lyrical and fun to pronounce; kwig-a-LING-guk sounds like a bird call to me. AK-i-ak sounds like laughter. And e-MUNG-UK sounds like throat clearing. Yupik is a very gutteral language, with many sounds deep in the throat, so it makes sense.

The entire region between the Yukon River and the Kuskokwim River is referred to as the Y-K Delta. There are 58 villages in this region, home to about 20,000 people. The great majority are Yupik Eskimo. The smallest villages--Nunam Iqua, Oscarville, Pitka's Point, Lime Village, Stony River--have less than 50 people. The largest village, Hooper Bay, has about 1200 people. Most villages are in the mid-range, with populations of 400 to 600.

Each village has a health clinic staffed by community health aides with very limited services available. Health aides can draw blood to send in to the hospital for processing; the only lab tests they can do in the clinic are urine pregnancy tests, rapid strep tests, dip stick test of clean catch urine, and finger-stick glucose. There is no imaging (x-rays) available, and only a limited formulary of medications which health aides can dispense on a provider's order.

There is an intermediate level of care available in the Delta which I have not previously discussed. The hospital operates four larger Sub-Regional Clinics in the villages of Aniak, St. Mary's, Emmonak, and Toksook Bay, with a fifth planned for Hooper Bay in the next few years. These clinics are staffed by two mid-level providers (physician assistant or nurse practitioner), in addition to community health aides. They have x-ray machines capable of doing chests and extremities; these are initially read by the PA or NP, and then transmitted electronically to Bethel for reading by a radiologist. They have small labs capable of doing automated blood tests (ISTAT chemistries, CBCs). And they have a larger pharmacy than village clinics, with more medications available; health aides can only dispense this expanded formulary when the PA or NP is in the clinic. The goal is to also have a full time dentist in each Sub-Regional Clinic (SRC), though that hasn't happened yet. Each SRC does include a fully equipped dental operatory. The Physical Therapy Dept. at the hospital sends one of our four physical therapists on field trips regularly to the SRCs, which helps provide service to patients who cannot travel easily. It is generally easier and cheaper for patients to travel to the closest SRC than to come to Bethel.

When I first came to Bethel, there was only one SRC, at Aniak. The other three have been built in the last few years. There has been discussion in the past of having physicians at the SRCs and mid-levels at all the village clinics. I expect that will eventually happen, and I hope it does. At this point, staffing is such a challenge for us that it is not even a goal that is in sight. The SRCs have not been consistently fully staffed with PAs and NPs in the last two years; and the hospital has never had a full, permanent medical staff in my eight years of experience here. It is hard to find medical and nursing staff that want to come here, and even harder to find ones that want to stay longer than two years. The life here certainly doesn't suit everyone. I feel incredibly lucky to have found my way here, because it does suit me. If there are any hardy and intrepid souls out there who think it might suit you too, let me know. We are always looking for a few good folks who are ready for the adventure of their lives up here at the edge of the planet.



Blogger Dr. A said...

I have had some friends that worked up there years ago. It's beautiful country up there, but you're right, it's not for everyone.

I admire you and the people that work up there. In my opinion, that is "real medicine" up there, instead of the suburban variety that I practice.

Thanks for the tour! It's like the health travel channel.

Saturday, July 01, 2006 5:34:00 PM  
Anonymous scan man said...

Great post TPA. I have two questions, one relevant, the other silly...
I guess all the health care providers in your region work for the government. Is there a special pay package for those working there? Like hazardous duty pay or something. If there isn't, is that the reason (apart from the harsh conditions) why you don't get adequate staff?

Now for the silly one.... Is there really a village named Eek?!

Sunday, July 02, 2006 6:38:00 AM  
Blogger TheTundraPA said...

Thanks, dr. a--I like that, health travel channel. Several people now have commented that I sound like a travel writer.

By "up there" do you mean Alaska in general, or Bethel specifically? Wonder if I know 'em...

hey scan man--so nice to have you visiting again! OK, silly first: yes, there really is a village named Eek, and it is pronounced just like the stereotypical woman who just saw a mouse in her kitchen. Population is about 300. Only 2 health aides.

Your second question is a bit more involved. No, we are not government employees. Years ago, the hospital in Bethel was owned and operated by the Indian Health Service and medical staff were commissioned corp of the Public Health Service. In the late 1960s, the native people here took over ownership of the hospital and formed a health corportation that governs the hospital and all its activities through a board of directors elected from the villages. We are the employees of the people we serve. There are still quasi-governmental ties; our malpractice insurance is through federal tort claims and we operate mostly on federal funding. The native people here have treaty-guaranteed 100% free medical care (including prescriptions, which covers even OTCs like Tylenol) for their entire lives.

The staffing challenge is multi-variate. Climate is a big one; it is truly harsh. Eight months a year of ice and snow and temps as cold as 40 below is pretty tough for those who weren't born to it. Distance is a big factor; when people come here, they leave family back in the lower 48 who are just a long damn way away. Traveling to visit is quite a yank (and very expensive), even if they are as close as the west coast, and ALL travel comes with a "weather permitting" clause; even 737s can't fly in some of our nastiest stuff, and it is common to get held over in Seattle or Anchorage waiting for weather to clear so you can get home to Bethel.

And then there is the work itself. This is by far the hardest job I have ever had, and every member of the medical staff feels the same way. I practice at the very edge of my ability, and often beyond my comfort zone, every single day. The population, on the whole, is much sicker than the lower 48, from pediatrics to geriatics. When it comes to infectious disease, the Eskimo people are almost like an immune compromised population; we have 50 times the US anticipated incidence of pneumonia; death-defying bronchiolitis (wink at Kate in Borneo); and rabid cellulitis/lymphangitis from trivial skin insults. We have higher rates of stomach and colon cancer, genetic diseases like congenital adrenal hyperplasia that are purely academic in the lower 48 but common here, staggering trauma (some alcohol related, some not), and heart-breaking mental health issues--depression, teen suicide, domestic violence, sexual abuse, alcoholism--ultimately tied to the slow Western absorption of this proud culture. This depth of pathology comes in tidal volume. There are just SO MANY patients to be seen, many of them really are sick, and there are just not enough of us to get them all seen.

People come here all charged up for the experience, and often quickly burn themselves out. You really have to take the marathon view to survive. That is one reason I only work 80% time; a day off in the middle of the week really helps my attitude. The Peace Corps' line is very appropo here: it is the hardest job you'll ever love. The Eskimo people are truly wonderful; they make the experience here worth all the hard work and the harsh climate. It is a challenge that only a few are truly ready for; the difficulty is finding those few.

Sunday, July 02, 2006 12:36:00 PM  
Blogger Borneo Breezes said...

Well TundraPA, I just figured out how to get into comments and find you have a very accurate, articulate response, one that ought to be a post on its own. This is a symnopsis for a whole course in northen health. And I am chuffed to be winked at, yes indeed I am.

Thursday, July 13, 2006 10:55:00 PM  

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