Really Bad Eczema

Remember the old TV ad with the sonorous voice-over that said “Eczema…seborrhea…the heartbreak of psoriasis…” ? I don’t remember now what product the ad was selling, I just remember the phrase. Many Yupik Eskimos of southwest Alaska could be posterchildren for that ad. I have never seen such severe atopic skin disease as I have encountered here.

Recently I spoke with one of the pediatricians on the medical staff of our hospital who has a special interest in the “triple A triad”: atopy, allergy and asthma. He considers our pediatric population to be “hyperreactive”—they have more hives, more rashes, more rhinitis, more wheezing than non-Native children in the lower 48 or in Alaska.
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Eczema is an extremely common problem among the children here, and it is often severe. Occasionally I see a child in whom it is limited to wrists or elbow creases, or perhaps around the ears; more commonly it is far more wide spread, sometimes involving the entire body.

The child in these photos is Joshua, a 4-year-old boy from one of the villages. His photos are used with his mother’s permission. His hospital record contains his entire medical history from birth on. He had no skin problems at all until the age of 2, when he was noted on Well Child Exam to have small areas of eczema at the elbow creases. His mom was given hydrocortisone cream for the rash.

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Over the next year he was found to have ever-increasing areas of eczema, more dry skin, more itching misery. Mom was given diphenhydramine suspension (Benedryl) to help with his itching and moisturizers to treat his dry skin. It is unclear how regularly these have been used; often, months have gone by with no refills being obtained.

At this point, his entire body is covered in a severe case of eczema, with constant itching, flaking and peeling skin, and frequent skin infections (impetigo) from the open sores he has scratched into being. He has gone from a laughing, happy boy at age 2 to a somewhat grumpy and petulant child with a scowl much of the time. And with good reason; how miserable can it be to have skin like this? It breaks my heart to see what he lives with every day.
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He is periodically treated with oral steroids when the eczema is at its worst. He is regularly given topical steroids: mid-potency creams like triamcinolone for the body and low-potency creams like hydrocortisone for the face. And lots of moisturizers such as Aqua-Phor and Eucerin for constant treatment of his dry skin.

I always wonder about medication compliance; Joshua has five siblings, and two of them have similar, though less severe problems. His mom tries her best with all of them, but Joshua’s skin care may be somewhat sporatic.

Joshua’s case is one of the more severe, but it is by no means rare. Nearly every village has a child or two with eczema this bad, and many children with less severe conditions. They often improve significantly by age 6 or 7 and may have minimal problem with it after that.



Fortunately, Joshua has not had the co-existing problems with asthma, allergies, and ear infections that many atopic children do. The ones who get all three of the Triple A Triad have a huge ration of misery to deal with in childhood. I wonder to what degree that experience affects their outlook as adults. Are they generally more cranky and/or whiney? More pessimistic? More complaining? More dissatisfied with life? I would think that possibility would be there, but I don’t see it in my adult patients who tell me they had “bad eczema as a child.”

I am optimistic that Joshua’s personality will not be molded by his skin’s discomfort. Despite his constant itching, he plays with other children, has outbursts of joy, and is sometimes quite charming. I hope he is one of the lucky ones whose skin will clear in the next few years and allow him some peace.

Waning Autumn

The last few mornings have been seriously frosty, with windshield scraping to remove ice and truck warm-up time to get the heater blasting before taking off. Now that we have passed the autumn equinox, daylight has noticeably dwindled from just a few weeks ago; the sun rises—much farther to the south now—about 8:30 in the morning, and sets before 8 in the evening. The air has a sharp briskness that was lacking earlier in the month, and the smells of autumn are dying away. From here it will be a short, fast trip into the cold, dark tunnel of winter.

We have had a lovely September in southwest Alaska, a gift to be much appreciated. Long, warm sunny days have extended the season for boating and fishing, given a pleasant experience to those out moose hunting, and made the autumn chores to get ready for freeze-up more enjoyable. Last year, September was a month of almost endless rain; I believe it was 23 out of 30 days with measurable precipitation. And temperatures in the high 30s (F), which is about as miserable a combination as you can get; I’d rather have 5 below and snowing than 36 above and raining.

The clear skies allow our daytime temperatures to climb into the low 50s now, but more and more of the nights will dip well below freezing. The hardening of the land, and the river, is a gradual and inexorable process that will take place over the next month. By Halloween we will be down to about six hours of daylight, and the river will be frozen hard enough to walk on. From that point until mid-March, we’ll be in the Deep Freeze.

I always seem to approach this time of year with significant feelings of trepidation. How bad will it be this winter? How cold? How dark? How will I stand it? Well, I know how dark; that doesn’t really change from year to year. And we tend to have more bright and sunny winter days (for about 4 hours) than summer ones. The severity and duration of cold, however, varies a lot from one winter to the next. Every autumn I feel that tiny tingle of dread that the coming winter will set new records for cold.

At 61 degrees north latitude, and at very close to sea level, our average daily winter temperature is zero. Anchorage is about the same latitude and elevation, but their average daily winter temperature is +30. The difference is caused by terrain; Anchorage is in a bowl, surrounded by very tall mountains. Bethel is on the wide-open tundra. There is nothing for thousands of miles to break the wind roaring in off the Bering Sea or pouring down from the polar region. Interestingly, though, the thermometer rarely reads zero. We are usually either 20 above or 20 below. And can go from one to the other in a matter of hours. Henry’s wife, Betty, calls it Bethel’s express elevator weather. Fronts can move in very quickly, changing our weather from one extreme to the other; sometimes they move out just as quickly, and sometimes they hang around for weeks.

I remember the winter of 1999-2000 as being exceptionally cold, at times dipping as low as minus 40. That is seriously cold. Houses freeze up. Cars freeze up. Nothing mechanical works well at all. People just don’t go outside. And when the wind is blowing, as it often is in the winter, the chill factor easily reaches minus 70 or worse. Severely life-threatening.

The following several winters after that were much warmer. Winter before last, we never even got down to minus 20. The temperature stayed in what, for us, is a delightful range: 10 below to 10 above. Perfect dog mushing weather.

Last winter had some pretty serious cold. Much of January and most of February hovered at minus 20 with a week or so at minus 40. A week or two of weather like that isn’t bad; it lets us boast about how tough we are. Five or six weeks of it gets pretty old.

Much of one’s ability to stand severe cold depends on two things (in addition to the quality of one’s gear): attitude and hardening. With cold, as with all things in life, attitude is everything. You have to get your mind right about it; and you might as well, if you’re going to live here, because there is certainly nothing you can do to change the climate.

The hardening is a process of gradually getting used to the cold; it is both long-term and short-term. Long-term hardening occurs over years and continues for a lifetime. Winter after winter, one’s ability to endure the cold gradually increases. My Yupik friend Goosma (see A Shot to the Heart, the moose-hunting story) tells the story from his childhood in the 1940s of his dad making him and his brothers run three times around the house (outside) barefoot, every morning, year round. “Make me strong,” he says with a smile.

Short-term hardening is the process we go through every fall. After the nice warm summer we are all soft, and somewhat dreading the coming onslaught. Henry works outside without gloves on as long as he can as part of his hardening process. It does seem to help. The more I can go without gloves on, the warmer my hands stay with them on. Short-term hardening requires daily exposure, and that means more than driving to and from work in a cold truck. An hour or more a day of being outside regardless of weather is what it takes to be ready for serious winter. Chores in the dog yard easily require that much time.

A hiatus in that daily exposure through the fall is a huge set back when winter comes. In October of 2001, I took a two-week vacation in Costa Rica. When I left Bethel, the temperature was in the high 20s. For two lovely weeks, I enjoyed the tropics, despite a late-season hurricane. It was 90 degrees or more the entire time. In the twenty hours of travel it took to get home, I went from 90 above to 20 below. I couldn’t believe it when I stepped off the plane in Bethel, wearing tropical weight clothing. I thought I would literally freeze to death before I could get home.

That break in my hardening process took over a month to catch up from. By New Year’s I had toughened up, but through November and December I was constantly cold when I was out mushing. I decided then that my warm-destination winter vacations would have to come in February or early March.

So here we are, a month from freeze-up, feeling the first hints of winter’s icy breath in our faces. Staring into the mouth of that dark tunnel, wondering how long and how cold it will be this year. The meteorologists’ predictions are for a relatively mild winter, and I’d love to believe them. They are right about half the time, so I could just toss a coin.

On Music

Two bloggers have tagged me for the currently circulating music meme, The Dread Pirate Rob at Musings of a Distractible Mind and Traveling Doc at Borneo Breezes. For the dwindling few of you who don’t know what a meme is (hint: short for me-me-me-me-me), a meme is a question or set of questions to encourage (or force) self-revelation. The current music meme asks for seven songs you are listening to right now, and instructs you to pass the meme on to seven more bloggers.

This morning I read OncRN’s response to this meme, and I loved her description of her attitude about memes. I agree. I am very self-revealing, but in my own way and time. I never feel like I can answer the questions correctly or completely; in fact I tend to want to argue with the questions.

So my answer to this meme is that I can’t answer what is asked. I will get around to some self-revelation here in a minute, but some discussion has to come first.

Many bloggers who have answered this meme have responded that “the iPod doesn’t lie.” So they produce a quick list from iPod and there you have it. Well…I don’t own an iPod. Or an MP3 player. Or a personal CD player. The majority of my life is spent either at home, where I have a lovely sound system, or at work, where I have no time or brain space for music. The distance from one to the other is less than one mile and takes less than 5 minutes to “commute”. If I am anywhere else, it is likely to be on a boat or snowmachine where it is too loud to listen to music, or on a dogsled where the only music I want to hear is panting dogs and whispering sled runners. So this technology that provides music in your ears everywhere you go and up-to-the-minute access of all that’s new and hot on the cutting edge is simply not part of my life.

Dare I tell you? I don’t even own a cell phone. The service in Bethel is pretty Neanderthal; no digital is available, only analog. That means no caller ID, no different ring tones for different callers, no voice-mail messaging, no camera capability, and no use whatsoever more than five miles out of Bethel. It simply does not work if you’re up the river fishing or if you fly over to Anchorage. I do wear a beeper on work days and can always be reached by the hospital operator when anyone needs to page me. That is enough of a leash.

Back in the days when I lived in cities…Spokane, Seattle, Chapel Hill, Santa Monica…one of my favorite weekend pastimes was book store and record store browsing. I especially loved smaller, non-franchise type record stores with knowledgeable, helpful staff and listening booths where you could preview new stuff before you bought it. I’ve always had pretty widely varied and somewhat eclectic tastes in music.

Forget listening booths; Bethel doesn’t even have a record store. Or a book store. OK, there is a single stand-up, turn-around rack in the grocery store with some CDs on it—a selection that you might find at a truck stop in Montana. Not exactly the cutting edge of the music industry in any genre. And the helpful and knowledgeable guy who is ready to make suggestions for new stuff to listen to based on what he already knows you like? No, he doesn’t work there.

Well, what about radio, you ask. Radio is a reasonable way to keep up with what’s going on in the music world. But not in Bethel. We have two radio stations. Period. One is an FM religious station (no thanks). The other is an AM station that is the bag lady of radio. They broadcast a little bit of NPR (portions of Morning Edition and All Things Considered), local news (excellently done by Henry’s niece Andrea the news director), charmingly (!) local programming like the Birthday Call In show (thirty minutes of people calling in to wish someone a happy birthday, five days a week), and in-your-face political analysis/talk radio such as the weekly Talk Line (which Dutch refers to as the Dumb and Dumber Show). Every other Tuesday night, they broadcast gavel-to-gavel coverage of the full four to six hours long city council meeting for an evening of edge-of-your-chair excitement. Sprinkled in amongst these gems is some music programming, often chosen and hosted by local people who do not have careers in broadcasting or journalism or music, but just want to do an occasional radio DJ gig. You can actually do that in Bethel. Some of them are even pretty good. But as a source of information about the latest and greatest in popular music, our local radio station isn’t quite it.

OK, yes, there is the internet. Somehow I have not managed to get the whole streaming thing down yet. Maybe I haven’t tried hard enough. One thing that I have noticed in general is that aging has a tempering effect on that fire in the belly to always be on top of what’s newest and hottest in those areas of life that are strictly part of the Comfort Zone. Things like food, music, clothes, movies and probably lots more; familiar is comfortable to many of us fifty-somethings, and the search for new-and-hot is less urgent than it was twenty or thirty years ago.

Music has the ability to evoke memory almost as intensely as smell does. I can listen to classic rock of the late sixties (Chicago; Blood, Sweat and Tears; Earth, Wind and Fire) and be right back in high school. Let me hear early Beatles songs and I’m twelve years old again (yes, nephew, that was Paul McCartney’s group before Wings). And the Big Band sound of the forties brings back images of my parents jitterbugging in the living room when I was five. I love them all.

I studied piano from adolescence through college and love classical music. I played guitar in high school, and love folk music. I dated a fiddle player in graduate school and learned to love bluegrass and string band music. Jazz, blues, Motown, yeah…love ‘em. I majored in theatre in college, so—Broadway musicals! Right there! I can sing the lyrics to dozens (though with my voice, you don’t really want me to).

The one area of music I’ve never really liked is the loud and screeching category. Cacophony. Whether it is heavy metal or Bartok. I’ve never been fond of rap, though the ER Nurse Rap from the UAB Medical Center (thanks, Grunt Doc!) is truly great.

So, back to the music meme (finally!). All of the above is by way of explaining to you how it is that I am a retro-grouch in a technologically challenged environment. I don’t listen to single songs; at best I listen to entire CDs, which I still call albums, though I no longer have a record player.

Some of my favorite artists to listen to, in no particular order:
Tina Turner
James Taylor
Norah Jones
Josh Groban
Tingstad and Rumbel
The Pointer Sisters
Manhattan Transfer
k.d. lang
Tracy Chapman
Phoebe Snow
Elton John
Indigo Girls
Simon and Garfunkel
Cleo Laine
Mary Chapin Carpenter
Leo Kottke

And classical: just about anything by Chopin, Mozart, Handel, Tchaikovsky, Beethoven, Debussy, Rachmaninoff, Lizst. Any piano played by Van Cliburn or Rubenstein. Any violin played by Perlman. Any cello played by Yo-Yo Ma. Any flute played by Jean-Pierre Rampal.

So have I answered the meme? Essentially, no. Have I been compliant with the spirit of the meme and been self-revealing on the subject in question? Definitely, yes. And as for the seven others to pass it on too…Ob-Gyn Kenobi, Health Psych, Navel-gazing Midwife, TBTAM, Intueri, Wandering Visitor, and Tales from the Emergency Room.

On Hosting Grand Rounds

This has been an exciting week in the blogosphere for me, far more so than I anticipated. Hosting Grand Rounds was a very positive experience, one that I enjoyed immensely. I strongly encourage you wavering medbloggers out there to step up to the plate and do it!

Before I hosted, I read with interest the post-Rounds posts created by some hosts (is that iambic tetrameter?) with their recommendations for future hosts. I wish to offer the same for those who may be curious.

My two most important recommendations are to give yourself adequate time, and be organized. Try to be realistic about yourself on those two items.

The adequate time question will be different for each host, and probably for each week. If it is at all possible for you, arrange not to be working on Saturday, Sunday, and Monday before your GR date. Put up your call for submissions post seven to ten days in advance, state your submission deadline, and request early submissions.

Put some serious thought and energy into the pre-Rounds interview questions Dr. Nick Genes will send you. He does his homework by reading your entire blog before the interview and asking well-considered and open-ended questions; do your part by giving him substantive answers. Once he posts your interview on Medscape, put a post on your blog announcing and linking it, and again encourage early submissions for your GR edition. As you will see, many bloggers will comply; as a future submitter to other hosts, I will make more of an effort now to do the same.

For GR 2:52, I received 47 submissions. They came in as follows: Tuesday 1; Wednesday 4; Thursday 6; Friday 7; Saturday 12; Sunday 11; Monday 6. So most (41 of 47) came in before the last day. I put the deadline for submissions as Monday at noon Eastern time (8 am Alaska time), which gave me 16 hours to work with. I planned to put the Grand Rounds post up at one minute after midnight Monday night, Alaska time. If I had had to work on Monday, I'd have never made it.

One thing that was interesting to me was the variety in submission emails. As requested, all had "Grand Rounds" in the title, which helped in my first step. When I submit, I generally just say "here's my submission: url-of-the-post". Many people do just that, but some were more elaborate. They included blog name, blog URL, post URL, and post summary. I found these to be really helpful, and it will guide my behavior as a future submitter.

So, how to be organized? This is what worked for me. I created a folder in my email just for GR. As each submission arrived, it went into the folder unread, so the title (containing GR) remained in bold. As the folder grew in size, it was easy to see where I was in the post-reading process. When I opened the email, I clicked on the link, went to the submitter's blog, read the submitted post (and sometimes a few others), decided which category it should be in, and gave it a rating on a 1 to 5 scale, with 1 being awful and 5 being fabulous. Most ended up being 3s or 4s.

I decided ahead of time on seven categories I would use to sort the posts. This came about originally because I intended to organize the whole GR edition like an issue of The New England Journal of Medicine. I was going to call it The Blogosphere Journal of Medicine. So I used the categories that NEJM uses, slightly adapted for the blogosphere, in essentially the same order they use. I subsequently decided that would be waaaay too boring, and decided to treat you to Postcards From The Edge of The Planet instead; but the categories worked pretty well, so I kept them.

Once I started reading posts (pretty much as they came in; don't get behind) I kept a notebook next to the computer (yeah, real paper and a real pen--I'm an old fart) and made an ongoing list that contained six items: blog name, blogger name, URL of submitted post, quality rating (1 to 5), category, and one-sentence phrase describing the essence of the post.

This list is what made the job the easiest. By Monday morning it was five pages long, with three lines for each submission. I should have organized the list by category to start with, giving each category its own page and listing the posts after I read them under their appropriate catagories. I didn't think of this until I was looking at five pages of posts listed in the order of their receipt. Those of you with more computer skills than I have will not have a problem with this, as you will do it all on computer and let the editor do the sorting for you; I found it too cumbersome to switch back and forth between a Word document and my email, so went to the paper system. Out came the scissors and tape. I cut the pages into 3-line strips, one for each post; sorted them by category; ordered the posts in each category by rating and/or my own preference; and taped them down to new pages.

Once that was done, it was a simple matter to go through the new ordered list and write the Grand Rounds post. As many of you know from my earlier writing, loading photos on Blogger has been a thorn in my side from the very beginning, and the GR post was no exception. It took me nearly five hours to find, scan, load and arrange the dozen photos I used. For some reason, Blogger would not load any photos on the left, and some it simply would not load at all. They were all less than 200 KB, so it was not a size issue. I wanted to close with a beautiful shot of the Northern Lights, but Blogger said NO.

The amount of time I gave myself worked out perfectly. I spent the entire day on Monday working on it, and finished the edition with one hour to spare. The post went up at 12:01 Alaska time on Tuesday morning. It took an hour to then go through the post on my blog and click on every link to be sure it worked. I highly recommend this. Four of them did not work, mostly due to single-character errors in the URL. As a Grand Rounds reader, I hate dead links, so wanted to be sure I didn't have any. With all corrections done, I went to bed at 1:30 am, too wired to sleep for at least an hour.

By 7:00 I was up again, interested to see what readers would think of the post, what comments I would get, and what my sitemeter would do. I expected the sitemeter to show a good-sized bump, but I had NO IDEA what was going to happen that day. It practically exploded.

The comments were wonderful, very positive and encouraging, and thanking me for hosting. But one thing I did not anticipate was comment carry-over. Dr. Genes needs to have the URL of your GR post to include in the pre-Rounds interview, so he recommends putting up the GR post to establish the URL and then taking it down, saving it as a draft, changing the date to reflect your edition's actual date and reposting it on Tuesday morning. I figured out how to do this, but decided I would let the early GR address be my call-for-submissions, which I would leave up till the deadline, then take down and replace the content with the actual GR edition. It worked fine, except that I had comments on the call-for-submission which carried over to the GR edition, which I didn't want. But I didn't want to delete them, either. Do it Nick's way. He's really smart about this stuff.

Now about the sitemeter. Holy cow. For the last month or so, I have been averaging 70 to 90 readers per day. After less than five months blogging, I felt pretty good about that, since the first month was less than 30 per day. Of course I had blogenvy of Fat Doctor's 300 per day, and Life in Alaska's 7,000 per month. But still. Seventy to 90 is a good steady core (thanks, TMD regular readers!); on good days it was over a hundred, and my all-time high was 210 on a GR day back in May when I had submitted a popular post.

At 7:15 am the sitemeter registered 117 readers. I kept checking every hour or two throughout the day, and my eyes got bigger and bigger as the sitemeter just kept going up. By midnight Tuesday night, it registered 676 readers. Let me say that again: six hundred and seventy-six! I was totally floored.

The surge not only continued on Wednesday morning; up until 4 pm, each sitemeter check showed even more readers than the same time Tuesday. It dropped off after 4 pm, and by midnight the total was 557. Thursday continued the decline and ended up with 346 (about the ballpark I expected for Tuesday).

I attribute the huge surge to two things: more people read Grand Rounds in the fall than in the summer (this is Borneo Breeze's idea, and I agree); and more bloggers this week put up a "Grand Rounds is up" post than usually do. I am aware of 26 blogs with such a post, and I may have missed some. Thanks to all of you who linked!


I have had the luxury of hosting Grand Rounds in the midst of nine days off work, which I am sure was significant in decreasing the stress factor and increasing the fun factor. It was simply fortunate for me that Nick was able to let me have the date I wanted, since I had to request time off months ago. I have a lot of vacation time and have scheduled a week off every two or three months, primarily to have time for writing. My favorite vacation is to just stay home and write; I live in one of the most beautiful places in the world--why should I go anywhere?

Let me close by encouraging those of you who may be thinking of hosting Grand Rounds to go for it. It was a wonderful and exciting experience, and I am really glad I did it.

Blogger is SO tempermental!

Grand Rounds, Vol. 2 No. 52

Welcome to Grand Rounds, the medical blogosphere’s weekly carnival of the best writing and thinking on topics related to health and healthcare. This week’s edition comes to you from the beautiful state of Alaska.

Those who have visited this site before are aware that Tundra Medicine Dreams is about my life and medical practice on the tundra in the southwest portion of the state. For those who are new visitors, I hope you will return to read more about this unique and fascinating place. I love sharing the subtle beauty of this area with people, and have posted many photos on the blog; for this Grand Rounds post I will offer you images of the more dramatic beauty of Alaska found in the central and eastern regions of the state. If you have never visited the 49th state, you should. At least once in your life. Alaska is an American treasure that no one should miss.

Many thanks to Dr. Nick Genes of Blogborygmi for organizing and coordinating Grand Rounds, and for producing such consistently excellent pre-Rounds interviews with each weekly host. You can view mine here (free registration required).

So, without further ado,

GRAND ROUNDS

Volume 2, Number 52

Editor’s Picks

Of the 47 submissions to this week’s edition, these five were my favorites.

At DR. HEBERT’S MEDICAL GUMBO, we learn about an overweight patient who wants to lose weight. At THE RUMORS WERE TRUE, M. Dyspnea wishes for more effective techniques to teach teenagers about the effects of alcohol on the brain. From my very own hospital here in Bethel, visiting resident Rob at ALASKA BOY…RIDES AGAIN describes a medevac story from one of our villages. Kim over at EMERGIBLOG gives us her dream design for a new ER. And the ever-endearing GRUNT DOC describes a chief complaint of “?” when the patient is both schizophrenic and deaf.


Perspectives

Blogger William Rubin at BILLY RUBIN tells us that medicine is a life of endless learning (so true!). Tony Chen at HOSPITAL IMPACT describes the privilege of being a health care worker. At ANXIETY, ADDICTION AND DEPRESSION TREATMENTS, Dr. Mada questions where the line is that separates healthy training in athletes from disordered eating. Louise at COLORADO HEALTH INSURANCE INSIDER wonders whether we are using too much ultrasound in pregnancy?

Henry Stern at INSUREBLOG asks “can marijuana be classified as a medicine?” MY LIFE, MY PACE suggests that too often medical students are whiners. Hsien-Hsien Lei at A HEARTY LIFE gives a report of a British television show called Cardiac Arrest. The eponymous blogger of VITUM MEDICINUS tells us his ten favorite things about the first term of medical school.


Patient Perspectives

At A CHRONIC DOSE, Laurie describes making choices about which symptoms we attend to. Susan Palwick at RICKETY CONTRIVANCES OF DOING GOOD discusses sleep apnea and the importance of CPAP. Elisa Camahort of HEALTHY CONCERNS is bummed about the Cheerful Oncologist’s recommendations on how to get your doctor to listen to you. K. Weaver of LIVING WITH DIABETES offers a patient story. And Mona at THE TANGLED NEURON discusses depression and Alzheimer’s.

Clinical Practice

Rob Lamberts at MUSINGS OF A DISTRACTIBLE MIND warns about bringing work stress home. At SUNLIGHT FOLLOWS ME, blogger TSCD tells an amusing story of a patient with abdominal pain in a bathing suit. South African blogger Karen Little of MILF’S ANATOMY has a difficult day.

New blogger Scalpel of SCALPEL OR SWORD? has a painful dental experience when the doctor becomes the patient. At SCANMAN’S NOTES, Dr. Vijay Sadasivam brings us the oldest published description of holoprosencephaly. The #1 Dinosaur at MUSINGS OF A DINOSAUR tells us how s/he (making no assumptions here) puts a new patient at ease.

At UROSTREAM, Kea Girl reveals herself as the surgeon who truly hates the poke of a needle. Alice at HOME SCHOOLED MED STUDENT gives us a description of two surgical patients. Wilderness medicine specialist Dr. Paul Auerbach of HEALTHLINE describes the diagnostic dilemma of a possible spider bite. At UNBOUNDED MEDICINE, Jon Mikel, M.D. uses a Wood’s lamp to diagnose vitiligo. And Dex at A BUDDING EMERGENCIST tells a story of the importance of details.

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Original Articles

From BORNEO BREEZES, Traveling Doc gives a description of public health efforts in Pakistan. Tara Smith of AETIOLOGY discusses the recent E. coli outbreak from packaged spinach. At INSIDE SURGERY, Dr. Lisa Marcucci educates us about nesiritide, a brain naturietic peptide.

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Review Articles

Always Learning, the blogger of WANDERING VISITOR, reviews a recent study on the association between diet and Alzheimer’s—one more reason I’m glad we have no McDonald’s in Bethel! Amy Tenderich of DIABETES MINE comments on a study to fight obesity by having no chairs in elementary school classrooms. At THE EXAMINING ROOM OF DR. CHARLES, Aiden Charles discusses a study finding that Asian women have the longest life expectancy of any Americans.

From the Philippines, Dr. Emer of PARALLEL UNIVERSES bemoans the improper use of statistics by the Department of Health. At HEALTHLINE, Dr. Enoch Choi reviews recent FDA information about the proper way to take your daily aspirin. Orac of RESPECTFUL INSOLENCE is happy about a recent study which finds that the age of your surgeon doesn’t matter until the surgeon is really old.

At INTERESTED-PARTICIPANT, blogger mj pechar discusses a statement from the British Medical Journal that the “morning after” pill has not reduced the abortion rate. At STRAIGHT FROM THE DOC, Gloria Gamat reviews a study suggesting that green tea and its extracts may slow the progression of Huntingtons disease. She reviews another study at CANCER COMMENTARY regarding a combination drug which inhibits the growth of aggressive tumors in prostate cancer. Dr. Joel Fuhrmann of DISEASE PROOF gives a review of the questionable benefits of alcohol consumption.

ALERT! Late addition--somehow one fell between the cracks! Sincere apologies to CLINICAL CASES AND IMAGES BLOG who reviews the new once-a-year drug to treat osteoporosis.

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Health Biz

Dr. David E. Williams of HEALTH BUSINESS BLOG comments on the real reasons behind a company’s opposition to electronic medical records. And Bob Coffield of HEALTH CARE LAW BLOG reviews an article on non-profit hospitals.

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Summary

So there you have it. I hope you enjoy this week’s compilation of the best of the medical blogosphere.

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Next week’s Second Anniversary edition of Grand Rounds will be hosted by Dr. Enoch Choi at HEALTHLINE. You may email your submissions to him at enochchoimd-thoughts at yahoo dot com.

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And if you haven’t yet participated in the Healthcare Blogging Survey sponsored by Envision Solutions and The Medical Blog Network, please do! Click here. The survey ends on September 29th.

Photo credits:

1. Mt. McKinley, known to Alaskans simply as "Denali"; North America's tallest peak. From a post card, photographer unknown.

2. Bethel from the river at sunset, by The Tundra PA.

3. Float plane on Naknek Lake, from Beautiful America's Alaska by George Wuerthner. www.wuerthnerphotography.com

4. Arrigetch Peaks, Brooks Range, ibid, by George Wuerthner.

5. Grizzly bear, ibid, by George Wuerthner.

6. Musher and sled dog team competing in the Yukon Quest, from Mushing Alaska 2003 Calendar, photo by Jeff Schultz.

7. Bald eagle. From a postcard, photographer unknown.

8. King salmon. From www.lamedialodge.com, photographer unknown.

9. Caribou bull, from America's Beautiful Alaska by George Wuerthner.

10. Alaska mountains, by Dutch (Mr. Tundra PA).

11. Polar bear kiss, by Thomas D. Mangelsen, www.mangelsen.com.

Momentary Pause

I am hard at work putting together the upcoming edition of Grand Rounds, and I would like to extend a hearty THANK YOU to all the bloggers who have submitted early. All 30 of you, and you know who you are. For anyone who has not yet submitted, please do! The deadline is not until noon (EDT) on Monday; any number of hours prior to that deadline is greatly appreciated.

I don't really have the time or brain cells to spare to put up a new post of substance before Tuesday, but I hated leaving the blog idle until then (blogaholic? me??) ... So for your meditational enjoyment, this was the view from the front deck about 10:30 pm on August 30th.

Stay tuned...

A Fat Whitefish

Wednesdays are my day off, and Henry often comes over for coffee for an hour or so before he starts work. Being self-employed, he starts when he wants to. This week he showed up with a beautiful fat whitefish for me, fresh from last night’s catch. He has a set net in the river on a slough not far from Bethel. Set nets are much like drift nets, except that they are anchored in the river and must be checked (hauled in and picked clean of fish) every one to two days. Set nets are usually placed in shallower water out of the main current of the river.

Henry’s set net has been catching lots of whitefish for the last few days, and he says they are almost all big fish. The one he brought me was certainly a beauty.

Whitefish are absolutely delicious; if possible, I like them even better than salmon. The meat is not as firm as salmon, and the flavor is more delicate. Perhaps similar to trout, but more robust. They can be baked, poached, or grilled, but my favorite is to fry them. Fried foods are not generally part of my diet, so it is a real splurge to have fried fish.

My friend Joan and her two teenage sons Michael and Luke often come over for dinner on Wednesday nights, so it seemed like just the excuse I needed for a fish fry. I filleted and skinned the big whitefish and used a pair of needle-nosed pliers to pull out the line of bones down the center. Then I cut the meat into large chunks. These were dipped in an egg wash, and then rolled in Japanese breadcrumbs (Panko is the brand I can get here). Then fried in a half inch of hot vegetable oil in my big cast iron skillet. Yummmmm! In for a penny, in for a pound; I even made homemade French fries to go with the fish, much to the delight of the two boys. Fresh cole slaw added a small note of health to this gallbladder-challenging dinner, but was probably smothered by the ice cream we had for dessert. I could feel my arteries clogging, but it was soooo good.

Sorry, no photos of the final product, which was quite pretty; the boys were so hungry they just couldn’t wait for a photo-op. Maybe next time.

Boils 101, A Workshop for Health Aides

Community Health Aides are the backbone of the health care delivery system in rural Alaska. They are Alaska Natives who live in the villages and have, at most, a high school education. The majority are women between the ages of 18 and 40; most are the sole monetary breadwinners for their families (husbands are doing the hunting and fishing of subsistence lifestyle), and many have five or more children of their own at home. Employment as a health aide provides them with an income that gives them significant social status in their villages where generally few jobs are available; but that position brings with it huge responsibility for the health and well-being of their families, friends and neighbors. It is a difficult job to do, and a highly stressful one.

The majority of training for Community Health Aides occurs at the hospital in Bethel. Each of the five levels of certification for health aides requires a two- to three-week training session in Bethel. Each training session will be attended by eight to twelve health aides, all at the same level, who wish to advance to the next level. About half of their time in each session will be in the classroom, and the other half will be spent working one-on-one with a Basic Training Instructor, a PA or an NP, seeing patients in the hospital. Invariably, the health aides prefer the hospital portion of their training. They learn by watching and doing far more proficiently than by lectures and reading. This is universally true in cultures that are based on an oral tradition, as Yupik Eskimo culture is.

One of the highlights of the year for the Community Health Aide Program (CHAP) is the annual health aide training conference held each August in the Yukon River village of St. Mary’s, Alaska. Health aides generally love to attend. The week-long conference is able to host fifty to sixty attendees, so about one third of the 158 health aides in our region are allowed (and have transportation paid) to make the trip, and any one health aide is able to attend about every three years.

The health aide conference is held at the old Catholic boarding school in St. Mary’s, which is no longer in operation as a school. No other village has a facility capable of hosting such a large group for a week; in a village of 500 people, 70 visitors (attendees plus staff) is a huge influx. The school’s dormitory provides reasonably comfortable housing, and the cafeteria is adequate to feed such a large group.

Various members of the hospital’s medical staff fly up to St. Mary’s for a day or two and teach hour-long sessions on different subjects for the health aides. It is a great opportunity to meet the people we spend so much time on the phone doing radio medical traffic with. For the health aides, it is an exciting opportunity to get away from their village and home life responsibilities, and meet and socialize with other health aides. Going to St. Mary’s allows them to develop collegial relationships, which enhances their own sense of professionalism.

One of the CHAP priorities in teaching health aides is to help them acquire skills that will allow them to treat patients in their home villages, rather than having to send the patients in to Bethel. A few years ago, after draining innumerable boils on village patients who had to come in because the health aides had not been trained to do Incision and Drainage (I&D) in the village, I went to the CHAP director and asked if I could teach a session on boils at the next conference in St. Mary’s. She was delighted.

When I gave some thought to how to organize a workshop on Boils 101, I knew the most important thing would be to provide a hands-on type of experience. The health aides needed to practice holding a scapel, doing blunt dissection with a hemostat, packing gauze into a hole. I developed a model which worked beautifully.

The star of the show was—you guessed it—pig’s feet! I bought four dozen fresh pig’s feet from the grocery store, along with two quarts of lemon yogurt. It took a little experimenting, but the technique that ultimately worked the best was to use an 18 gauge needle on a 20 cc syringe, insert it subcutaneously and advance it at least an inch; inject air to raise the largest bubble possible, then switch syringes (without removing the needle) to one filled with lemon yogurt and inject the yogurt into the air bubble. A little red food coloring on top of the “dome” and--VOILA--a reasonably decent boil! And one of the best parts, for the health aides, was that all materials were food-grade; many took their pig’s feet home and cooked them up for dinner.

The health aides loved it. My workshop was the hit of the conference that year, and everyone wanted to try it. I brought bottles of lidocaine with syringes and 27 gauge needles for numbing up, I&D kits, culture tubes, bottles of plain ¼” gauze, and sterile gloves. They were able to practice the entire procedure, from doing a V-shaped anesthetic block to packing the wound. I had them use the hemostats as if they were doing blunt dissection of loculations within the abscess, and described for them the feel of that, but the model did not reproduce that aspect for them.

Another visual aid that helped a lot was a video. One of the ER physicians allowed me to videotape her doing an I&D on a really choice BOB (boil on butt)—with the patient’s permission, of course. It required moderately aggressive destruction of loculations and yielded about 60 cc of thick yellow pus. The health aides were squirming in their chairs while watching it, but they got the idea about getting the pus out. They really understand that that is the key, not antibiotics.

We have a LOT of boils here, and the great majority of them are methicillin-resistant Staph. aureus—the dreaded MRSA. Almost all are sensitive to trimethoprim-sulfamethoxazole (Septra, Bactrim). We only use antibiotics if the erythema (redness) is greater than 10 cm in any one direction--i.e., a cellulitis in addition to an abscess. For patients who are allergic to Septra, we use clindamycin or levofloxacin.

Teaching health aides to I&D abscesses is now a routine part of their training. For abscesses on the face, in the ear canal, or directly over a bony joint such as a knee or shoulder, the health aides still send the patient to Bethel. Or if the patient is younger than 4 years old. But many patients are now spared the expense and inconvenience of having to travel to Bethel to have a boil drained. It is one small thing that has made life easier for rural Alaskans, and I am pleased to have been a part.

A Shot to the Heart, Part 4

We started back to Bethel two days later, hoping to make it home in two days of travel, and hoping the weather would continue to hold for us. On the morning of our departure, Goosma showed up in a small skiff to commend us on our efforts and bid us farewell. He came into the cabin to get warm and drink some coffee and stayed for a long chat. He had come by the evening before while we were up the Swift, and finding the camp empty, helped himself to an inspection of our hunting endeavors. We were proclaimed to have passed with flying colors. He said we had done an excellent job of butchering, transporting, cleaning, trimming, drying, wrapping, and hanging. He called Henry in Bethel to let him know of our success and what a good job we’d done to keep sand off the meat. We were honored to receive Goosma’s praise; it is not lightly given.

We departed about noon with high spirits and high hopes for an easy trip home. The sky remained clear, but wind was really a problem on the river, and we were taking it in the face which made for a rough ride. After about six hours of traveling we were ready to get off the river and out of the wind, so we stopped a few miles above Napaimute, which is not far from Aniak, the half-way point.

We were on a very straight section of the Kuskokwim which runs due east-west for a couple of miles. In the center of this stretch we pulled to the south bank and made camp in a stand of birch that was quite a little hike up the long steep bank, but which had an excellent view. We were about 20 feet higher elevation than the river, and across it we could see three successive rows of progressively higher mountain ranges, and then an incredible sky.


The Coleman stove and a pot of beans had been among the first things off the boat, and by the time we finished hauling in and setting up camp, dinner was hot and ready. A deep red sunset exploded to our far left, directly down the river; the water seemed to flow like blood from the setting sun. The transition to night was quick, reminding us that winter could start to happen any time now.

As the darkness grew complete, the row of mountains in front of us became a proscenium to the most incredible night sky. The Big Dipper rose, crashing bright right up the center of the stage, backed by stardust to infinity. The whole night sky seemed to hold its breath waiting for the moon to rise when, with a whisper and a crackle, there were suddenly Northern Lights dancing all across the sky in front of us! Wavy sheets of crackling blue-green energy, flowing, moving and shifting as if blown by the breath of the Great Spirit. It was totally mesmerizing to sit and watch, with the river flowing by at our feet, reflecting it all. Tracy and I sat together for over an hour, watching the display in silence, each lost in her own thoughts and happy to be sharing such an incredible experience.

The amazing wave of good fortune that had smiled on us throughout the trip continued to give us blessings all the way home. The weather stayed clear and, though colder than on the trip upriver, still very pleasant to travel in. The river was shallower and we found a few sandbars, but we never got stuck. The gas was expensive ($5.00 per gallon in Sleetmute), but at least it was there when we needed it. Editor’s note: this was in 2003; in 2006, gas was $7.00 per gallon in Sleetmute. The current, and our increased skill in reading the river, carried us home faster than we had left it, and we made the trip in two days.

It was just about dark, 9 pm, when we rounded the last bend and entered the small boat harbor, and I was reminded of Michael Faubion’s song from his album about life in Bethel, Paris on the Kuskokwim:

“…when you’re coming in from Kwethluk,
around the river bend,
the Bethel lights are a beautiful sight,
Paris on the Kuskokwim…”

After two weeks in the wilderness, Bethel’s lights did seem like Paris. By the time we pulled up on the beach and got out of the boat, I understood the feeling of men who jump off a ship to kiss the ground of their homeland. I took a deep breath and let it out slowly. Three women went far up the river and made it home safely, moose and all.

A Shot to the Heart, Part 3

The next day about six pm, Brian showed up at camp with his 10- and 12-year-old sons to take Lynn and Tracy up the Swift River to hunt moose. He was sure they were going to find one.

Watching them pile into Brian’s boat, I had some trepidation; it didn’t look seaworthy enough to get them across the river, much less up the Swift and back with a moose packed in as well.

Brian’s boat is a wonder to behold. It is an old hand-made wooden boat about 16 feet long and four feet wide, built of cedar planks and 2 x 4s. The bottom is plywood. There is no toprail for the gunnels, just a 1 x 3 grab rail level with the boat’s sides. Brian danced nimbly about the boat on these edges, hardly even making it rock. The two bench seats fore and aft of the stand-up driving station are removable 2 x 6” planks. The driving station is an open framework of 2 x 2s with a plywood front, which serves as a backrest for the front seat. The wood is old and leaky and the boat requires constant bailing. It is powered by a 40 HP Johnson 2-stroke with a jet foot; it only draws a few inches of water. It also has no reverse.

One of the boys pushed them back into the Kuskokwim and off they went. They cruised into the Swift River and made their way past bend after bend in the river with Brian sweeping confidently around each turn. Suddenly he pulled the boat to the bank and cut the motor.

“There it is—moose! Right there! Can you shoot it from here?” he whispered tersely.

Lynn was up in a blink, rifle to her shoulder sighting through the scope. About 85 yards away, a magnificent bull moose stood at the edge of a dry wash, munching on willows. He was turned directly towards them, displaying a full frontal view of his eight-tined rack, his head and his chest. As she sighted in on him, he stood, immobile, offering.

“Thank you” she whispered as she squeezed off a first shot and then a second.
From that distance she couldn’t tell where she had hit him, but in a moment she would know; the first shot had done it—a shot to the heart.

He turned and took a few slow steps. Brian moved the boat around a point and he and Lynn were out and racing through the trees toward the moose in a flash. They watched as the huge animal dropped, all movement stilled. The two hunters stood over the moose in silence, offering thanks.
Lynn had some time alone with him afterward as Brian went back to move the boat up, get the knives, and bring Tracy and the boys to help. Now the work would begin.


After three long hours of hard labor, the moose was butchered using only two Bowie knives and a Leatherman, and the meat was packed in the boat with the head riding on top. Daylight had disappeared completely. Now all they had to do was take a very heavily laden leaky old boat down the Swift River in the dark and get it back to camp to unload 600 pounds of moose meat. Hey, no problem. After a few ballast changes to achieve optimum balance they were off down the Swift, with Brian skillfully plowing through the curves and barely shipping any water.

As light disappears from the land at the end of the day, the river draws light from the sky into itself until the water seems to glow in the dark as if it lit from the earth’s inner fires; Brian used that light to read the river as easily as a well-known poem.

They pulled up at our camp about 10:30 p.m. and quickly unloaded the moose onto a tarp on the beach and covered him. The boys bailed for a minute or two while Brian gulped some warm coffee and then they were off into the darkness, bound for Stony River. The boys had school the next day.

We retired to the fireside for warm drinks and rest and silence after they left. Lynn was so tired she could barely stand up, but was still so wired from the experience that she could hardly sit still. She paced for a bit and then came to sit beside the fire with me.

“It was so incredible,” she said several times. “So absolutely incredible.”
Tracy was very quiet. She simply nodded at this. Taking the animal’s offering had been a profound experience for both of them.


The next day was the Ides of September, the 15th of the month. It could have been 20 degrees and snowing or 35 degrees and raining; instead it was 50 degrees and sunny, with a fresh breeze, and we counted our blessings one more time. Brian said that moose hunting season around here is generally one long month of endless cold rain, no fun to be out camping and tromping through the woods in. But we had not only a full moon to camp under, we also had the most perfect Indian Summer weather imaginable. Nearly cloudless blue skies and bright sun for 12 to 14 hours each day, warm air cooled by a light steady breeze; dreams of camping don’t get any better than that. It was perfect weather for hanging the moose to dry for a few days; he would be significantly lighter by the time we packed him in the boat to go home.



After a big breakfast of pancakes, bacon and eggs, we started the next stage of moose preservation. It took the whole afternoon to transport the pieces off the beach and up to the drying shed, hang them, wash them with river water and then spray them with a citric acid solution, and finally wrap them in game bags. Lynn’s dog Jack did his part in harness, helping pull the meat-loaded sled from beach to drying rack, about 50 yards. Not a great distance, but 600 pounds is a lot of moose. The Little Dog, Pepper, ran back and forth between beach and shed, offering encouraging barks, very excited by the sight and smell of so much meat. We all three worked hard that afternoon, getting the mountain of moose meat hung, washed and wrapped. I kept the fire going all day so there was hot water for washing and fresh coffee always ready.

Our food supplies included fresh potatoes, carrots, and onions; so with chunks of fresh moose meat and a gallon of filtered water from the rain barrel, I cooked us up a great stew for dinner. By 8:30 we were all three tired to the bone and headed straight for bed. We did get short and much-needed showers first with heated river water funneled into the solar shower bags.

Fresh meat needs to hang for several days, so we had some time for R&R before starting the long trip home. The hunting was done, the moose was hanging, it was two days until we left and we had the following day to pack. That left us one entire day for going fishing, taking walks, picking berries, reading, sleeping, whatever we wanted. It had been very windy for several days, probably portending a big change in weather, but so far the sky remained blue and the sun bright. We were hoping like mad for just a few more days before it crashed. In his thirty years of moose hunting on the Kuskokwim River, our friend Henry has many stories of straggling home through rain, snow, sleet and hail. Eventually, we probably would have similar stories, but this first time on our own, it would be nice for this trip not to be one of them.


In the afternoon, Lynn and Tracy took the Zodiac across the river for some rod-and-reel fishing while I stayed in camp to read and do some writing. They had been gone about two hours when I heard the buzz of a small boat coming up the river. It was Brian, and the Zodiac pulled in right behind him. He wanted to go back up the Swift and look for another moose, this time for himself. He easily admitted that he is not a very good shot and hoped Lynn would be his shooter. Alaska game statutes allow for a proxy shooter, so she would not be in violation of any game laws if she shot a second moose as long as it went to someone else. If we got one, he said, we would simply gut it and leave it there; he would come back the next morning with a couple of his friends to butcher and pack it out. The meat would be more tender and succulent for being allowed to age without the trauma of movement for 12 hours or so. And the wolves were pretty far back this year, so he was not worried about predation overnight.

This was my first experience with Brian’s boat, and on close inspection one must seriously question whether it was safe to get into. With its low sides and constantly seeping water, it looked like it could swamp awfully easily. The wooden planks were worn and I couldn’t help thinking “my God, if we hit a rock we’re going to go to pieces!”

Oh well. We all hopped in, of course, and were away like a shot. Brian drove his boat like the sports car it was, a craft perfectly adapted to the job it must perform. We were into the mouth of the Swift in no time, skirting obstacles easily, flying around curves on the shallow inside corner, shooting over rapids that seemed impossible. He knows the river like the shape of his own hands, and negotiated the narrow channel with skill and style and complete ease, and did it wearing a boyish grin most of the time because he was really having fun.



We stopped at the spot where our moose died and took some pictures. Brian found Tracy’s camera on the ground under some leaves where it had been left behind in the gathering darkness when they butchered the moose. Two days in the elements didn’t seem to have damaged it.







A little further up the Swift, Brian pulled in at his dad’s second camp, a simple cabin and a steam bath made of logs high up on a knoll with a breathtaking view of the Swift and Sunitna Rivers, and the Alaska Range in the distance. The Swift has its origin in those mountains. It is such a gorgeous spot that I wanted to just stand and drink in this view for a long time. Blogger refuses to load this photo.

We were quickly off again upriver. The water was so clear you could see rocks and sticks three feet down. It was bracingly cold.


We turned into the Sunitna and the current slackened perceptibly. It is pure, clear, cold water also, narrower than the Swift, with more trees right at the bank. There is a house-sized boulder on the left side with a lovely camping spot beside it. This is where Goosma figured we would pitch the wall tent if we made it this far up in my boat. We jumped out for a little rod-and-reel fishing, but nothing was biting, so we were off again.

Quite a bit further up, Brian showed us Goosma’s land. After what we traveled through to get here, we were amazed that Goosma thought we could get my big boat and motor up here.

“He sure has a lot of confidence in us,” Lynn commented.

A little further up, Brian told us, is a great fishing hole; so of course we had to try it. Cruising on step, he turned into a tiny slough without even slowing down. We rounded a curve and two trumpeter swans rose from the water and slowly flew off. They were huge and beautiful. I couldn’t get my camera out quickly enough to capture them.

The pool they had been swimming in was quiet and deep. Clearly visible at three to four feet deep we could see a dozen ruby-red salmon swimming in circles. They were silvers (coho) who had finally reached their spawning stream. Salmon live most of their lives in the ocean and return to the fresh water streams of their birth to spawn and die. It is a biological imperative to which they give maximum effort. As soon as they enter fresh water they begin a slow and inexorable process of deterioration which begins with color change. They come from the ocean completely silver and begin to turn rosy pink and then more and more red. Their bodies start softening; eventually they can rot while they are still alive.


We cast lines for about 15 minutes and Tracy landed one. The color was incredible. But even more incredible was his nose. It was grotesque. It was a malformed, upward sweeping snout, some two inches long. It looked bizarre; his softening process was moderately advanced, but he was still firm. Brian said they still taste great at this point in their life cycle and took this one home for dinner, since we did not need the food.

Light was fading fast when we turned downriver to head home. By the time we were halfway down the Swift, there was very little light at all, and it was really chilly. Brian drove full speed ahead, skipping expertly around snags and boulders, following the current with the unerring sense of long experience. We pulled into our camp nearly frozen as total darkness engulfed us and the waning moon rose. Brian pressed on for Stony River without even waiting for hot coffee.

...to be continued...

A Shot to the Heart, Part 2

The next day began with breakfast at Andrewski’s house. He invited us for coffee, toast, and corned beef hash, which he cooked on the top of his Toyo stove. We discussed the current low water conditions on the Swift River and how much trouble we might have getting my boat up into it. Once past the shallow mouth, he said, the river is deeper and easier to negotiate. He thought we could do it, but he offered us his permanent fish camp on the Kuskokwim, close to the mouth of the Swift. He has another camp with a log cabin and steam house that is quite a way up the Swift, at the mouth of the Sunitna, but thought my boat would not make it that far. He was certain my boat would not make it up the Sunitna to Goosma’s land.

After some discussion we gratefully accepted his offer of the Kuskokwim camp. That would be our base camp and we would make day trips from there in the Zodiac. It is about 30 minutes upriver from the village of Stony.


The camp was not hard to find; it is the first sign of human presence for many miles after leaving Stony River, and sits up on a shelf of land with good visibility both upriver and down. We pulled in and found a tidy camp that was perfect for our needs. There is a pebble-strewn beach, which makes unloading the boat much easier and less perilous than the mucky mud flats at Stony Landing. The five-foot high riverbank has a wide walkway cut into it leading up to the flat shelf where a half dozen log structures are scattered among the birch trees. The shelf is about 100 feet deep, and is backed by a very steep hill covered thickly in green and golden birch. There is a large, single-room log cabin in the center of the clearing; a much smaller bunk house with a single window and its own small wood stove; a log steam house, a generator house, an outhouse and a small cabin we dubbed the “entertainment house,” for it is partially carpeted and contains only a sofa, a television and a stereo cassette/CD player. This, we learned later, is Brian’s cabin.

By the time we made this quick inventory there was a noticeable but tiny, high-pitched buzz telling us a boat was coming from downriver. We could barely see a tiny black speck moving on the river, though we could hear the motor’s voice quite clearly. It was a good several minutes of watching the speck slowly get larger as the voice got stronger before Andrewski beached his 18-foot skiff and jumped out smiling. He simply nodded at us; the fact that we found the place was obvious and did not need stating.

He had said to us that morning at his kitchen table that “lotsa guys never make it to all the way up to Stony from Bethel, but have to turn back.” His way of acknowledging that three women doing it was pretty significant around here, too.

Before the massive chore of unloading the boat began, Andrewski wanted to take Lynn up the river in his boat to show her the entrance to the Swift River. We had heard that it is fairly intimidating, that the water rushes out of it into the Kuskokwim in a furious boil. They don’t call it the Swift for nothing. The mouth has a half dozen small channels, but only two are negotiable by motorboat, and only the deeper of those two would be possible for my boat.


Lynn and Tracy jumped in with him and they took off like a shot. Andrewski raced up the river at the very edge, where the current is less and therefore takes less gas. When they returned about 20 minutes later, both women had big round eyes. They said later that he drove straight up the Kuskokwim and then turned full speed straight into the side of the river, into what looked like a log graveyard and boulder field strewn across a shallow creek.

“You would never turn a boat in there if you didn’t know exactly what it was; never, never, NEVER!” Lynn exclaimed.

Both women had their hearts in their mouths as he went screaming up the shallow creek that calls itself a river. He headed for a log at full speed; it was dead ahead, and Tracy thought he was going to try to jump it! She was looking for a place to grab hold of the boat when he came around at the last minute and brought the boat up beside the log.

“New log” was all he said. It was blocking further passage.

When they returned, Lynn grabbed her small chainsaw and she and Andrewski went back up to cut it free. She said later that Andrewski drove his boat right up onto the log, so the front half of the boat was out of the water, resting on it. Then he leaned over the side of the boat and began cutting. Lynn was worried about her saw blade and/or entire chainsaw going into the water, but Andrewski never let that happen. As the saw went through the last bit of wood, the log broke free and moved into the current. Andrewski dropped the chainsaw still running on the floor of the boat, ran back to the motor and backed the boat out of the way.

As they watched to see that the log didn’t re-wedge itself, Andrewski said quietly, “Lynn, you want to turn that saw off?”

On their return to camp, Andrewski had a few final instructions on how to get my boat up the Swift. He gave us the keys to the bunkhouse cabin, told us to make ourselves at home and use the steam bath if we wanted. Then he hopped in his boat and was away downriver.

Unloading took us a while, but we finally got the gear stored under a tarp and the guest cabin cleaned out and set up with our sleeping bags and pads on the three bunks, our two-burner Coleman stove on the table, and food stored on the shelves. Tracy built a fire in the woodstove and the cabin was warm in minutes.


We decided on steaks and potatoes with onions for our first-night-in-camp supper. And there was a bonus; my friend Joan gave us a bag of her special hot cabbage dish and a loaf of homemade bread, and we had a nice bottle of red wine to go with it. Of course we were starved by the time the food was ready, and it was all fabulous.

After dinner we sat for a while around the fire, listening to the quiet and absorbing the peace. It was so good to be there. How lucky we were to have been offered this incredible place to camp.

Despite all good intentions to get up early and be out on the river by sunup looking for moose, the accumulated stresses of the trip upriver demanded some rest before we continued, and we all three slept soundly until mid-morning. The built-in bunk beds were a little narrow and short, but they were at least level and flat, so no one was complaining. It’s a good thing none of us is taller than 5’6”.

The day was a little chillier than the previous ones had been. I could tell we were at a higher elevation; the air had a sharp autumn tang that was still missing in Bethel. There was a heavy, fairly dark cloud cover that morning, and a rising wind. Lynn and Tracy took off in the big boat for an exploratory lookaround up the Swift River.

I was content to remain in camp reading and writing and resting up a bit from the rigors of travel; I am older than my two best friends, and have a few back problems. For me this trip was more about camping than it was about hunting. I have never shot an animal, and don’t forseeably intend to, though I believe I could if it were necessary.

I had a fire in the fire ring and coffee in the thermos. It was a quiet morning. I sat on the bank of this huge, amazing river, and watched as it swept endlessly, majestically, silently by me. The current in the center was swift. A tremendous uprooted tree floated by at quite a good pace and was pretty quickly lost to sight around the bend downstream, about a mile away.

Across the river two ravens were fighting and squawking shrilly over a dead fish. They kept at it so long I was tempted to get out the .22 for a little target practice. They’d be in no danger, since I wouldn’t aim close to them, but maybe they’d shut up.

A loud SPLOOSH startled me from my rivertrance, and following the sound, I could see something struggling in the water near the opposite shore, a short way down from us. The binoculars revealed the osprey I had seen the evening before; it had dropped from the sky like an avenging angel—the sploosh. As I watched, the bird struggled and strained to get the large fish held in its talons out of the water. The cargo was too heavy to get lift off, and the bird was not about to let go! So he struggled and flailed, beating the water with his wings, humping the fish out of the river one jump at a time. The splashing continued for a minute or so and then bird had fish up on shore and was beak-deep in fish guts in a flash. With cold swiftness, bird tore fish to shreds and gobbled up most of it. The leftovers were quickly set on by ravens. I had to tell myself to sit back and breathe.

What I learned later was that eagles (osprey is also known as “fish eagle”) have a locking mechanism in their claws. They must choose their prey well, for once they dive and grab, their claws lock closed and will not release until they begin to eat. The osprey would have drowned before he could let go of that fish which was too big to fly off with. I had witnessed a death struggle for him to get the fish to shore.

The motor buzz telling me Lynn and Tracy were back came about two hours after they had left. The drawn, tense looks on their faces told me something had happened up the river. By the time they moored the boat, stashed the gear and came to the campfire they were starting to relax a little, but were still clearly wired on adrenaline. It took several minutes of pacing before they were ready to sit down and tell me the story—a story that Tracy would forever after call “The Magic Boat Ride”.

They had gone into the mouth of the Swift and managed to find the one channel deep enough to allow them passage. They went several miles upriver, following twists and turns, past logjams and sweepers and beaverworks, through land so wild and beautiful, so distant and remote, it seemed a human sound had never split the air. It was twisty, windy going, narrow channel, fast shallow water, challenging, a little scary.

When they pulled over to the side of the river to sit with the motor off and listen for animal sounds, they gained an appreciation for just how swift the Swift is. If not tied off very securely they would quickly be swept downriver. After nearly an hour of quiet watching they decided to head back. Further access upriver looked decidedly hazardous, and the trip back downriver wasn’t going to be exactly easy. They looked at each other and grinned. Out here when something goes wrong, you have only yourself and your companions to depend on. Everybody better be paying attention.

As they moved back from the bank, the bow of the boat caught the current and whipped the boat around, sending it charging downriver in a nanosecond. Lynn had the motor running to have some control, but the ripping fast current threw them toward a snag and they could not steer around it. The lower unit hit with a thud that threw them forward and made their stomachs lurch. The motor died instantly and they were wedged on the snag with incredible current racing past them and the deafening sound of rushing water roaring all around them. Only the high transom on the back of my boat prevented the river from swamping them completely.

Lynn jumped to the starter and miraculously, the motor roared to life. She threw it in reverse, gunned it hard and the boat came off the snag. The lower unit was apparently intact. Off they went again, careening down the Swift with Tracy in the bow using an oar to fend off trees, sweepers, the bank, whatever came close. The current was running so fast it was all they could do to avoid obstacles and get out of there.

They were headed toward a bend, riding the cutbank current, on a path that would take them into a head-on collision with the bottom of an upended tree with roots radiating out like a sun, and the size of a garage door. Tracy threw all her weight against the oar and deflected them just enough. The force knocked her back on her butt in the bottom of the boat.

Finally they threaded their way through the boulder field at the mouth of the Swift and roared into the Kuskokwim. What relief--and what an incredible river! Once the adrenaline wore off, they were both exhausted.


After lunch, the three of us went out in the inflatable Zodiac to explore some more small tributaries. We had been advised to check out the Tahloweetsik River, which empties into the Kuskokwim a few miles above the Swift. It is shallower and slower than the Swift, with eddies that support the shallow-water plants that moose love to eat. Lynn wanted to see how far up the Tahloweetsik River they could get, and look for moose sign. She wanted to do an overnight siwash camp (bare bones and silent, sleep with your gun) as soon as they found some sign. What she was looking for were things like trees with their bark rubbed off five to eight feet up, piles of scat that look like little mounds of raisins, hoof prints, tufts of hair snagged in the bark of trees, or the sounds of cow and bull calling to each other. The sounds of bulls taunting each other with insults and the clashing of massive antlers would come later in the season as the rut progressed.

We returned a few hours later, having seen more gorgeous scenery and picturesque side rivers, but no sign of large mammals roaming the area. We felt fairly certain that the best chance of finding moose would be up the Swift River.

...to be continued...

A Shot to the Heart, Part 1

Three Alaska Women Go Moose Hunting


The Yupik Eskimos who live beside the 800-mile-long Kuskokwim River in southwest Alaska believe that hunting is a joint endeavor between man and animal, and both must agree to participate. When the animal stands facing the hunter, it is offering itself to be taken for the hunter’s needs; it knows this and makes the offer willingly. The hunter must be worthy of the offer, seeking the animal with an attitude of respect and gratitude.

As Lynn sighted through the scope of her Winchester 270 at the bull moose standing 85 yards away, she felt a lot of things. The adrenaline thundering in her veins had her heart pounding like mad, her breathing deep and full, her eyesight sharpened, her muscles tensed and ready. She was nearly shaking with the effort to control her body’s fight-or-flight response. At the same time, she felt deeply the respect and gratitude that were the animal’s due; but even these were surmounted completely by her awe at the magnificent beauty of the animal. He stood facing her head on, six feet tall at the shoulder, displaying the full width of his chest and his mighty eight-point rack, calmly chewing on young willow shoots. Perfectly still, he looked at her.

“Thank you,” she whispered, as she gently pulled the trigger. It was a shot straight through the heart, and he died after taking only a few steps and then sinking slowly to the earth.

The sound of the gunshot echoed away, down rivers, across valleys, up against mountains, deep into the Alaskan wilderness. In all these square miles, there was no one to hear it. To this remote spot on the bank of the Swift River three of us had traveled hundreds of miles to meet this moose, a long river journey up the Kuskokwim River from the town of Bethel, then several days hunting up and down the main river, exploring tributaries, looking, looking, always looking. Three women: Lynn, Tracy, and me. We came here to learn the lessons of the river, and the land, and the moose; we sought to hunt with honor, and to receive what was offered with gratitude.

The area around the upper Kuskokwim River is a huge and beautiful land, almost completely untouched by human presence. The tributaries that run into it are fast and deep, cold and clear. Wildlife is abundant, and the land hums with an energy that feels like stars are singing.



The trip began a week earlier, after months of planning. The three of us had been best friends for about eight years. Lynn and I both work at the hospital here in Bethel. She is an experienced hunter who had taken two moose in previous hunts. Tracy is a dedicated angler from southeast Alaska who had never hunted but loves to camp, hike, fish, and do anything outdoors. She is physically fit, generally competent, usually cheerful and always helpful; an ideal traveling companion. Like Tracy, I have always loved the outdoors, but had never hunted before.

We left Bethel in my 22-foot handmade aluminum boat loaded with camping gear, a wall tent with a wood stove, rifles, an inflatable Zodiac, a spare outboard motor, 110 gallons of gasoline, plenty of food and two dogs. Downriver people like ourselves usually face a journey upriver with a combination of excitement and trepidation. Everybody who travels the river has at some point been stuck on a sandbar that appeared out of nowhere or lost in a side slough that looked like the main river. Preparation for river travel must be well-planned and carefully executed, for the dozen or so upriver villages cannot be depended upon to have supplies or gas; and if they do, prices are likely to be steep.

The plan was to travel three hundred miles up the Kuskokwim River past the village of Stony River and spend two weeks camping and hunting moose. It would be an ambitious undertaking for anyone, but for three non-Native women to do it was considered audacious in the extreme. Tongues were wagging and skeptical eyes were watching us as we left town.

We cruised out of Bethel on the first Sunday in September under clear skies with a light breeze at our backs. The river was friendly and just smiled at us as we made the only big mistake of the entire trip right at the start; after three hours on the river, we were suddenly back in Bethel. We got turned around on a slough up above the village of Kwethluk and never even realized we had headed back downstream. In telling the story later, we came to understand that it is a mistake many people make at least once, but at the time our egos were certainly chastened by the experience.


The trip to Stony River took twenty hours over three days. We found beautiful, isolated campsites each night and felt continuously smiled upon by the river gods. We found a few shallow spots in the river, but managed not to get caught by them. Watching the miles of riverbank go by, it was evident that we were gaining elevation. The river gradually became more narrow and swift and mountains appeared in the distance. The season seemed to advance quickly; trees that were all green in Bethel were dressing the hillsides in green and gold by the time we made it to the village of Aniak, about half way.

Our ultimate destination was some land up the Swift River and the Sunitna River, tributaries to the Kuskokwim, another twenty miles past Stony River. We had an invitation to stay there from our friend, Goosma, a retired river boat pilot who divides his time between Bethel and his home in Stony River. We were to check with his brother Andrewski, also a river boat pilot, when we got to Stony.

The village of Stony River is quite small; perhaps 45 people live there. About half the homes are log, in variable states of repair. As in most Eskimo villages, there are quite a few old government-built houses from the 1960s. Lots of old abandoned equipment stands about, lending a somewhat run-down air to the place.

When we pulled in off the slough that leads into Stony River from the Kuskokwim, we were at Stony Landing, the home of Andrewski and his wife Maria, one of the nicest homes in the village. Andrewski greeted us warmly as friends of his brother and directed us to find his son Brian to get help finding a place to stay for the night.

Brian is a strikingly handsome young man in his late 20s with beautiful, straight white teeth, wide Eskimo cheekbones, snapping black eyes and a movie star smile. He is tall and dark with jet-black hair that stands up like a roach, and he moves with an athletic grace. He was very warm and friendly and glad to help. In the end, Goosma’s daughter Anna offered us her house; she was housesitting at her dad’s place while he was down in Bethel.


...to be continued...