Sunday, October 08, 2006

Eskimo Ingenuity

One of the responsibilities of my job as a health care provider in southwest Alaska is to spend some time each day on the phone talking with health aides about the patients they see in their villages. (I have written before about the unique role that health aides play in the delivery of health care in rural Alaska here and here.) This phone consultation is called Radio Medical Traffic (or RMT), so-named because it was once done over VHF radio (before the days of HIPPA).

Last week I was doing RMT with a health aide in one of the downriver villages. His name is Abe; he is a forty-something Yupik Eskimo man and one of the few male health aides. I always enjoy talking with him; he is an excellent health aide, with a good grasp of the basic essentials of medicine and a lively curiosity and desire to learn more. We usually have interesting discussions about his patients, and he always has good questions. I have encouraged him to apply to PA school, but he does not have the prerequisite college coursework, and he does not want to leave the village for two years; and he really enjoys being a health aide.

One of Abe’s patients that day was a young man with a beaver in his lungs (asthmatic bronchitis). He’d had a chest cold with a productive cough for about a week (no fever), but the day before he had started wheezing and feeling somewhat short of breath. His respiratory rate was up to 28 and his oxygen saturation was down to 94%.

Abe and I discussed getting him started on albuterol. All the village clinics have several nebulizer machines which they loan out to patients for short-term use, but Abe said that none were available that day in his clinic. He did have a good supply of albuterol metered dose inhalers in the drug cabinet, however.

“OK,” I said. “Give him an MDI with a spacer, and show him how to use it properly.” A spacer vastly improves the efficacy of an MDI, even for an experienced user; for novices, I consider them essential. A spacer is basically a plastic tube; the MDI attaches at one end, discharges its “puff” into the tube, and the user slowly inhales the puff from the other end. Some even have fancy bells and whistles, like an alarm that sounds if the user inhales too quickly.

This technique allows more of the medication to get deeper into the lungs. When the MDI is held to the lips and discharged, more medication sticks to the mucous membranes in the mouth and less gets down into the lungs. The force of the discharge hitting the back of the throat may also cause the user to cough, preventing any medication from getting into the lungs. And the user’s timing of discharge-and-inhalation is crucial. A spacer eliminates these problems.

“But,” said Abe, “we’re out of spacers. The hospital pharmacy only sends us two per month, and they’ve already gone out.”

“No problem,” I answered. “Take the cardboard core out of a toilet paper roll. Show him how to hold the MDI at one end with his hand wrapped around the junction. It’ll work just fine.”

“OK!” Abe said enthusiastically. “We can Eskimo him up!”

I could just see the grin on his face.

A few days later I told this story to my friend Henry, who has lived here for over thirty years. He laughed and nodded.

“One of the things the Yupik people are very proud of is their ingenuity in rigging up something to solve a problem. I once saw a man carve a piston from a piece of ivory to make a snowmachine engine work. I’ve seen a washing machine motor rigged to push a boat when the outboard motor failed. They are amazingly inventive when it comes to making things work.”

I thought about Abe and the spacer problem. I knew he would take care of his patient, and find a way to get the albuterol where it needed to go.



Anonymous Leah said...

Us girls were always amazed at dad's "Old Indian Tricks"!

Would you consider writing about "traditional" roles in your neck of the woods? A co-worker once interrupted my bear encounter tale to ask "Where were the men with you?" I was co-worker gently explained to him that in Native cultures (us Indians, anyway) that it was common for the women and children to be out in the woods (without a man) with only a gun for protection. That we were raised to be self-sufficient and men needed! I know he didn't mean any harm, but I was struck by his traditional thinking. I'm assuming that it's common for Eskimo women and children to be out berry picking, camping, fishing, etc. without a man along for protection...only a good rifle.

Monday, October 09, 2006 9:48:00 AM  
Anonymous Anonymous said...

we do the toilet paper trick here in NY, too! if a patient can't afford an expensive spacer, we teach them how to use the toilet paper roll...

Monday, October 09, 2006 4:20:00 PM  
Anonymous Anonymous said...

Good post. I spent time, during med school, in a small village in Yugoslavia, where farming was done with horses and wooden plows, and homes were of sun-dried mud bricks. Their ingenuity in making things work was among the many things that impressed me (including the guy who pushed a hand-cart bearing an old brass still, from home to home, distilling their plum juice fement into slivovitz. Offered still warm and gaspingly raw, as it dripped from the shiny tank.)

Tuesday, October 10, 2006 6:41:00 AM  
Blogger TheTundraPA said...

leah--right you are! Most Native women here, both Indian and Eskimo, are taught to be self-sufficient, to use a rifle, to handle themselves in the wilderness. It is imperative to survival.

anonymous--necessity is the mother, as they say.

Dr. S--thanks for stopping by! This post was kind of a "quicky" and not really one of my best. I hope you'll browse around a bit and read some others. I also hope my readers who are not followers of Grand Rounds will go to your blog and read your recent post "Taking Trust". I was deeply moved by it. TMD readers can find it at Thanks for visiting, Dr. S. I hope you'll stop in again.

Tuesday, October 10, 2006 8:15:00 AM  
Anonymous Moof said...

Loved that one, Tundra! I think we need to import a bit of that Eskimo ingenuity to the NE! ;o)

Tuesday, October 10, 2006 8:49:00 AM  
Anonymous d said...

What a great idea! I wonder if Flea will be stopping by. I seem to remember a post of his going by lamenting Medicare's lack of coverage for spacers.

Tuesday, October 10, 2006 2:38:00 PM  
Anonymous Anonymous said...

Wonderful! Keep sharing your experiences, I really enojoy them.

Tuesday, October 10, 2006 2:46:00 PM  
Blogger A Bohemian Road Nurse said...

Glad I found your blog--very fascinating.

Tuesday, October 10, 2006 5:58:00 PM  
Blogger Shinga said...

Spacers are available on the NHS in the UK but people still forget them or don't want to carry them around if they are bulky - or if they have medications that require different spacers. The cardboard tube is a popular portable spacer here.

Regards - Shinga

Saturday, October 14, 2006 6:57:00 AM  

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