Tuesday, November 28, 2006

Grand Rounds, Volume 3 Number 10

Tuesday has become my favorite day of the work week because I love Grand Rounds. So much good blogging, and always a few new blogs to explore. The medical blogosphere is growing so quickly that I feel like an old-timer after nearly seven months.

This week's host for Grand Rounds is Dr. R.W. Donnell at Notes from Dr. RW. He does an excellent job of organizing and moderating a reasonably-sized edition with 32 posts. I was pleased to be included in this week's GR.

Pour yourself a nice hot cup of coffee and enjoy the best of the medical blogosphere.


Sunday, November 26, 2006

Steambath Boil

Author's note: the accompanying photo is not the patient described in this story. The story is fiction.

Enakenty is 81 years old. He lives in a downriver village just far enough away from Bethel to make it difficult to come in to the hospital, except by plane which he generally can not afford. He receives a small pension from his years as a riverboat pilot, so does not qualify for Medicaid, which pays for travel. As an Alaska Native, his health care is 100% free to him, once he is in Bethel or Anchorage; but getting there to receive it is up to him. He speaks only Yupik, his eyesight is failing, and he seems occasionally forgetful to his family, so he is not safe to travel alone. The escort’s ticket to Bethel is an extra $150; to Anchorage is an extra $500. If he really has to come in, he prefers one of his sons to bring him; but sometimes he just refuses to come. “It’s my life!” he says.

Enakenty has three sons and two daughters, all that are left of the ten children he and his beloved Gertrude gave birth to during their forty years of marriage. Together they buried five small children, victims of disease and drowning. Twelve years ago he had stood silently watching as his sons dug their mother’s grave among those small headstones. Even now it is sometimes hard to believe that his Gertie is gone. Cancer of the pancreas. So fast, barely six months from the time she got sick until she was buried.

Now Enakenty lives with his youngest son’s family. Carl and his wife Unda only have three children; his other two sons and both daughters have five to seven kids each, and they really don’t have room for him. As the youngest child, Carl’s siblings fully believe it is his responsibility to care for their dad far more than it is theirs; that is the job of all youngest children, what they were born for. When the youngest child is a girl, she may not be allowed to marry prior to her parents’ deaths, as that would allow her husband to take priority over her parents.

Fortunately, Carl is very fond of his dad, and is usually the one who brings him in to the hospital for clinic visits. Unda is fond of the old man too, and truly does not mind his living with them. He is a wonderful storyteller, and can keep her three children mesmerized with a story in the evening. And he is a very good ivory carver. Her ten-year-old son, Nicodemas, frequently badgers his grandfather to teach him to carve. Unda hopes the boy has his grandfather’s skill for the craft; a good ivory carver can make a significant income by selling his work. The pain in Enakenty’s arthritic hands keeps him from producing more than one or two nice pieces per year, but the money from them is always welcome.

The old man loves to take steambath. He and his sons usually steam together three or four times a week, most often in the bathhouse built by his oldest son, which is right between their two side-by-side houses.

About five years ago, Enakenty accepted an invitation to steam at a bath across the village. It was not very clean, and Enakenty had not brought a piece of cardboard to sit on inside the bath. He considered declining but did not want to appear rude, so went into the bath and sat on the dirty floor in his bare skin. Soon after that bath, he developed a boil on the back of his right thigh.

For a week he tried to care for the boil at home. He started doing frequent warm packs. He tied a red string around his leg above the boil to prevent the infection from going up higher. He chewed large wads of tobacco until they were juicy with saliva and then taped them over the growing boil. By the fifth day the pain in his leg was intense, and he couldn’t walk without limping. He could barely sit down. On the sixth day there was a four inch red streak ascending toward his hip; the boil was a golf ball of hardness surrounded by fourteen centimeters of hot redness. He felt hot all over and a little bit sick.

The health aide simply raised her eyebrows when she saw the huge abscess and said “Why’d you wait so long to come in?”

He shrugged. “Thought it’d get better.”

Christine was a Session III (of five) health aide who had just taken “Boils 101”, the new inservice for health aides on incision and drainage of abscesses, and she knew this needed draining badly. “Gotta get the pus out,” she muttered to herself as she pressed gently around the boil, trying to find the spot where the boil was making its own pathway of relief. No natural opening was yet apparent. She hated causing the grunt of pain that Enakenty could not hold back every time she pressed.

“Enakenty, this boil is big, and it’s really deep. It has to be cut or it won’t get good. It’s making you sick,” she said, noting his temp of 100.6 degrees. “You need to go up, and let ‘em take care of it up at Bethel.”

“Can’t,” he responded. “No money to go. You can do it, I trust you. Just poke me hard with that knife and let’s get it over with. I’ll take the pills.”

She put a page in to her village doc at the hospital, who called back shortly. He agreed that Enakenty needed I & D right away. He went over the procedure with her and assured her that she could do this, despite the fact that it was her first one since the inservice.

“Give him 800 mg. of ibuprofen with a little food about 30 minutes before you do it,” the doc said. “Be sure to culture the pus, and start him on Septra twice a day for ten days. Call me back if you have any problems, OK? And do daily packing changes for a week or so.”

The I & D went smoothly, and Christine removed about a half cup of pus from the abscess. Enakenty asked for a bite stick to clamp between his teeth, to help him take the pain. Afterward she packed a foot of sterile gauze ribbon into the wound. She sent him home with antibiotics, more ibuprofen, and instructions to continue frequent warm packs and return the next day for repacking. She also told him he had to stay off the leg and elevate it. “No walking around, OK? You have to rest!” His only response was a noncommittal grunt that could have meant anything.

When he returned from the clinic, Unda was waiting for him. She settled him on the sofa where he could reach his crutches and piled up some pillows to elevate his leg. A homemade cloth bag filled with dried beans went into the microwave; when it was very warm she tied it to the back of Enakenty’s leg with a wide strip of cloth.

With Unda watching closely and reheating the bag of beans frequently, the old man spent the next five days on the sofa with his leg elevated. The Septra caused no side effects, and his fever and the pain improved rapidly with ibuprofen. He saw one of the health aides daily for packing changes, which were the most painful part of the whole ordeal.

Just pulling the long, pus-soaked ribbon out of the wound was painful. It burned deep, and he squeezed his eyes shut against it. But worse than pulling was replacing. By the fourth day, the wound still held nearly a foot of ¼” wide gauze packing without being tight. Every time the tweezers stuffed a bit of gauze into the wound, he flinched. If the tweezers touched the sides, it hurt even more. By the third repacking, he would not let anyone but Christine do it. She never let the tweezers touch the sides.

It took a full week of repacking, but the abscess finally healed. The red streak disappeared by the third day of antibiotics; cultures indicated that, like most boils in the villages of southwest Alaska, this one was MRSA, and sensitive to Septra. Enakenty was glad he wasn’t allergic to it, like one of his daughters. By the fifth day he no longer needed the crutches, but still spent hours on the sofa with his leg elevated, entertaining his four-month-old granddaughter.

After the boil healed, a small scar remained. It was Enakenty’s reminder always to take boil precautions in the steambath; he never again forgot to bring his own piece of clean cardboard to sit on in the bath, and he kept a spray bottle of bleach solution to clean the floor with after steaming in the bath he shared with his son. In the years since, Enakenty was proud that no one had come away from his family’s steambath with a boil.



Saturday, November 25, 2006


The Tundra PA is a happy gal tonight! Two yummy presents arrived today, sort of like an early Christmas. The first was my new camera! Dutch was as distressed as I was at the loss of my old one, so he jumped on the internet and found me a replacement. We decided on the Canon Power Shot A710 IS (for image stabilization--whoo hoo). It was delivered right to the house, which is a big deal since we don't have home delivery of mail. And I love it! It is similar to the A620 that I lost, but has some nice new features. It is smaller and easier to carry around in a pocket, which is great.

My second big yummy arrived home from the post office with Dutch. My new extreme Jeff King suit came in the mail from Cabela's today. My old outdoor gear was getting pretty worn and needed replacing, so I decided to treat myself to a big present. Its official name is the extreme Trans-Alaska suit, but because it is showcased for Cabela's by one of the top professional mushers, most mushers just call it the Jeff King suit.

No matter what you call it, it is a beautiful piece of workmanship. It is a one-piece outer garment worn over several inner layers of fleece and/or polypropylene. It is nearly impenetrable to wind, has a comfortable amount of padding and a drop seat for bathroom needs. It has many pockets inside and out, some of which are designed to hold handwarmer packets. And it is comfortable to wear!

The rest of the gear you can see in the photo are a beaver hat, beaver musher's mitts, and Steger mukluks, the warmest things you can put on your feet. Behind the Jeff King suit is my giant purple over-parka, made by Apocalypse Design in Fairbanks. It is the last word in survival.

Next weekend is the state championship wrestling tournament. It is being held in the village of Akiachak, about fifteen miles upriver from Bethel. My friend Joan's older son Michael is a varsity wrestler for Bethel Regional High School, so Joan and her younger son Luke will be flying up to watch Michael compete. Henry is thinking of taking a dog team up, and Dutch and I will likely go with him, on snow machines. If the blizzard we are waiting for moves in tonight, we could have a good snow pack by then, which would improve the hardness of the trail significantly. My fingers are crossed.


Wednesday, November 22, 2006

Flat Shawn's Alaskan Adventure

Last year about this time, I received an email from Uncle Bob asking me if I would be willing to help his best friend's grandson, Shawn, with a school project. The boy's second grade class was studying geography and social studies. The lesson plan was based on a popular children's book called Flat Stanley, in which a boy gets "flattened" by a bulletin board that falls on him, and his parents put him in an envelope and mail him to different places to have adventures. Uncle Bob asked if I would mail Shawn a post card from Alaska with a note on the back about his "flat" adventure here.

I had never heard of Flat Stanley, but the idea fired my imagination so much that I wrote a whole children's story about Shawn's flat adventure in Alaska. I included photos of Flat Shawn doing the things described in the story, as well as postcards, a calendar of Alaskan wildlife, and a videotape of the Iditarod Trail Sled Dog Race. Shawn was delighted. His teacher may have been a little overwhelmed; I never heard anything back from her.

Remembering what fun it was putting this project together, I decided to share it here on Tundra Medicine Dreams. I subsequently learned that the Flat Stanley project is a widely-used teaching tool in elementary education in the U.S. Any of you who may be involved with a Flat Stanley project are welcome to use Flat Shawn's Adventure (with appropriate attribution, please) as part of the project if you would like.

As always on this blog, names have been changed.

Flat Shawn’s Alaskan Adventure

My name is The Tundra PA, and I am a physician assistant who has lived in Alaska for almost ten years. Recently, I received a letter from my Uncle Bob, who lives waaaaaaay down south in Mobile, Alabama (where I used to live when I was in second grade). Uncle Bob told me about his young friend and next-door-neighbor, Shawn, who is in second grade. Shawn’s class is studying the regions of the United States by sending flat versions of themselves (based on the book Flat Stanley) to different places to visit.

“Would you invite Flat Shawn to Alaska to visit?” my uncle asked.

“You bet I would!” I told him. What a great idea Shawn’s teacher had to help the children learn about the different parts of our great country this way.

“Hey, Shawn!” I said. “Fax your flat self on up here, buddy, and let’s have some fun, Alaska style!” And so he did.

Fun Facts About Alaska

The day that Flat Shawn jumped off my printer and ran
to the living room window to look out, it was a really cold day. Like about twenty degrees below zero! Brrrrr! So we decided to stay inside where it is warm and toasty next to the wood stove and drink hot chocolate and learn some facts about Alaska for him to share with the class when he returns home.

The first thing to know about Alaska is that it is big. Really, really BIG. If you could pick up Alaska like a piece of a puzzle, and lay it down on top of the “lower 48” (which is how we Alaskans refer to the contin
ental U.S.), it would look like this:

“Wow!” said Flat Shawn. “It goes from sea to shining sea,” he said with a smile.

Alaska is the biggest state in the United States. It is over twice as big as Texas, the second largest state. North to south, Alaska is 1,400 miles long. East to west, it is 2,700 miles wide. It has almost 600,000 square miles and only 600,000 population. “That’s only one person for every square mile!” Flat Shawn said in amazement. “No wonder it looks so empty out there,” he said, gazing at the open tundra through the window.

“You’re right, Flat Shawn,” I told him. “In the lower 48 there are over 70 people per square mile.”

“How about the cities?” he asked.

“Well,” I told him, “Alaska has only three cities of any size. Anchorage is the largest, with 225,000 people (much smaller than Mobile!). Fairbanks is next, with 32,000 people; and the state capital, Juneau, is third with 30,000 people. Can you find those cities on our map of Alaska?” I asked him. And he did.

Alaska doesn’t have counties like other states do; it is just too big for that. The state is divided into regions like this:

The five regions are very different from each other. Southeast, South-Central, and Interior are full of huge mountains; 17 of the 20 tallest mountains in the U.S. are located there. The tallest is Mt. McKinley, known simply as Denali by most Alaskans. At 20,320 feet, it is the highest point in North America.

Southwest and Far North have only a few mountains that are much smaller than those in the Interior. These two regions have lots of flat, wide-open land called tundra, which is nearly treeless. I live in the small town of Bethel, in Southwest Alaska. The tundra here seems to go on forever, like being on a ship in the middle of the ocean. In fact, Bethel is kind of like an island, because you can’t drive here in a car. There are no roads that come here. You can only get to Bethel by plane or by boat (or by fax machine, if you are Flat). In Alaska, that is called “living in the bush”.

Alaska has two huge rivers and hundreds of smaller ones. The largest is the Yukon River; it is over 2,000 miles long. The second largest is the Kuskokwim (pronounced cuss’-ka-kwim), which is 800 miles long. Bethel is located on the Kuskokwim River, about 80 miles from the ocean. The river has all five species of salmon in the summer, and my friends and I love to go fishing for them. Fresh salmon is so yummy!

The Far North and much of the Interior are above the Arctic Circle. Flat Shawn quickly finds the Arctic Circle on the map. Those areas get very, very, very cold in the winter. Barrow is the most northern town in the U.S., at the very top of Alaska. In the winter it can get as cold as 70 degrees below zero! And when the wind blows, it feels even colder than that.

Besides being very cold, when it is winter in the Far North, it is dark all the time. Truly, it is nighttime 24 hours a day, seven days a week. The sun never rises at all, from mid November to mid January. It is very hard to know what time it is without looking at a clock. But the flip side of all that darkness is that in the summer, the sun never sets! It is bright daylight 24/7 from June to August. You can play softball or ride bicycles as easily at midnight as you can at noon—and people do!

“Wow,” said Flat Shawn, “you’d have to have really good clocks up there to know when to go to bed and get up. It’s hard to imagine.”

“You’re right,” I said. “Here in Bethel, we don’t have total darkness like they do in Barrow. For us, on the winter solstice (the shortest day and longest night of the year), the sun rises about 11:00 in the morning and sets about 3:30 in the afternoon. It stays low on the horizon and doesn’t get high overhead, but at least we get to see it. And in the summer, the sun rises about 4:30 in the morning and sets at 2:00 in the morning. We only have a few hours of semi-darkness each day during the summer. We play midnight softball too!”

“I want to come back in the summer and try that,” Flat Shawn said.

The other interesting thing that happens during the long winter nights is the Northern Lights. The scientific name for them is aurora borealis. They are usually green-blue in color, sometimes with pink, purple, or red mixed in. They wave and flicker in the night sky like a living curtain of color, blowing in a cosmic wind.

“I hope you get to see them while you’re here, Flat Shawn!” I told him. “We only have them occasionally, and you have to get up in the middle of the night to see them.”

“That’s ok with me,” Flat Shawn said. “I’ll wake up anytime to see that.”

“What about wild animals?” Flat Shawn asked. “Are there lions and tigers and bears around here?” He looked out the window with a worried frown.

I smiled and shook my head. “No lions or tigers. We do have bears, though. Mostly black bears around here, which are on the small side—for a bear, anyway. Alaska has lots of other bears, though. We are the only state in the U.S. that has polar bears.”

Flat Shawn peered hard out the window, in case one was walking across the tundra toward the house.

“Don’t worry,” I assured him. “Polar bears aren’t here in Southwest Alaska; they are only in the Far North. Alaska also has grizzly bears and Kodiak bears, but not around here. And you wouldn’t see them now anyway, because it is winter, and they are hibernating.”

Flat Shawn breathed a sigh of relief. “That’s good,” he said. “I don’t think I want to see one close up.”

“We have other wild animals,” I told him. “We have moose, caribou, fox, wolves, wolverine, beaver and muskrat; and in the sea there are seals, walrus, and whale.” The Yupik Eskimo people who have lived in this region for thousands of years hunt these animals for meat and fur. The meat keeps them alive and the fur keeps them warm in one of the harshest climates on earth. When they hunt and fish, they are very careful to waste nothing, and to honor the spirit of the animal they hunt.

“Will I get to see a moose?” Flat Shawn asked.

“Maybe not moose, they are mostly way upriver from Bethel; but you might see caribou. There is a large caribou herd that lives fairly close. The herd numbers over 20,000 caribou, so it is not hard to find them. They wander around the tundra all winter, and sometimes come within 20 miles of Bethel, so maybe we’ll see them while we are out adventuring,” I said.

Flat Shawn turned away from the sunset filling the west-facing window and sniffed appreciatively. “Something sure smells good, and it’s making me hungry. Is it time for dinner?” he asked.

“Indeed it is,” I said with a smile. “I hope you like moose stew and cornbread.” After finishing seconds of each, it was clear that he did.

“Did you hunt that moose?” he asked after dinner.

“No,” I said. “I’ve never killed an animal, myself. That moose meat was a gift from a Yupik Eskimo friend who lives way upriver from here, in a tiny village. Only about 50 people live in that village, and they are all Eskimo. My friend’s name is Golga, and he is a very good hunter. He frequently comes down to Bethel and brings moose or caribou meat with him.”

“Will I meet any Eskimos while I’m here?” he wanted to know.

“Yes, you will. About half the people in Bethel are Yupik or Cupik Eskimo. I will introduce you to some of them,” I said. Flat Shawn’s eyes sparkled as he thought about all the new adventures he was going to have.

The next morning Flat Shawn was up early and ready to get started. “But it is still dark out!” he said disappointedly. “And it is after nine o’clock! When will it get daylight?”

“Oh, about 10:30 or 11:00,” I answered. “Plenty of time for you to have a nice hot breakfast and think about how to dress to stay warm.” It warmed up a little from yesterday; today it is only ten below zero. And tomorrow should be right around zero, which feels really warm after twenty below. The coldest I have ever seen the thermometer go to was forty below. That is too cold to even go outside. Cars don’t run well, and everybody just stays home to keep warm.

The key to staying warm when it is cold out is to dress in layers. And the best outer layer is fur. It has kept the Eskimos warm for thousands of years without any fancy high-tech gear. I find Flat Shawn a beaver hat, beaver mittens, and knee-high boots of wolf and caribou fur called mukluks. They were all made for me by an Eskimo woman who lives here in Bethel.

“Goodness, Flat Shawn, if these are going to fit you, we need to make a full-boy-sized version of you,” I said. So we found a cardboard box and made a Large Flat Shawn to go with the smaller one that jumped off my printer.

“I can have even more fun now!” he said.

After breakfast he went out on the deck with Bear, my Alaskan Husky dog. “You are right!” he said. “I’m really warm with all this stuff on.” He jumped up on the Adirondack chair and I took his picture with Bear. He and Bear had fun running around in the snow.

Flat Shawn Rides a Water Truck

While they were playing, the water truck arrived, and Flat Shawn watched while the driver, an Eskimo man named Charles, filled our water tank. “You know, Shawn,” he said, “Bethel is very different from where you live. Most people here don’t have pipes that bring water to their houses and carry sewage away. Each house has its own water tank and sewer tank, and every week a truck like this big one here comes to the house and fills up the water tank. A different truck comes and empties out the sewer tank. People have to be very careful not to waste their water, or they might run out.”

Flat Shawn’s eyes were round with amazement as he looked up at the giant truck. “Could I ride in the truck with you?” he asked Charles.

“Actually, the truck is almost empty and I was just heading back to the pump house to fill it up so I can continue my deliveries. The house next door is my next stop, so I’ll be back in about twenty minutes. If it’s OK with The Tundra PA, you could ride to the pump house with me and watch the truck get filled up, and then I’ll bring you back.” Charles smiled at me and I nodded. Flat Shawn climbed up into the truck’s cab quick as a flash.

“And that’s a mighty fine beaver hat you’ve got on, too,” I heard Charles say as they drove off. “You look like a real Alaska boy.”

In a short time they were back, and Flat Shawn jumped down from the truck and waved as Charles drove on to the next house on his route. “Look!” he said to me. “One of the guys took my picture with Charles while the truck was being filled. We can add it to my report about Alaska.”

The snow that started falling while they were gone was turning into a real blizzard, so we went back inside. “This is not good weather to be outside,” I told him. “Let’s learn some things to prepare for the adventure you are going to have tomorrow.”

Flat Shawn Goes Dog Mushing

“I love learning new things. What are we going to do tomorrow?” Flat Shawn asked.

“Well, tomorrow we are going dog mushing,” I responded. Flat Shawn’s eyes sparkled. “Dog mushing is the state sport in Alaska,” I told him. “Back in the old days, before snow machines were invented, that was how the Eskimos traveled around. Most families kept a team of dogs that were trained to pull a sled. The whole family could ride in the sled, and they often traveled long distances that way. Sometimes they would hold races to see who had the fastest dogs.”

“Today there are lots of sled dog races around Alaska, but the most famous one is the Iditarod. It is a race of almost 1100 miles from Anchorage all the way to Nome, held every year in March. The winning team will finish in about nine days. Each team starts with 16 dogs pulling a sled with one musher. The musher must take very good care of the dogs so they can run that far. It is hard work, but the dogs really love it. They have thick fur coats to keep them warm and strong bodies to pull the sled. The musher trains them all year long so they will be ready for the race. It is exciting to watch a good dog team at work.”

I put a video into the recorder about a previous year’s Iditarod, and Flat Shawn watched closely to see how the teams and mushers worked together. “If your school has internet access, your class might want to follow the Iditarod when it is run next March,” I told him. “There is a whole program for school children about it, with activities and lots of fun stuff to do." He wrote down the website www.iditarod.com and taped it to his shoe.

“My friend Henry is a dog musher, and he is going to take us mushing tomorrow,” I told him. “It won’t be a race; we’ll just go out with his dog team and get some fresh fish from his fish net. You can ride in the sled, and my friend Dutch and I will go on snow machines. You can drive the snow machine on the way home, too.”

“But I don’t have a driver’s license!” Flat Shawn said. “And I don’t even know what a snow machine is,” he added.

“That’s OK,” I told him. “I’ll show you, it’s easy. Most people in the lower 48 call them snowmobiles. Kids up here start driving small ones when they are about five or six years old. You’ll catch on quickly, I’m sure.”

The next day is sunny and bright and a little warmer, about ten degrees above zero. We warm up the snow machines and put Flat Shawn’s smaller version of himself in the backpack for the trip over to Henry’s. When we arrive at Henry’s house he has the sled ready and is hooking eight dogs up to the gangline that pulls the sled. He has over twenty dogs, and each one hopes to be chosen for the team. They are all barking excitedly, and it is pretty noisy for a while. Flat Shawn jumps in the sled, Henry says “Let’s go, dogs!” and they take off. Dutch and I follow behind on our snow machines, keeping the team in sight.

Once the team leaves the yard, all barking stops and it is quiet. The dogs are working now, and focused on their job. Each dog wears a harness and they are attached to the gangline in pairs. The two leaders are in front; behind them are the swing dogs, then two team dogs, then the two dogs just in front of the sled who are the wheel dogs. Wheel dogs have to be extra strong, because it is their job to keep the sled from bouncing sideways when the trail is rough or uneven. They all work together, running smoothly. The leaders follow commands from the musher to follow the trail. Gee means to turn right, haw means to turn left, and whoa means to stop.

It is about ten miles to the place where Henry has a fish net under the ice. The Kuskokwim River is frozen hard, and the ice is about eight inches thick. By the end of December the ice will be two to three feet thick, and cars and trucks will be able to drive on it. But for now, there are only snow machines, four-wheelers and dog teams traveling on the river.

Flat Shawn Goes Ice Fishing

It takes us about an hour to get to the fish net. Henry stops the dogs and jabs his ice hook into the frozen river to hold the dogs so they can’t take off on their own. Dutch and I park the snow machines nearby. Flat Shawn jumps out of the sled and looks around with wonder. “This is really the wilderness, isn’t it?” he says. And he is right. We can see miles in every direction and there is not a single person anywhere. No buildings, no houses, no sign of human life.

Two tall sticks are frozen into the ice marking each end of the fish net. Henry pulls out his ice chisel and starts chipping a hole next to one of the sticks. It takes a while, but eventually he makes a hole in the ice about two feet across. Cold river water sloshes in the hole. Then he does the same thing next to the other stick. We tie a long rope to one end of the fish net and start dragging the net out through the hole. “Holy cow!” Henry says. “Look at all the fish!” By the time the net is out of the water we have 29 fish. That’s a really big catch; usually there are only eight or ten fish. Winter is not the season for salmon; these are whitefish and lushfish. Whitefish are tender and tasty, much like cod; lushfish are bottom feeders like catfish, and are kind of pre-historic looking. I like whitefish the best.

We feed the net back into the water and reattach the net to the sticks, then fill in the hole. Henry will come back every two days to empty the net again.

Flat Shawn helps me count the fish and put them in a big bag that Henry brought. We load the bag into the sled while Henry gives the dogs a snack of frozen meat. We drink some hot chocolate and eat sandwiches that I brought, and then it is time to go back to Bethel.

Flat Shawn Drives a Snow Machine

Flat Shawn looks over at the snow machines and says, “can I really drive that thing?” “Sure,” I tell him. “Sit on it like a motorcycle and squeeze the lever on the right handle and you’ll go forward. Steer it just like a motorcycle or a bicycle. Squeeze the lever on the left handle and you’ll stop. It is that simple.” Flat Shawn gives it a try and finds that it really is easy, and lots of fun. He sits in front of me on my machine and does some of the driving on the way back.

The trip home is quick, and Flat Shawn is proud of his driving. “You did a really good job,” I tell him. “You’re an honorary Alaskan now!”

The next morning we finish writing his report to the class about his trip to Alaska. “I guess it is time to go, isn’t it?” he says. “I had a really good time.”

“I’m so glad you could come for a visit, Flat Shawn,” I tell him. “And I hope you learned a lot about our 49th state. It is a wonderful place. Like our state motto says, it is The Last Frontier. Perhaps some day you and your family can visit here in your real selves. Until then, send your flat self on up anytime you wish!”

He gives me a quick hug and then jumps in the package with his report to the class. I take him to the post office and wave good-bye as the postmaster sends him Air Mail back to Mobile.


Photo Credits:

1. Flat Shawn by Shawn

2. Denali (mt-mckinley-reflected.jpg from www.jhk1.nl/page/picspag/pics5.html)

3. Tracy catches a king salmon by The Tundra PA

4. Northern lights (northernlights98.jpg from www.omineca.bc.ca/free.html)

5. Polar bears (3lazypolarbears.jpg from www.soulcysters.net/showthread.php?t=112924)

6. Flat Shawn & Bear by The Tundra PA

7. Flat Shawn with Charles and the water truck by The Tundra PA

8. Henry & dogteam crossing Hangar Lake by The Tundra PA

9. Flat Shawn helps count fish by Dutch

10. Flat Shawn drives sno-go by The Tundra PA


Tuesday, November 21, 2006

Grand Rounds Vol 3 No 9

Doctor Anonymous is the host for this week's edition of Grand Rounds, the weekly carnival of "the best of the medical blogosphere." Until recently, the trend has been for Grand Rounds hosts to include all posts submitted in the carnival, which makes it not necessarily "the best", but simply a potluck of whatever any blogger wanted to submit. A grass-roots initiative, spearheaded by Kim over at Emergiblog, has called for improving the quality of Grand Rounds by reducing its size and including only the best posts.

This calls for some stringent decision-making on the host's part, and Dr. A has done an excellent job of it. The post summaries are clear and concise, the links are easy to find and follow, and the look is clean and professional. His solution to the inclusion vs. exclusion problem is to include a link dump at the end with those he did not include. Which is sort of like including them, but not calling them "the best." Seems like a manageable compromise.

Grab your coffee and enjoy some great reading!


Sunday, November 19, 2006

Distance Triage

Monday afternoon’s Radio Medical Traffic was intense. The community health aides in the far-flung villages of southwest Alaska were seeing lots of patients with acute viral symptoms ranging from mild to severe. Most were not toxic and could be managed at home with symptomatic and supportive therapy. Most health aides are very good at assessing whether a patient really needs to come to Bethel or not. If anything, they err on the side of sending a patient in too soon, rather than too late.

The Yupik Eskimo people of this region have a huge burden of respiratory disease. Many of the elders had tuberculosis in the 1940s and 1950s, and bear the large diagonal scars on the upper back from lobectomy to treat it. Many more people, including younger ones, have gone through year-long INH/Rifampin courses for having positive TB skin tests. The incidence of common bacterial pneumonias (community acquired) is considered to be fifty times the rate of the lower 48, for all age groups. An astounding number of infants have severe RSV disease, and almost every Yupik home has a nebulizer for administering albuterol. Many infants have multiple admissions for pneumonia before they are 12 months old. Severe asthma. Severe COPD. Even quite a lot of moderate to severe bronchiectasis in all ages from young to old. Sometimes it seems like the entire Yukon-Kuskokwim Delta is coughing.

On Monday afternoon, the volume of traffic from health aides reporting their patients was huge. By the end of a long afternoon shift, I had triaged 112 patients with them. Anything over 75 is a lot, but over 100 is especially brutal. I did not finish talking to health aides until nearly 7 pm. Health aides are finished working at 4 pm, and do not like having to wait up to two hours to get a call from the hospital RMT person to discuss their patients and decide on a plan of care. I can’t blame them, they have families to get home to. When traffic volume is high, there is just no way to call every health aide before 4 pm. The stress is always there to move quickly with the traffic, to try to get it done as early as possible.

It was after 5:30 when I called one of the coastal villages that was still waiting to hear from me. Over two hundred miles away, the last commercial plane flight left the village at 4:30. The health aides know that if they have a patient that might need to come in to Bethel on that last flight, and they have not heard from the regular RMT person, they can page the physician assigned to inpatient duty for urgent decisions regarding their patient. The system and its back-ups usually work pretty well.

I read the Patient Encounter Form as I waited for the health aide to come to the phone. 3 mo. old female with cough and fever x 3 days, worse today. OK; quick check of vitals, and holy cow! Temp 104.7 rectally. Heart rate 200. Respiratory rate 56. O2 sat 90%. What time was this? 11:05 am.

When the health aide answered, I managed not to jump on her. She has only recently advanced to the first level of health aide training past entry level. But “where is the patient? What’s going on, did you send her in already?” tumbled quickly out of my mouth.

“No, she’s good. She went home. Her mom’s not worried,” the health aide told me.

Oh. Not worried. When I first came here, I was repeatedly amazed at how well the Yupik compensate for their respiratory disease. Children with multi-lobar pneumonias and fevers greater than 101 degrees play tag with their cousins through the hospital lobby. Elders with COPD on daily inhaled steroids and bronchodilators go hunting in the fall and winter. The fact that mom wasn’t worried did not mean that I wasn’t worried. I asked the health aide to get mom and the baby back to the village clinic immediately and reassess the baby.

“She’s much better,” the health aide assured me when she called back. Temp 103.6 after Tylenol which she did not throw up. Heart rate 180. Respiratory rate 56. 02 sat 91%. “She’s alert, taking bottle, even her eyes aren’t too heavy,” she added. A health aide assessment of “heavy eyes” is a very bad sign. The baby was still retracting some, but had no nasal flaring or cyanosis.

Despite the baby’s apparently compensated state, I wanted her in Bethel. The question was how fast. The last commercial flight for the day ($100) was gone; the next would be the following morning, arriving in Bethel about 11 am. Sending out a medevac for her costs about $3500 (not to the patient), in addition to taking the team out of availability for the duration. Limited resources require careful monitoring. I called my friend Dr. G over in the emergency room. He agreed that the baby should come in, and took over the patient’s management from there, activating the medevac team and coordinating with the health aide her removal to Bethel. I was delighted, as I still had two more villages to finish doing radio traffic with.

The following morning, the baby was on my schedule for “ER followup.” She looked great. X-rays in the ER had shown a dense right lower lobe pneumonia. With nebulized albuterol her O2 sat improved to 96%. (Everything causes bronchospasm here, it seems.) She was given a first dose of IV ceftriaxone, and would have been admitted, except that the inpatient unit was on divert (due to full beds, or not enough nurses, or both). Because she was stable, eating/peeing/pooping well, acting alert and vigorous, she was discharged to stay at the hostel for three days with daily follow up in clinic and return to ER if she suddenly got worse. The hostel owns its own fleet of nebulizers for overnight use by the patrons/patients.

I was glad to see her looking so good. She still had mild retractions and both wheezes and rhonchi and probably some rales too, in those junky sounding lungs. She improved noticeably after a neb treatment and some percussion and postural drainage. She and mom went back to the hostel with plans to neb every 4 to 6 hours and follow up the next day.

By the third dose of ceftriaxone she was ready to go home. Her vital signs were nearly normal (still a bit tachypneic with a respiratory rate of 24) but afebrile and her lungs sounded much clearer. Bright-eyed and vigorous, I watched her suck a bottle with gusto. Mom was very happy to take her home.

Patients like this one make me long for a day when we will have limited radiology availability in the village clinics. A small x-ray machine that would do chests and extremities and telerad the images to Bethel for interpretation would be fabulous. With so many people coughing and running fevers, I want chest x-rays on everyone. And a complete blood count (CBC). This patient could have been treated in the village with IM ceftriaxone and/or oral Augmentin and nebulized albuterol, if we had the technology to make the diagnosis from there. Once we do have the technology, it will save a lot of patient-travel miles.

This is the level of care currently available at the four sub-regional clinics in Aniak, St. Mary’s, Emmonak, and Toksook Bay. I hope someday that every village clinic will be staffed by a pair of physician assistants or nurse practitioners, have some limited lab and xray, and a slightly expanded pharmacy. The sub-regionals could then have physicians on staff, an ultrasound tech, a dentist, a pharmacist, a certified medical technologist in the lab… Maybe some day. The Tundra PA loves to dream.

Photo by The Tundra PA.


Saturday, November 18, 2006

Puppy Training

One of the most fun parts of maintaining a dog yard is raising and training puppies. Henry’s yard now has ten puppies, born from the two July litters. I put a few pictures on the blog when they were two weeks old. Now they are strapping four-month olds, and bounding all over the place.


The puppies live together unrestrained in a big 10’ x 20’ pen. They play together in a very
rough-and-tumble way, and dominance fights break out frequently but are quickly resolved. They all get along together quite well.


By the age of five months, they will go on
individual chains, and each will have his or her own house. They will also start training in harness. Two or three at a time, they will be hooked up with a team of older, patient dogs and go out for short easy runs.



Before their first hook up, they are allowed to go out with a team a few times, to see how much fun mushing is. It is a chaotic event that is a lot of fun.


Last Sunday Henry, Dutch and I took the puppies out for one of these. Henry hooked up seven of the older dogs and the puppies were turne
d loose to follow along. Dutch and I walked behind the team, encouraging puppies along. We only went about a mile before turning around. The puppies got yummy meat snacks several times, thus learning to pay attention to the musher and stay close.


Once the puppies got into the idea of heading along a trail, they rushed back and forth ahead of the team in a big pack, yapping with abandon and glee. They tended to swarm over the team and sled, and had to learn a few painful lessons abou
t staying out of the way.

When we returned to the yard, Henry took the bucket of meat snacks into the pen and all the puppies followed him right in. They got lots of pets and head scratches for being so good, and a special treat: a small chunk of whale blubber.


All photos by The Tundra PA. Puppies in the pen; part of the dog yard; cutting meat snacks; feeding meat snacks; Dutch with puppies, Henry with team; whale blubber.


Thursday, November 16, 2006

First Long Run

Sorry I have no delightful photos to accompany this post; read on to hear the story of how I lost my camera.

Henry and I took a dog team out yesterday for our first long run of the season. Andrea and Trevor (his niece and her husband) have been doing bare-ground training with the top 14 dogs in the yard since August (more to come on this), so the dogs are in good shape for this early in the season. Henry and I, on the other hand, were something of a different matter.

It was a gorgeous day to be out. It was cold; zero degrees with a brisk wind that probably put the chill factor about -20. But the sun was bright, the sky was blue, and the snow was sparkling. Now if only there had been a little more of it…snow, that is.

Early in the season, the trail is hard, rough, and bumpy. I mean teeth rattling, bone jarring, thigh straining bumpy. Tundra only looks flat from above; down at ground level, it is full of dips and rises, ottoman-sized mounds of frozen dirt and tough ground-cover plants, three-foot banks at the edges of the jillion tundra ponds, and sudden drop-offs when the trail crosses a small river or slough. Once we get a foot or so of packed snow, the trail will be smoothed out, kinder and gentler. Yesterday we had a body-pounding experience.

Since we didn’t know what conditions we might encounter, Henry wanted to take one dog team and one snowmachine. I will clarify a bit of history here that I have been vague about until now. I no longer have my own dog team. In 2005 I gave my sled dogs to a young village musher who was just starting out. It was an agonizing decision to make, but after a second back surgery—for an injury sustained while mushing—my surgeon said “no more.” It would have been hard not to see the wisdom of his dictate.

So now my love of sled dogs and the sport of mushing is fueled by my participation with Henry in the care and training of his dog team. He and I usually run dogs together twice a week through the winter. We take one large team of ten to twelve dogs; he usually drives and I ride in the sled, though when the terrain is easy I drive some too. It is nowhere near the same as driving my own team of dogs, a team that I raised and trained and care for, but at least it gives me some connection to the sport that I love, and I cherish it.

Henry wanted to pull the hook (musher talk for “leave”) at 11 am. I had my snowmachine out and idling smoothly by quarter till, so no problem. I thought. People are just beginning to travel around on snowmachines, and the trails around town are not well hammered in yet. Trying to get over a very rough patch on my way to the river, I rolled the snowmachine. Totally. Skis to the sky. I wasn’t going fast, and wasn’t hurt, just banged a little and shaken up. I got it rolled back upright and tried again. Before making it over the hump, I almost rolled a second time and just watched from the ground as the snowmachine teetered on its side and then went back down. Third time’s the charm and the only damage is a bruise on my thigh.

Henry had the dogs hooked up and was ready to go when I got there, so we took off. The trail out from his house is about two miles of wrinkled, rutted land before it gets to Hangar Lake. Really harsh going on a snowmachine. Once we got to Hangar Lake it was smooth traveling for several miles, and then we hit a lot more rough tundra.

Our destination was the Gweek River, about 8 miles from Bethel. Just before we got there, Henry headed off the main trail and started breaking trail through some willows. We made it almost to the river ice before we had to stop and clear some small saplings to open the trail; fortunately, he brought his chain saw, which made quick work of it. We were quite pleased with our new side trail; Henry had been warned that the main trail dropped off steeply from the tundra to the river’s surface—a four foot drop, straight down onto hard ice.

Another mile up the Gweek we pulled over alongside some willow trees and took a long break. It had been about a 45-minute run for the team. We snacked the dogs on frozen fish chunks and shared coffee and sandwiches. Being out of the wind and facing the sun, we were in a (relatively) warm spot. It was so beautiful out there.

I reached for my camera to take a picture and discovered to my horror that it was gone. The pocket I always keep it in was unzipped. The most likely spot to have lost it was back where we cleared trail, so I left Henry and the dogs to cut some small wood for the woodstove in the steambath and headed back to the new trail.

I spent an hour searching, but the camera was not to be found. Henry and the team showed up and helped me look some more, but still no camera. We watched the trail closely, all the way back, but there was no sign of it.

The trip home held yet another moment of anxiety. Henry and the team easily crested a five-foot frozen bank, and I watched them continue on, giving them time to get ahead of me. To make the bank on the snowmachine, I had to get a running start at it and power over. I almost made it when the track started slipping sideways, lost traction and slid back. I dragged the machine into position as well as I could, but there was no way to get a running start from where I was, and no way to get further back. Second try, no success. I was stuck.

Just as I was wondering how far away Henry would get before he came back to find me, a big snowmachine with two young Yupik men came up the trail behind me. They sussed it out in a glance, jumped off their machine, grabbed mine and simply hauled it up the bank for me. What a relief! I thanked them both appreciatively, and they just smiled. Henry and I had not seen any other travelers out on the land all day, so I felt incredibly lucky that these guys came by when they did.

I caught up with Henry not too far ahead, and he was wondering what had happened to me. He was just about to turn the team around. We made it the rest of the way without problems. I was so tired by the time we got to Henry’s that I left my snowmachine at his house and took a cab home. I just couldn’t face that roll-over spot again.

After an hour on the sofa it was clear that the piper would have to be paid for the day’s fun. I was already stiff and sore, despite ibuprofen and three glasses of water. I was in bed before 10 pm and awoke even more stiff and sore. I gave a moment’s wistful thought to calling in sick today, but I would have to be nearly dead before I could do that to my colleagues. So I hobbled off to work and have spent the day moving like a really old lady.

It is hard work having this much fun…


Tuesday, November 14, 2006

Grand Rounds Vol 3 No 8 is up

This week's edition of Grand Rounds is posted at The Rumors Were True. Our host this week is topher, an American studying medicine in the Caribbean. His theme is Monty Python, and he weaves it skillfully around the posts without detracting from them.

Of note is that this edition of Grand Rounds is more manageable in size than recent editions have been; he included the best 26 of the 60 submissions. As a GR reader, I appreciate that; I want to read the best of the medblogosphere. An edition that includes 50+ posts is simply too big. This particular question, of quality vs. quantity in GR, has been the subject of brisk discussion today over at Kim's Emergiblog; she has a well-stated post opining that quality is where it's at. I have to agree, as do most of the commenters.

Thanks, Kim, for saying what needed to be said. And thanks, topher, for an excellent edition of Grand Rounds.


Saturday, November 11, 2006

Checking the Ice

The thermometer has hovered around +10 degrees for two days now, with occasional dips to near zero in some spots. Freeze up is coming along nicely. There have been occasional brief snow showers, enough to whiten things up but not enough to cushion the bumpy terrain of the tundra. From the banks, the Kuskokwim River looks quite solid, and people are venturing out carefully, walking and pulling small sleds.

Henry is getting antsy to get on the back of a dogsled and get out into the country. Traveling is still a little chancy at this time of the year, but with careful checking it can be safe. Henry asked Dutch and me to go with him for an afternoon outing to check the ice. From his dogyard he must cross Hangar Lake to get out of town, and its state of frozenness governs the start and end of his mushing season.

Bethel’s only long empty road is the road that goes out to Hangar Lake. It is perhaps a mile and a half long, and ends in a small turnaround at the edge of the lake. Hangar Lake is large enough to be a float-plane base in the summer, and thought to be about ten feet deep. It is just a large tundra pond. Long, tough marsh grasses grow at the edge, and as the lake freezes, these provide a matrix that strengthens the ice. It is often possible to travel around the edge of the lake several days before the center is safe.

It was a beautiful afternoon to drive out to the lake. Huge blue sky without a single cloud, low sun making dramatic shadows and no wind to speak of. Since we weren’t sure how much thin ice there might be, dogs had to stay home, much to their disappointment. They know once we start dressing into serious outdoor gear, that we’re going to do something fun.

No one else was out on the lake. The ice looked great. There was already a snowmachine trail showing in the snow that headed straight across the lake. When we hiked around the edge we found no thin ice or problem spots. Henry had his long-handled ice chisel and chipped a few small holes here and there to be sure. Often vertical fractures appear in very clear ice, and these give the perspective needed to guess at the ice’s thickness. W
e could easily see five inches of thickness in some of the fractures. Probably strong enough to drive a car on, though nobody will for a while yet. I was really wishing we had the dogs with us. The Big Dog loves to run.

After an hour of hiking, we sat on the tailgate of the truck and drank coffee from the thermos. It was so beautiful out there, peaceful, and very quiet. With no wind and the sun shinning on us, it felt almost balmy.

Henry told us a funny story. Henry is a long-time friend of an outstanding Yupik musher from one of the upriver villages, Mike Williams. Mike is a veteran of over a dozen Iditarods, and
skillfully manages the diet and training of his large dogyard. His son, Mike Jr., is an up-and-coming young musher in the mid-distance races.

Mike recently arranged for an Inupiat musher in Barrow to send him a thousand pounds of whale blubber to use for dog food. It arrived by cargo plane, frozen into one
solid 4’ x 4’ x 4’ lump. A fork lift was used to load it into Mike’s truck. After that, it was his problem.

Henry agreed to help Mike out. They decided to put about 300 pounds of whale into Henry’s big freezer; Mike wanted to take the rest home to his dog team by boat (this was late September). After 3 days sitting in the back of Mike’s truck, the edges of the block softened enough that the outer strips of blubber could be peeled off. Each one was about four feet long, a foot wide and nearly a foot thick, and weighed thirty or forty pounds. They used crow bars and boat oars to pry the strips apart.

The biggest problem was holding on to them. Blubber is pure fat; they were slipperier ‘n goose snot as my hillbilly kin might say. Grease from the warming blubber got on everything, including both men as they tried to carry and stack the big strips.

When they couldn’t manage to peel any more strips off, Mike drove his truck to the small boat harbor where his skiff was moored. The cube of thawing blubber now weighed about 700 pounds, and the two had to load it from the back of the tr
uck into the boat. Henry was afraid of putting a hole in the boat if they just shoved the cube off the truck and let it fall.

They decided to try to lower it gently, but between the grease on the surface of the cube and all over both guys, it somehow didn’t work. Just as the cube came down, the boat (which wasn’t moored to the truck) danced sideways and splash! Seven hundred pounds of whale blubber are now sitting in three feet of water. Floating, actually. Thawing would now commence at a much faster speed. The cube was quickly surrounded with a thick grease slick.

They managed to drag the cube out of the water and pry it apart into hunks small enough to pick up and heave into the boat, and Mike took off to get it home to his dogs. I hope they like it; he says “it lets them run really fast.”

Driving home from Hangar Lake, Dutch and I drove past the waterfront and stopped to watch people out ice fishing. It is called manaqing. First a hole is chipped or augured into the ice about a foot across. A short 18” stick is used as the fishing pole with very stout line attached to it. A large hook is on the end of the line. The hook is baited and lowered through the hole in the ice; the fisherman sits or stands at the edge of the hole and bobs the pole until something strikes. Then s/he rolls the pole, wrapping line around the end until the fish is brought up.

The target fish right now is lush, a bottom-feeding cod relation. Some people say the meat tastes like lobster. A delectable Yupik dish is fried lush livers. The liver is actually a fairly large organ in this fish, two to three inches long and an inch thick. Fried quickly in hot oil with a breadcrumb coating, they are quite delicious. They don’t taste like liver at all (this from an avowed liver-hater); they taste like a fish pate with a crust.

An afternoon of ice fishing is often a family affair. Several adults and a few kids will drag a small sled with tools and supplies out to a spot on the ice and chip four or five different holes so that each one fishing has his or her own hole. A dozen lush would be a good catch for a family. Today had perfect weather for ice fishing; I hope all the folks out there caught some.

Photos by The Tundra PA. The road to Hangar Lake. One edge of Hangar Lake. Henry. Float plane launching ramp at Hangar Lake. Kuskokwim River in front of Bethel. Families ice fishing. More ice fishing. Dad shows daughter how to hold manaqing stick. Two kids fishing, Dad at the sled.


Wednesday, November 08, 2006

Freezing Up

Winter seems a little slow to take over southwest Alaska this year. We are about two weeks behind our usual point in the freezing up process. Spring was about that late in leaving, so perhaps it all balances out. The river is solid ice all the way across in front of Bethel, but just barely. No one is walking on it yet.

Shelf ice starts at the edges of the river and grows out until it meets in the center. Open leads and thin ice can exist in the center well in to winter. When people must cross the river before the ice is trustworthy, they do it in pairs dragging a small skiff between them. If the ice breaks, or they come to open water, they hop in the boat and row to better ice. By December the river should be safe to cross with a dog team, and perhaps by snowmachine.


The sky is beginning to have a more wintry look. Our winter sky has the most amazing variety of shades of blue in it; sometimes even the air looks slightly blue. The sun is not nearly so high in the sky now at midday, and has a watery quality to it that offers little warmth. When the wind is blowing (often!), there is none at all. Daylight approaches us stealthily now around 9 am, and has faded almost completely by 6 pm.


The migratory birds are all long gone. Ravens are once again the kings of the skies around Bethel, and there are lots of them. They are large birds, quite bigger than crows in the lower 48, and bright, inquisitive, and saucy. They talk a lot, too. Ravens can be quite a nuisance, with their ability to get into things and wreak havoc. They are very entertaining to watch; quite the acrobatic flyers, they do stunts seemingly just for the fun of it, like rollovers. Eagles do them as part of their mating flight, but I’ve never seen eagles do it just for fun, as ravens do.

The thermometer outside my kitchen window read +12 degrees this morning, and warmed up to +20 by late afternoon. Hopefully, we won’t get above freezing again for a while now. Most people here look forward to freeze up; life is a lot cleaner without the mud of a rainy fall. Bethel is much prettier wearing a white dress.






Photos by The Tundra PA. The river in front of Bethel; boats frozen in at Brown's Slough; sunset from our deck looking southwest; Bethel dumpster.


Tuesday, November 07, 2006

The Hundred Day Cough

Author's note: the accompanying photo is not the patient described in this story. The story is fiction.

The latest epidemic of whooping cough to hit southwest Alaska started about two months ago in one of the coastal villages. An eight-week old girl, scheduled to have her first round of immunizations in a week, was brought to the village clinic by her mother because "sometimes she just stops breathing." Mom had noticed two episodes of apnea with peri-oral cyanosis; both times she responded to direct stimulation and started breathing again, but Mom was worried. Mom reported that the infant had a slight cough which seemed worse at night.

On physical exam by the health aide, the baby looked fine. She had normal vitals, was breathing well, and had no runny nose or watery eyes. Her cough was minimal. But as the health aide watched her lying on the exam table, she simply stopped breathing. Again, she responded to stimulation.

The baby was medevac'd to the Alaska Native Medical Center in Anchorage, where she was diagnosed with pertussis. She was treated with antibiotics and admitted for supportive care for a few days, and then discharged home with her parents.

Within two weeks there were four more cases of pertussis in her village, two in kids less than one year of age, and two in teenagers. Soon cases showed up in a neighboring village. By the time the epidemic ended there were 24 cases in four villages. Health aides became very adept at performing nasopharyngeal swabs.

Whooping cough is an infection of the respiratory system caused by a bacterium, Bordetella pertussis. Its close cousin, Bordetella bronchiseptica, causes kennel cough in dogs. When untreated, whooping cough is an illness with three stages. The early stage, or catarrhal phase, is much like any viral upper respiratory illness; it produces runny nose, watery eyes, dry cough and sometimes low-grade fever. It lasts for one to two weeks. The middle, or paroxismal phase, causes the characteristic coughing paroxisms that end in a sudden whooping inspiration, and can end in vomiting. This phase may last several weeks. The final or convalescent phase is a gradual decline of all symptoms; though a persistent cough may last for many more weeks, it will not be as intense or paroxysmal as earlier in the illness.

Pertussis is highly contagious and is spread by droplet transmission of respiratory secretions. The biggest risk factor for getting it is being coughed on by someone with active disease. In most village homes in southwest Alaska, crowding is the norm; from five to twelve people often live in a rather small home, which increases the likelihood of disease transmission.

The population at biggest risk from the infection is very young babies, who do not usually have the characteristic whoop. Neither immunization nor disease confers immunity for more than a few years, and children are not routinely immunized for it after age 5 years. In adults, it typically causes minimal illness, and boosters have not been routinely recommended. Adults are recognized as a potential reservoir of bacteria which can be transmitted to children.

When the epidemic was recognized in the coastal villages, a public health effort was quickly put into place. The physician assistant/nurse practitioner team from the closest subregional center traveled to each village with identified cases. They addressed a "town hall" type meeting of the entire village and educated the villagers about pertussis with handouts, videos, and an audio tape of the sound of the cough. Villagers were asked to identify themselves to their health aides, or to the PA and NP if they felt they had symptoms consistent with pertussis. Many came forward. All were tested. Those the mid-levels felt had symptoms truly consistent with the disease were treated prophalactically with macrolide antibiotics (erythromycin, azithromycin); and all positives were treated.

The educational sessions were also an opportunity to get immunizations updated on those who were behind. Over a hundred DTaPs were given during the four educational sessions. Adults are also now being immunized with TDaP to see if boosting them with pertussis vaccine will decrease the burden of disease in young children.


Monday, November 06, 2006

Grand Rounds at MSSP Nexus

Grand Rounds Vol. 3 No. 7 is up at MSSP Nexus blog. This week's host is Rita Schwab and she does an excellent job of organizing a huge edition. Grab your coffee and enjoy some good reading--the best of the medical blogosphere.


Sunday, November 05, 2006

Six Month Anniversary

Tundra Medicine Dreams is six months old tomorrow. When I look back over how much I have written and posted since then, it seems so long ago. The blog, and my thinking about it, have evolved over that time, though that may be more evident to me than to TMD readers.

My initial intent was to be totally anonymous, to have no identifiable information about myself on the blog, to tell no one at the hospital about it (except my Clinical Director, for legal reasons). What was I thinking? I don’t live in a high-population area, marginally distinct from other high-population areas (i.e. urban Midwest) where anonymity is possible and even easily achieved. I live in a small community that is very different from most of the rest of the world. Word gets around here; anonymity in the hospital would be difficult to maintain.

And in the blogosphere? Probably there as well. When I hosted Grand Rounds in September, Nick Genes asked me in the pre-Rounds interview how important anonymity was to me. I had to admit that it had become less important than it initially seemed when I first started writing Tundra Medicine Dreams. He pointed out that a web-saavy clinician in the lower 48 could probably figure out who I am.

As a result of Nick’s interview with me on Medscape, Tundra Medicine Dreams and The Tundra PA came to the attention of The AAPA News, the twice-monthly news magazine of the American Academy of Physician Assistants. They wanted to run a story about me, but insisted that they must use my real name and identify me as a Fellow of the Academy. I took a few days to think about that, and to discuss it with Dutch. It meant “coming out” and I had to decide if I were ready for that. He felt that it was time, and he encouraged it. The News is distributed to the 60,000+ PAs who are members of the Academy, and once the story runs (possibly this month) any vestige of anonymity will be vaporized. I wonder if a tsunami is about to crash over me.

With these events as background, the six-month anniversary of TMD, and the start of winter, which is always a time of introspection for me, the blog has been much on my mind lately—even more than usual, if that is possible. Its voice (my voice), its direction, its presence as an entity in the medblogosphere, and where I want it to go in the next six months. The huge question is just how personal and self-revealing I want to be.

Several commenters have stated recently, both on the blog and in private email, that they want to know more about me, my background, my friends, my personal life. There has been a request for photos of me on the blog, which I have so far carefully avoided. The concept of fame is not one that I can apply to myself at this point in my life; but I recognize that, because of Tundra Medicine Dreams, I have become a personality that is known to people beyond the circle of individuals that I have actually met. Who I am and what I am doing is interesting to them, and some of them want to know more. What I have to decide is how much more I want to tell.

When I started writing TMD, my orientation to my own “voice” on the blog, as the narrator, was that I was creating a persona. The other characters I have introduced—Dutch, Henry, Joan, Michael and Luke, Betty, Andrea, numerous health aides and patients—are also personae. They are my creations, based on real people. I have thought of these creations as sort of a Sub-Arctic Lake Wobegone Tales, or Spoon River Anthology. My friend Traveling Doc (of Borneo Breezes) suggested in an email that if TMD is going to become a book—it might—then I should enlarge upon these characters, realize them more fully. I am thinking of doing a series posts, the TMD Kusko Anthology perhaps, that would do just that. Going in this direction means that I may be absent from Grand Rounds for a week or so (*sigh* I love what Tuesdays do to my sitemeter). Feel free to leave your thoughts in the comments. Reader input is always encouraged, considered, and appreciated.

Happy six month anniversary, Tundra Medicine Dreams! You have changed my life; you have allowed me to think of myself as a writer.


Wednesday, November 01, 2006

Shadows Dancing

My search for spirit tales among the Yupik Eskimo culture revealed another gem which I would like to share with you. The following essay was written by a Yupik woman, Juanita Treat, who has worked at the hospital for over twenty years as an interpreter. Joan found it among the material she dug up for me from her course on Yupik culture back in the early 1990s; Juanita had written it for one of the students in the class. I showed it to Juanita and she was amazed to see it. She remembered writing it those many years ago, but did not have a copy herself. She was happy to allow me to reprint it on Tundra Medicine Dreams.


By Juanita Treat

Folklore, mystery and magic surround the spirituality of the Native people of this land. Folklore because not much is written on this section of our culture. Mystery because this is not something we usually discuss. Magic, I’ll leave that to your imagination.

When the long, dark winter nights settled in and the cold winds whispered and whined through the cracks and eves of the house, families would light the coal oil lanterns and shadows began their slow magical dances on the walls, the fire crackling in the wood stove, whispering of stories yet untold. These were times when the elders passed down age-old stories to the younger generation so they would not be forgotten.

This was also a time to teach the unwritten laws of the land, sea, sky, and the ruler over all these things. Not only were the young taught to respect their elders, but also to respect the land, sea, sky and all living things that resided within. We believed that by doing this, the land, sea and sky in turn would also respect us and provide for us our daily needs. Last but not least, was that the greatest respect was shown to the Power that made all these things possible.

When these stories were done, the room would grow quiet and the elders would begin to tell stories of forces that resided among us; and these were also respected and feared. So intense were these stories that no one moved a muscle or dared to ask questions. We heard, during those times, that these forces could foresee the future, cast out demons, and could maim or destroy you during your sleep. We were warned, after this, to always respect these forces that were identified, and not to talk about this to anyone, or they could cast a spell on us. Spirits were also talked about, and the close encounters people had with them.

One of those evenings, they began to whisper of a lady who had been visited. She was all alone at home with only her two young children. The children were playing on the floor not too far from where she stood cleaning the table after their meal. All of a sudden the dogs started making weird whining noises deep in their throats, and the children stopped playing and the house became very still and quiet. They heard footsteps crunch on the snow outside their door and come to a dead stop; again everything grew very quiet and dead still. All of a sudden the door flew open and a gust of cold, damp, musty air blew in; but no one was there. The dogs again began whining deep in their throats, and the lady, fearing for her children, walked slowly out the door. But she found no footprints in the snow. Shaking in her shoes, but determined to get rid of the ghosts, she completely encircled her house and then slowly made her way back in again and shut the door. The dogs stopped whining and settled back down and the children began to play and all was quiet for the rest of the night.

We are told that if we ever see a spirit that we will become deathly ill and sometimes we could die from this. When my grandmother was young, before they went to bed they would always put a pail of water and a dipper by the door so when the spirits came by at night they could have a drink of water and leave you alone. A young girl laughed at her parents’ warning and didn’t do as she was told. The next morning she woke up very thirsty and no matter how much water she drank, couldn’t quench her thirst. Three days later she was dead.

Grandma Petka was a respected elder of our community and when someone became sick she was often asked to go to that person’s house to pray for them. One such evening, we heard that the old Moravian minister had taken ill and hadn’t been able to eat or get out of bed for three days. His wife, fearing for his life, sent word to my grandmother to please come up and pray for her husband. Grandma was embarrassed, but out of respect for the old minister and his wife, she went to their home to pray for him. I know that when someone got sick, Grandma always did a water/spirit ceremony that called upon all the good spirits to come and take away all the bad spirits; I can only assume that this is what she did before she prayed for him. After this, the old minister fell asleep and when he awoke, he asked for something to eat and was able to move around again. Throughout my life, I remember people coming to ask Grandma to pray for them and to perform the water/spirit ceremony for them. I can only liken this to your baptism ceremony.

We also respect the dead, and when someone leaves us, we bathe them, put on their finest clothes, and for three days we join the family of the departed by eating with them, singing, mourning our loss and sharing stories, because we believe that the soul of the departed is earth bound for three days and is amongst us for those days. We never used to bury our dead, but would place them above ground surrounded by their worldly possessions. Out of respect for the dead, these articles were never touched unless we exchanged something we valued for the things we took.

One time an elder, who was known throughout the community to be very stingy with her belongings, passed away. Her daughter, forgetting this, gave away her mother’s scarves to some women of the village. That night, for some reason, seemed to be an especially dark night; during the course of the night, the dogs, only in front of the women’s houses with the scarves, began to howl and growled from deep within their throats. The next day the women talked about it, but brushed it off as coincidence and let it pass. That night the wind blew and houses creaked and again the dogs began to howl and make the same slow, long, deep-throated growls they had the night before. The women didn’t sleep a wink that night and the very next day they took all the scarves and burned them so that the lady who had passed on could have them back. That night, the dogs never made a sound and all slept peacefully through the night.

After a death, the next child born into a community is named after the departed. If a man passed away and the next one born is a girl, she will receive his name; and if he was married, the wife calls the little girl her husband. When a visitor comes to our home we are taught to welcome them in and feed them and give them something to drink because they may be a family member who has passed on, and by treating them with kindness we are giving to our loved ones. The passage from the Bible comes to mind, “do unto others as you would have them do unto you.”

All the years that I spent with my grandmother she would also teach me bits and pieces, especially early in the morning. She said these things that she taught me would stay with me better because my mind was fresh and not cluttered in the mornings. I remember her talking to me about the things we would see in the years to come, when the earth’s crust would become thin. We would see sons and daughters killing their families and diseases with no cures. I didn’t know what she was talking about at that time, but now when I think back, I marvel at the knowledge she had back then, and she was considered illiterate, even though she could read the Bible in Eskimo. How did this lady know what was to come to pass?

Winter is coming and once again the shadow dancers will appear. I feel that our Native medicine men are still at work, guiding all people to help us in our mission as protectors of the land, sea and sky.