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.




Blogger Mother Jones RN said...

Thank you for sharing that very interesting story. I always enjoy your posts.


Monday, November 27, 2006 8:38:00 PM  
Blogger always learning said...

I've never understood how some health systems have such blatant problems. Who dreamt up a great insurance system with 100% coverage, but NO method of helping people access care? I mean, that's not an easy feat for the elderly or infirm to get health care even if public transportation is good, and it seems nearly impossible in rural Alaska!

Some of the VA systems have a great system where a van will travel once a week and take people on a several hour ride to the closest VA. It's not ideal because it's only once a week, and the poor patients have to make sure they get back on the van by a certain time, but it's better than nothing!

Tuesday, November 28, 2006 6:32:00 PM  
Blogger Al said...

Man! These guys and gals are tough as nails!

Tuesday, November 28, 2006 6:46:00 PM  
Blogger TheTundraPA said...

mj--thanks for visiting!

always learning--transportation has always been the problem here, combined with weather. Some of the villages of this region are very far flung. Routine transportation for health care is covered for those who have Medicare/Medicaid, and for those children who have a state-funded program called Denali Kid Care, which is most of the children in our region. The folks who have neither (I'm guessing here) are about half the population. The hospital pays for transportation for anyone from a village to Bethel for danger of loss of life, loss of limb, or cancer. And anyone who ill or injured enough to need Medevac will get it, regardless of financial status. The difficulty is the young adults (20 to 40 years olds) who are generally healthy but get sick enough that they need to come to the hospital but not sick enough to Medevac. And the older folks who don't qualify for Medicare. That is part of the difficulty in doing Radio Medical Traffic. Interpreting the health aide's information and making decisions about necessary and available treatment can be a real challenge. It is all part of bush medicine.

I appreciate the fact that you have been interested enough to read back through the archives and leave comments on several different posts. Thank you!

al--you're right. No other way they could have survived here all these years.

Tuesday, November 28, 2006 7:45:00 PM  
Anonymous peter said...

I had a boil a few years ago, and I hadn't steamed for over a year when I got it. I was coaching basketball at the time and probably got it from one of the kids through a pat on the back or something. It was on my left leg, just below the knee. Anyway it got so bad, I was at Bethel Family Clinic (the alternative to YKHC, no offense, I'm a kass'aq and YK was busy) and I almost fainted at one point even before they were lancing it. So thats a long way of saying, yeah, they are tough folks. Many of our students have multiple boils at a time. Officially kids aren't supposed to come to school when they have a boil. Off the record I'd say 1/4 to 1/3 of them have boils at any given time. Crazy. Some families virtually "always" have boils bouncing around between siblings and parents and grandparents in one home. Others get them only very rarely, though they all steam. I heard that the CDC came out here to investigate why the YK Delta gets so many, but I don't know that much came of it. Thanks for the as-usual fantastic reporting of everyday life on the delta!

Wednesday, November 29, 2006 8:49:00 PM  
Anonymous mchebert said...

Although I am not in as remote an area as you are, I have had similar experiences. Patients with skin infections that could be life threatening but who lack them means to get to a hospital for one reason or another.

I have managed infections I had no business treating as an outpatient. I have pleaded with patients to get to a hospital. So far my luck had held.

You can only do the best you can.

Thursday, November 30, 2006 8:35:00 AM  
Blogger Sara the NewEnglander said...

That was a great story. I can't imagine how tough people have to be to live in such a secluded place like that.

Thursday, November 30, 2006 7:11:00 PM  
Anonymous Anonymous said...

Too bad the native corporations don't help their people with the transportation costs. ~Val

Saturday, December 02, 2006 1:56:00 AM  
Anonymous ozziedoc the 4th yr med student said...

Another wonderful blog TTPA.

I'm spreading the word! I am directing doctors in England who are disheartened with the UK to your site, in the hope that they will be inspired to undertake some voluntary work in Alaska......don't know if it will work, but I am trying!

Saturday, December 02, 2006 11:18:00 AM  

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