AAPA National Conference

The 35^th Annual Conference of the American Academy of Physician Assistants is about over, and it has—as usual—been an excellent CME (continuing medical education) experience. PAs are required to earn 100 hours of CME every two years, and this conference is a great way to achieve some of those. I should log about 25 hours from this week.

There are nearly a dozen sessions to choose from every hour, starting at 6:30 in the morning and going until 8:00 at night. Topics cover just about everything in family practice, as well as lots of surgical and sub-specialty areas. Sometimes it is difficult to choose. I’ve attended lectures on early detection of ovarian cancer, management of animal bites, neurologic complaints in primary care, skin cancer, atypical presentations of disease in the elderly, management of female pelvic floor dysfunction, use of hyperbaric oxygen in non-healing wounds, new treatments in rheumatoid arthritis, wilderness medicine, working with people who self-harm, acute knee injuries in sports, treatment of interstitial cystitis and chronic pelvic pain…and on, and on, and on. The lecturers have generally been quite good, and at this point my brain is just about stuffed.

One of the things I love about PA conferences, as compared to MD conferences, is the very “hands-on” approach. The focus is on clinical relevance, without a lot of dense slides and droning on about this study and that study and endless discussion of minutia (zzzzzzz…). One of the things I love about this particular conference is how empowering it feels to be in the midst of over five thousand PAs from all over the country. PAs are now licensed to practice, and have some form of prescriptive privilege in all 50 states. For a profession that only began some forty years ago, that is quite an accomplishment. Attending this conference with so many of my colleagues reminds me that I am proud to be a PA!

Philadelphia has been a nice city to visit, and we’ve been blessed with mostly pleasant weather for the last week. A bit warm for an Alaskan at 80+ degrees, and more humidity than I like, but the air conditioning works well here, and I haven’t suffered. My 22-year-old niece was able to fly up from Kentucky to join me for the Memorial Day weekend, and we had a blast together. We took a tour of Philly on an open-top double-decker English bus that was just great. It drove us around to all the historic sites—Independence Hall, the home of Betsy Ross, the Liberty Bell, the Franklin Institute, the Rodin Museum, the Philadelphia Museum of Art (home of the “Rocky Steps”), and the Basilica of Saints Peter and Paul. You can just hop off the bus at any stop and catch the next one when you are done touring that site. And the tour guides are lively and quite funny.

One of the highlights of this trip was getting to meet two of my favorite bloggers. The wilderness medicine lecturer was Dr. Paul Auerbach, author of the gold standard textbook Wilderness Medicine, as well as the blog Medicine for the Outdoors. He has left a comment on Tundra Medicine Dreams before, so I hoped to be able to meet him. He gave three successive lectures and was surrounded by people asking questions after each one. I did manage to introduce myself and shake his hand, but there was no time to actually talk, which I regretted.

The other blogger I was delighted to meet and actually spend a few hours with was Dr. Dino from Musings of a Dinosaur, and family Darling Spouse, Jock and Fledgling, and the Rolling Peke. My niece had a great time playing Frisbee with the sons and Dr. Dino and I had lots to talk about. Did you ever meet someone and feel instantly like you had known them forever? That's what it was like. My personal interpretation is that we knew each other in a previous life. Instant connection. Dr. Dino is a delightful individual, and just as salty in real life as in the blogosphere. Add some yummy barbequed ribs, beer from the local microbrewery, and three purr-bucket kitties, and you have one fun afternoon. And to put all your minds at rest, Dr. Dino does not have scales or green skin!

The conference wraps up tomorrow, and then I’m headed back to cooler, drier climes. The puppies have probably doubled in size during my absence. And soon it will be time to go salmon fishing. The first kings are already coming up the river. Yummmmm, fresh salmon! I can’t wait.

Puppy Update

Princess's puppies are three weeks old today. They continue to grow and develop beautifully, and are staggering around in their house on unsteady little legs. Their eyes are still that universal newborn dark blue color with an unfocused gaze. I wonder how much they are able to see at this point.

Sled dog pups get their dew claws removed on the second day of life, and this litter was no exception. Booties are much easier to get on and off a working sled dog without that floppy and useless claw just below the wrist. Henry did a good job removing them (not always easy) and the little stubs have healed up nicely.

At three weeks they are walking enough to fall out the front door of their house occasionally. And now they are big enough that Princess has a hard time getting them back in. It is time to build a little ramp up to the front door. It is fun to watch them explore their world.

And on a completely different note, I am flying out tonight to attend the annual conference of the American Academy of Physician Assistants. This year's meeting is being held in Philadelphia, a city I've only been to once, about twenty years ago. I'm really looking forward to it. Posting may be even more infrequent until I return home.
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Tuesday's Joy

...is another edition of Grand Rounds. This week it is up at impactED nurse. Our host threw down a challenge to medbloggers: pick your single best-ever post and submit it--with an explanation of why it is your best.

The challenge was taken up, and the result is a great edition of Grand Rounds--the best of the best. Grab a hot cup of coffee and enjoy!

...and in case there are any blogosphere tourists left who are unfamiliar with this, Grand Rounds is a weekly blog carnival with rotating hosts, offering a selection of the week's best medical blogging. The schedule for upcoming hosts (and the archives of past ones) is maintained here.
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Prom Night

Bethel’s high school prom is an event unlike any prom anywhere else. To understand why that is, you must understand Bethel.

This is a dusty, grimy little river town with mostly dirt roads and wooden boardwalks. To say that the dress code here is “relaxed” is an understatement. I would wager that well over half the adult men in Bethel do not own a suit. Women rarely wear high heels and most don’t wear makeup. Getting “dressed up”—for Sunday church, for a wedding or a funeral—generally means that your jeans are clean and have no unintended holes in them, and that you scraped the mud off your boots.

A formal event is a rare occurrence here, and requires extensive planning. Bethel has no dress shops, tux rental shops, shoe stores, florists or limo-rental services. We have no department stores, and no mall. Shopping for clothes in Bethel is pretty much limited to browsing the jeans and t-shirts in the clothing sections of the two grocery stores. Not exactly prom appropriate.

Bethel Regional High School is a small school with a total student body of about 225. This year, 35 seniors will graduate. In my high school of 800 students (250 in my graduating class), the juniors and the seniors each had a separate prom; here there is a single prom for both juniors and seniors and whomever they choose to invite.

Preparations begin months in advance. Rented tuxes are ordered online and mailed out from Anchorage. For the girls, a shopping trip to Anchorage is generally required. The state wrestling and basketball championships earlier in the spring (with travel paid by the school) offered excellent opportunities for shopping. The girl’s basketball team was eliminated early, and the girls dedicated the rest of their time to the pursuit of the perfect prom dress. Corsages and boutonnieres must also be ordered early, and they cannot be bought in Bethel.

In my day (granted, a few years ago), not to have a date for the prom was a social black mark of the highest order. If you didn’t have a date, you spent the last school day before the event talking widely about how prom is nothing but a stupid and juvenile social ritual and a huge waste of money and you wouldn’t go even if someone had invited you. What you did NOT do, under any circumstance, was show up without a date, either alone or in a party of your same-gender friends. It just did not happen.

What also did not happen at prom in my day was the appearance of parents. There were a handful of chaperones—favorite teachers, invited by the Prom Planning Committee to serve that function—but no other adults.

This is where Bethel’s prom is different than any other I ever heard of. It is a community event, and one that inspires quite a stir around town. It is the one opportunity to see our young people really dressed up.

The prom starts at 8:00 pm, and only the attendees are allowed in the door. By 8:30 the community starts lining up at the door—families, little kids, neighbors, anyone who wants to come. At 9:00 the doors are opened and the crowd surges in. The focus of the prom decorating committee has been the creation of a stage-type backdrop and runway. Once the crowd has gathered around the runway—cameras ready—the Grand Promenade begins. An announcer introduces each couple individually and they walk “onstage”, pause for photos, and then proceed down the runway with several more pauses for photos. Dozens of flashes going off at once, it resembles a Hollywood Grand Opening. And this year’s prom theme is “Hollywood.”

Those attending without a date are introduced alone. Several girls were introduced as pairs; not that they are lesbian (though they could be, and that would be fine), they just decided to come together since they didn’t have dates. Plenty of girls were dancing together, too. The mores of the 70’s (at least in the Deep South) did not allow such flexibility; sometimes change is a very good thing.

The Promenade lasted about an hour. Afterwards there was much milling about and more photo-taking. Then the non-promers were invited to leave so the kids could get on with their Big Event. Dutch and I were quick to skedaddle, and left hoping the rest of the adults would do the same.

Not having kids in the school system here, I have not previously attended the Grand Promenade. This year our young friend Michael, son of Joan, was attending for the first time (he’s a junior), so of course we had to go. Now we will probably show up every year, just to see the kids dressed up. In Bethel, there is nothing like it.

All photos by The Tundra PA. Michael is that handsome dude in the next to last photo.

Urban Jewel

Anchorage is really a lovely small city. Nestled in a bowl surrounded by tall mountains, perched on the edge of Cook Inlet, it is a city with stunning landscapes and breathtaking views. To me, there is a feel very similar to Seattle about Anchorage, only smaller; it is about a quarter the size of the bigger metropolis. Anchorage is sometimes referred to as “Seattle’s bedroom” and described as being “not really Alaska, but you can see it from there.” With a population of over a quarter million people (40% of all Alaska residents), it is by far Alaska’s biggest city, and has enough skyscrapers in the downtown skyline and hustle-and-bustle city energy to really feel like a big city on a small scale.

Except for winding Spenard Road, which was originally a moose trail, the city is laid out in a four-square grid that is easy to read on a map and easy to get around in. The city is compact enough that getting across town never takes too long, even with some traffic (compared to, say, Seattle; or—egad—Los Angeles). And no matter where you are, there is the looming presence of the huge Chugach Mountains, like protective shoulders hunched around the city.

One of my favorite spots in Anchorage is Lake Hood, a large municipal lake dedicated solely to float/ski planes. The lake is over a half mile across, and the entire perimeter of the lake is taken up with float plane parking spots. Pilots rent the spots and moor their planes there. Many of the sites have small gear “shacks”—some as elaborate as small log cabins—and tiny docks next to the mooring hardware sunk in the lake bottom. But there are no homes on the lake. And no boats of any kind, and no swimming allowed. The lake is completely restricted as an aerodrome, and signage peppers the lakeshore conveying that message.

There is a large and lovely hotel, the Millennium, located on one part of the lake shore, but no other businesses. The Millennium is one of Anchorage’s nicest hotels, and serves each year as headquarters for the Iditarod. The location on Lake Hood makes it very convenient for the many small planes—collectively known as “the Iditarod Air Force”—which support the race.

About half of the lake has a well-maintained bike/walking trail along the shore, which is well used year ‘round, with occasional benches where one can sit and watch the planes land and take off on the lake. Lake Hood is not far from Anchorage International Airport, and is one of my favorite spots for killing a little time when I am ahead of schedule for check-in.

This past weekend Dutch and I were back in Anchorage for two days. My hip continued to be quite painful since the trip over in April to see the orthopedist and get the MRI which diagnosed a labral tear of the acetabulum. I decided to go with the next step and get the steroid injection.

For this the orthopedist referred me to an interventional radiologist. With fluoroscopy guidance, he inserted a 3 inch long needle (22 gauge) into the hip joint. Once he removed the lidocaine-bearing syringe, leaving the needle in place, there was an eruption of fluid from a good-sized joint effusion. He said he expected there to be some after a month of irritation in the joint, but he was surprised at how much was there. I was surprised because I had had no sensation of fullness or pressure or anything to suggest a fluid collection. He aspirated some into a syringe and it was clear and light yellow—a very good sign. No blood and no pus. He then injected triamcinolone and depo-medrol into the joint, along with marcaine.

The whole procedure took perhaps thirty minutes, and I had immediate and substantial pain relief. Just removing the effusion allowed me to extend the hip (i.e., lie flat on my back) for the first time in over a month. I was still limping, but not nearly as much as before. The radiologist said to expect continued improvement for up to two weeks.

When I made the plane reservations for this trip, I wasn’t sure how much recovery time would be needed after the procedure. Not wanting to push myself, I made the return trip for the following evening. We could have simply gone to the airport and gotten on the next flight to Bethel, but trips to the city are costly and generally infrequent, so we decided to stay as planned and enjoy ourselves. Dinner and a movie might not seem like much to get excited about, but it is when you are from Bethel, where we have no movie theaters and few restaurants.

The next day we decided to forgo shopping (having been in town only three weeks earlier) and take a drive down to Alyeska, Alaska’s only major ski resort. It is about 45 minutes south of Anchorage on the scenic Seward Highway which runs along the edge of Cook Inlet, the northernmost reach of the Pacific Ocean.

The resort is still operating its upper slopes, where the snow is reasonably fresh for spring skiing. Dutch and I hopped on the tram at the base of the mountain and rode up to the top. The view was beautiful. Alyeska has the lowest elevation of any ski resort in America—under 4,000 feet. But considering that the base of the mountain is not much above sea level, there are some nice long runs between top and bottom. Alyeska is also the only ski resort in America where you can see the ocean from the top of the lift.

It was nice to get out and drive a little, something I miss living in Bethel. We returned to Anchorage with a couple of hours to spare before our flight out, so we spent the extra time at Hood Lake watching the planes and enjoying each other’s company. The lake may be closed to human swimmers, but there were a number of ducks and waterfowl on the lake. And a beautiful bald eagle flew right over our heads as we sat on one of the park benches, being chased by a raven who complained loudly at the raptor’s presence.

When we got to the airport for the flight home, we ran into quite a few people from Bethel that we know; that is usually the case, and the waiting area at the gate for any Bethel flight often resembles a party as people are chatting and visiting. Living out here at the edge of civilization on what is essentially an island surrounded by an ocean of trackless land draws us together in a unique way. Anchorage is a nice place to visit...and most of us really like going home.

Photo of Anchorage by unknown photographer, from Wikipedia article. All other photos by The Tundra PA.

If It's Tuesday, Grand Rounds Must Be Up

Of course it is! The host for Vol. 3 No. 33 is The Blog That Ate Manhattan. TBTAM presents us with an excellent collection of posts. This week's edition is a tribute to Barbados Butterfly, the blog of an Australian surgical registrar which was closed by her employer. Those of us who were her regular readers miss her voice; the blog was well-written, interesting, lively and entertaining. TBTAM's tribute is timely and appropriate. And her choices for this week's Grand Rounds give us some excellent blog-reading. Thanks for hosting, TBTAM!

A Visit to Platinum

Earlier today, Dutch had one of those serendipitous opportunities to do something fun and unexpected that come along every so often. A friend invited him to take the extra seat on a charter plane to the village of Platinum for a quick down-and-back afternoon trip to look at the site for a new fish processing plant. What a great way to spend a clear and sunny spring day.

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I knew he’d have a good time. His friend is a hard-working, energetic young man named Brian who once worked for Dutch, and for whom Dutch served as a mentor. A different job opportunity drew him to Anchorage a few months ago, and Dutch has missed him. Brian was glad to have his new company send him out this way on the reconnoiter mission.

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Platinum is a tiny village on the edge of Kuskokwim Bay, about 125 miles south of Bethel. It has 41 residents. The children are either home schooled or sent away to school; the building sits empty since it was closed a few years ago. There is no village clinic or health aide; patients travel 12 miles to Goodnews Bay, the closest village. Simple problems are often cared for by a man with some nursing training who has lived in the village for about fifteen years.

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Platinum is located on a spit of land at the mouth of Goodnews Bay. It was named for the eponymous mineral being mined there in 1927. A fish processing plant being built there would be a huge financial benefit to the community.

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The flight down took about 45 minutes and was smooth and beautiful. It was a great day to be out flying. The Kuskokwim River is completely clear of ice, as is Kuskokwim Bay and as far out into the Bering Sea as they were able to see. The mountains that are the tail end of the Kuskokwim Range march right down to the sea at Platinum.

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Brian and Dutch were met at the airstrip by a guy with a pick up truck who drove them around the village. Dutch took pictures and Brian talked business and they were back on the plane home within an hour. It was a nice Saturday afternoon.

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All photos by Dutch.

A Gentle Break Up

Break up refers to the rapid transition of Alaskan rivers from ice to water. During the winter, nearly every one of Alaska’s hundreds of rivers freezes solid on the surface to a depth of several feet. When spring comes all that ice gets washed down the rivers and out to sea. It happens quickly, within just a few days’ time.

The event is often violent, with loud sounds like rifle-shot as the great plates of ice break apart into huge chunks. The plates bang against each other and pile up at the river bends, uprooting trees and generally scrubbing the banks clean as they bob heavily along toward their destiny as sea water.

The Kuskokwim River usually takes about three days to go from solid ice to flowing river. This year it happened gently, with very little of the ferocious display that Nature is capable of. Our early warm weather started the ice rotting, and it seemed more to melt away to than break up.

Dutch and I took a drive down to the river front on Thursday after work. The quad-pod for the Kuskokwim Ice Classic was still standing, though a little tilted, and the icepack it stood on was about fifty yards downriver from where it had been erected. The cable to the building on shore had been broken, and the moment of break up was declared as May 3^rd at 8:35 pm, about five minutes before we got there. I was much aggrieved that I had left my camera at home. My closest guess was off by 42 hours, so I won’t win the jackpot.

By this morning, 36 hours later, the river was almost completely free of ice. This year there was no parade of huge icebergs down the river, no jumble of trees and logs, no dead animals caught by the ravaging ice. All of which means we have a low flood risk this year. Most of our flooding occurs when the big ice plates get jammed up together at the bends and shallow spots in the river. This year the ice softened up enough before breaking up that we had a river full of slush rather than one full of big ice cubes.

We are breathing a huge sigh of relief over this year’s break up. The flooding that often follows it requires a huge amount of work to move animals and property to high ground, and to clean up the muck left behind when the water recedes. Nobody minds the occasional year with no flooding.

With the river flowing freely, summer can’t be too far off (though we do have a snowstorm predicted for tomorrow). As always at this time of year, I can’t wait for my first taste of fresh king salmon!

Photos by The Tundra PA.

New Puppies

In February I wrote about the homecoming of Princess, the dog I bought from Susan Butcher seven years ago. Though a little thin, she came to Henry’s yard in good health and in very fit condition after having run the Kuskokwim 300 in January. Henry immediately put her in lead position for training runs with young dogs, and she did beautifully. We decided to breed her as soon as her next heat cycle occurred; no one knew when her last heat had been.

Princess has had two previous litters. Both times she was sent back to Butcher’s kennel in Fairbanks for breeding; the sire of both litters was Riker, Butcher’s top-choice stud dog (who commands a stud fee of $500). He is a smart, tough-minded lead dog whose litters are known for a high percentage of leadership potential among the pups. Princess’s first litter had six pups, the second litter had seven. Each litter had one almost totally white dog with a few black markings (not albino); the rest of the pups looked very much like Riker: gray/black/brown fur with very little white. Those two litters were born a year apart, and by the time they were grown it was difficult to tell them apart unless you knew them well. They all looked very much alike, and very much like their dad.

It can be very difficult to tell when Princess goes into heat. She has what is known as a “dry” heat cycle: there is very little bloody discharge. The vulva becomes somewhat swollen and moist, but this is difficult to notice due to her tail carriage. Princess’s tail does not curl up and over her back like many sled dogs; it is only slightly curved and she tends to carry it down, often tucked between her hind legs. This position obscures the vulva completely. Princess also tends to have widely spaced heat cycles; they occur every nine months instead of every six, like most bitches.

The main way to tell when Princess—or any other female—is in heat is by the attention of the males. They are all suddenly intensely interested in her, sniffing and licking her genital area, licking up her pee, peeing all around her (sometimes on her). When this behavior is going on, a quick check under the tail usually reveals the reason. A moist, swollen vulva indicates her estrus cycle.

The heat period usually lasts about three weeks in dogs. For the first ten days the bitch in heat will produce a scant bloody discharge. If she is fastidious, she may keep herself quite clean, and the only noticeable change is that she is licking herself a lot. During this time she may be flirtatious, but she will not accept the male for breeding until the discharge shifts to a creamy pink. Then she is in full standing heat, which lasts about a week. Her readiness can be tested by seeing if she flags: pat her strongly on the hips just above her tail a few times; if she drops her hips a bit into a crouch and holds her tail to one side, that’s flagging, and she’s ready.

Most bitches will breed three or four times during that week. When the male achieves full penetration, a bulb-like structure in the base of the penis swells to an impressive size, which makes him unable to withdraw. This lasts for nearly a half hour after the coupling, and is known as the “tie.” A single tie is adequate to conceive a litter of pups, but two or three ties are desirable. If a female ties with more than one male during her heat, the resulting litter may have more than one sire.

Princess came in heat in late February. Riker was not available to sire another litter, so we bred her to one of his offspring, a handsome dog named Sitka. She was at the end of her heat by the time we brought them together, and they only tied once. Fortunately, once was enough.

Gestation in dogs is about 58 days. Princess was bred on the first day of Iditarod, March 3^rd, so her puppies were due on May 1^st. I took some photos of her on the 1st, and her belly was so big it looked about to pop. She waddled restlessly around her circle and had that anxious look they get when they are about to whelp.

On May 2^nd, Henry called me in the late afternoon and said “She did it! There’s lots of puppies, come look!” So of course, I did.

She has six beautiful puppies. One is white with a few black markings (of course!), one is tan, one is a sable gray much like Princess, and three are almost all black. One of the black pups is male, the other five are female. All are healthy and about the same size, and all were nursing vigorously. She looked tired, but every bit the proud mom. I sat at the door of her house, petting her and talking to her for a while, and admiring her beautiful pups. She did a great job. Now the fun begins!