One of the more unique aspects of my job—and one of the most enjoyable—is traveling to a village and spending several days working with health aides and seeing patients in the small village clinic. Life has a different pace and a different focus in the villages, and it is refreshing to experience that.
Napaskiak is a Yupik Eskimo village of about 370 people located 14 miles downriver from Bethel. The people of this village have relatively easy access to Bethel for shopping and health care compared to people from the farther villages. Napaskiakers easily travel in by boat in the summer and by snowmachine in the winter. During the difficult transition periods around breakup and freezeup of the river, they come by small planes operated by the commercial charter services which offer scheduled service; a round trip ticket is about $120 for the seven-minute flight.
After three years as the assigned health care provider for this village, I finally had the opportunity to make an official hospital-sponsored village trip last week. It was the first time they had had a provider visit in four years.
Pulling off a village trip that runs smoothly requires some planning and preparation. The health aides are notified as far ahead as possible that the trip will happen and are encouraged to begin putting together a list of the patients they consider the most ill, the most fragile, the most home-bound in the village. They are also asked to start creating a list of equipment and supplies that they are short on. The Village Operations department of the hospital does a good job of supplying the village clinics, but many health aides tell me that at times they just can’t get certain things. The tiny blue ear scoops for removing ear wax is one example.
The hospital, of course, wants me to see as many patients as possible in the time I am there. And they want me to see all of the patients in certain categories: all the pregnant women, all the children under one year of age, all the people with diabetes, all the home-bound elders, and as many as possible of the patients who are on chronic medications. In addition to seeing patients, other activities are encouraged as well, such as going to the school and giving health talks to the students, or meeting with the village’s Tribal Council to discuss health issues of concern to them.
For this trip, I also had the pleasure of company. A newly-hired PA on our medical staff, Claire (NHRM), was assigned to go with me and learn how to do a village trip. Claire is a delightful and enthusiastic young woman who has been a PA for several years; she is excited about having moved to Bethel and taking up the work we do here with the Yupik people. She is a wonderful addition to the medical staff and I greatly enjoy working with her. This was her first village visit, and she was nearly vibrating in anticipation.
Our flight across the river left Bethel at 8:30 in the morning, just before sunrise. We were the only passengers in a small four-seater plane and the trip literally took about five minutes. We never flew above 300 feet. When we landed at the airstrip, the charter company’s agent was there to meet us on a four-wheeler pulling a small trailer. Our gear went into the trailer and Claire and I climbed on the four-wheeler behind the agent. He drove us over the boardwalk the half mile or so to the village clinic.
Napaskiak is laid out in one long line bordering a slough just at its entrance to the main Kuskokwim River. A well-maintained boardwalk extends from one end of the village to the other—perhaps a mile—with houses one or two deep on either side of the boardwalk. The houses are not numbered or named; everyone knows where everyone lives. The clinic, the school, and the store are located in the center of the village; the big Russian Orthodox church is at one end of the village and a small one is at the other. The post office is close to the small church.
Four-wheelers are the transportation of choice in Napaskiak. They go everywhere, and the boardwalk is wide enough for two vehicles to pass each other. Most people have a trailer to pull behind their vehicle; this is how they get their water. The village has a small water treatment plant with a large outdoor spigot labeled “Public Watering Point.” Homes have one or more 33-gallon plastic garbage cans designated as water containers; these are loaded on the four-wheeler’s trailer, filled at the Watering Point, and carried into the home to be dipped from as needed. Living with dipped water adds a whole other level of complexity to life; we easily take for granted the ease of turning a faucet in the kitchen or bathroom and having fresh, drinkable water flow out endlessly.
It was shortly after 9 am when we carried our gear into the clinic and greeted the two health aides, Harold and Aggie, and the clinic clerk, Katya. What we noticed right off was that they all had their coats, hats and gloves on. It was pretty chilly in the clinic.
“No heating oil,” said Harold. The clinic’s tank had run dry the evening before and the furnace had shut down. Normally the tank is refilled before it gets so low, but the entire village had been low on heating oil for several days. Fortunately, a fuel barge had stopped at the village the day before and filled the main storage tank, so the clinic’s maintenance man was able to go that morning and get fuel to restart the furnace. It would take several hours before the building was warm again.
Claire and I decided that the time could be best used by doing home visits on elders. Harold grabbed a couple of charts and the health aide home visit kit (BP cuff, oxygen saturation monitor, stethoscope, thermometer, first aide supplies) and the three of us climbed on the clinic’s four-wheeler.
Our first stop was at the home of Lillian, the village’s oldest resident. Her age is listed in her hospital chart as 95 years, but her family says she is actually about six years older than that. Many elders in the Yukon-Kuskokwim Delta have uncertain birth dates; eighty years ago, such records were not kept. The local missionaries back then often assigned birth dates arbitrarily, and tended to use the date of first communion as the birthday.
Lillian welcomed us to her home, which was thankfully warm. She speaks no English at all, but Harold translated readily. She lives with her granddaughter, who takes care of her in the evening and does the cooking; but in the daytime she is home alone, as her granddaughter has a job. Lillian’s eyesight is failing but she gets around in the small house without bumping into things. She is at increased risk of falling, and we were there because she had fallen a few days earlier and the family was worried about her.
Claire and I checked her pretty thoroughly and she seemed well enough. Clearly there were no broken bones, and we only found one small bruise. Her upper and lower extremity strength were both quite good—likely the result of a lifetime of hard physical labor. A Yupik woman born in 1905 could expect nothing else. Her gait was slow and halting, but she picked her feet up well with each step. The family was hoping we could get her a wheeled walker to use in the house. I pulled out my clipboard and put that down as the first item on a list of things to be done on our return to Bethel.
The next stop was at the home of a man in his seventies who had had a moderately severe stroke some years earlier. His right arm and leg had marginal function. He sat in his wheelchair and could move around the house by pulling himself forward with his left leg. His wife wondered if we could get him a bedside commode, as she had trouble helping him get to the honey bucket in the middle of the night. Item two on the list.
Our third stop was to see a young mom who had called the clinic that morning because her two-week old baby was coughing. She has seven other children; the oldest three are in school, but the five-, three-, and two-year-old are home with her and the baby, and taking them all with her to the clinic for the baby to be checked was more than she could manage.
“Is it bronchiolitis?” she asked somewhat hopefully as soon as we were introduced. She knows about bronchiolitis. Most of her kids have had it and she is quite proficient with albuterol and a nebulizer. She is also experienced at “pounding”—percussion and postural drainage, or P&PD. If it were bronchiolitis she could keep the baby at home, give him albuterol nebs and P&PD every four to six hours and have daily rechecks at the clinic. Her fear was that this was pneumonia, which would mean a trip to Bethel and probable hospital admission for the baby. That would require a complicated arrangement between her sisters and aunties and her husband to take care of the other children while she was gone.
We unwrapped the baby near the living room window where the light was good and were reassured by his ease of breathing. No blue lips or nailbeds, no grunting, minimal retractions. His temp was 99.8 rectally, his heart rate was 158 and his respiratory rate was 62. The sat monitor read 94%. Yikes.
Mom knew he needed a neb treatment, but since it would be his first, she wanted him checked first. Oh, yes, I thought, let’s do that RIGHT NOW.
His breathing sounded junky, full of moist rhonchi that the health aides often describe as “snoring lungs,” but he was alert and looking around and moving all extremities. Mom quickly set up the nebulizer, poured an ampule of albuterol into the cup and had the baby breathing medicine in no time. After the treatment she turned him over in her lap and effectively patted his tiny back, helping him cough up the small mucous plugs that were interfering with his oxygen saturation. The monitor now read a reassuring 97% and his respiratory rate dropped to the low forties. Since he was afebrile and responded quickly to the albuterol, I was reasonably sure that this was bronchiolitis and not pneumonia. But lack of fever in a neonate does not necessarily mean lack of bacterial infection; the hospital has a standing order that all infants less than eight weeks of age come in for a septic work up, including lumbar puncture, for any fever greater than 100.3 degrees.
Harold, Claire and I agreed that the baby could be watched closely for the next 24 to 48 hours, with nebs every four hours and daily rechecks at the clinic. If he seemed worse at any time to Mom, or if his temp went above 100.3, he would go to Bethel. By Medevac if necessary.
We returned to a warm clinic just before noon. The staff went home for lunch and Claire and I unpacked our gear in the itinerant sleeping room, which has two bunk beds, a microwave and sink. No refrigerator. With daytime temps in the thirties and nighttime temps in the twenties, I figured I could keep the half-and-half for my coffee from either freezing or spoiling by putting it outside in the daytime and inside next to the back door at night. Worked perfectly. The frozen dinners we brought simply stayed outside all the time. Thank goodness for a microwave.
The next few days went by in a flash. Claire and I both saw a steady stream of patients, but the pace seemed much more relaxed than at the hospital. There were no emergencies to wake us up in the middle of the night, which can easily happen in the villages, and for which I was grateful. Our evenings were quiet; fortunately both Claire and I are avid readers and were happy to have time for it. There is a television in the clinic, but it only picks up two channels and both of them are quite fuzzy. I had hoped we would be able to take a steambath with some of the village women, but that did not happen.
Our last morning there, two young children were brought to the clinic who were both fairly sick. One was a two-year-old who had been taking albuterol nebs for a week or so, now weaned down to once or twice a day, but she had suddenly developed a fever of 101.8 and now had “heavy eyes,” a common health aide descriptor for lethargy. We gave her back-to-back nebs times three with P&PD after each neb, but she did not perk up much. Her temp came down to 100.2 with a dose of ibuprofen. I put a call in to the pediatrician on call in Bethel and we discussed the case. She needed to come in on the next commercial flight that afternoon; in the meantime we would do hourly nebs and watch her. Dad stayed at the clinic with her while Mom went home to pack.
The second young child was a one-year-old named Max with one of the worst cases of impetigo I have ever seen. He had been on topical mupiracin ointment and oral cephelexin for a week, and the infection was spreading and getting much worse. Blood cultures drawn at his visit in Bethel five days earlier were positive for Staph. Though his temp was 101 and his rash looked horrendous, he was a smiling, happy, drooling baby.
This time I grabbed the digital camera from the telemedicine cart and took photos of Max. Then I logged on to the telemedicine program and created a case presentation for him: his demographic info, a brief history of this episode of illness, and the photographs. I sent it to the pediatrician in Bethel and then called her and told her it was coming. She pulled up the case, reviewed it with me, and we decided that Max also needed to come to Bethel on the afternoon commercial flight.
Claire and I finished up with patients about 3 pm and got paperwork and supplies packed that we needed to take back with us to Bethel. The agent for the charter company called at 3:30 and said that our two sick children and their mothers would be taking our seats on the flight. We were bumped. They would try to get another plane out in about two hours to get us, but weather was closing in and they might not make it. I looked out the window to see snow falling rapidly and visibility about half what it had been an hour earlier. “Welcome to the bush; it is all part of the experience,” I told Claire.
We had planned our food well, and neither of us had any left. I laughingly told Harold that he would have to cook dinner for us if we did not make it out that night. “You’ll make it,” he said seriously.
At 5:15 it was still snowing fairly heavily when the agent called again and said a plane would be coming for us in about thirty minutes. We piled our gear in the trailer and hopped on the four-wheeler behind Harold. Snow was stinging my eyes and my hands were freezing with fleece gloves on as we roared up the boardwalk to the airstrip. Harold was barehanded and did not seem to mind. “It’s not winter yet!” was all he said when I mentioned it.
No plane was in sight when we got to the airstrip, but another four-wheeler was waiting. On it was a young girl of 14 or so, an older woman and a screaming toddler. The girl and the woman patiently watched the sky. The child just screamed. Thank goodness this is a short flight! I thought to myself.
Soon we heard the buzz of the plane’s engine and in no time it was pulling up in front of us. The people on the other four-wheeler had no luggage and just watched as Claire and I handed ours to the pilot who stowed it. We climbed into the six-seater and buckled ourselves in. Then the older woman came forward with the toddler and tried to put her into the plane. The child screamed even more, she fought, she tried to hold on to the woman.
“Would you hold her?” the woman said to Claire.
“Oh, well, sure,” Claire responded, thinking the woman wanted to get herself strapped in without fighting the child to do it.
“Thanks,” she said. “Here’s her bag. Her mother will be waiting in Bethel.” And with that she handed over a tiny purse-like bag and backed away from the plane! Claire and I looked at each other in disbelief.
The child was no longer fighting, but she was still screaming. Claire, mother of a toddler herself, put her arms around the little girl and began singing a lullabye. The child became quiet almost immediately. Crocodile tears shined in her eyes, but she did not make another sound.
“What do we do if her mother is not there?” Claire asked me.
“Let’s just hope she is,” I said.
We walked into the small waiting room in Bethel, which was full of people, carrying the silent child. “Is this child’s mother here?” yelled Claire over the din of many conversations. We looked around. No one came forward. After we toured the room repeating the question, a very thin young woman said “My baby!” At the sound of her voice, the child started crying. Mom comforted her and by the time we had collected our luggage she was smiling and laughing.
Claire and I looked at each other and laughed as we walked out the door. “Welcome to the bush!” we said in unison. It wouldn’t happen anywhere else.
Photos by The Tundra PA. Stories and image of Max and Lillian used with their family's permimssion.
Labels: Bush Medicine
Claire sent me a few photos from her camera--some of which I took--so I will add a short addendum to the previous post and share them with you.
Village transportation. Four wheelers are the best way to get around in the village. There are no streets or roads in the village that a car or truck could drive on. A few people have them for driving up to Bethel in the winter on the ice road, but must leave them parked at the edge of the river. The only pathway through the village is the boardwalk, which is about eight feet wide and constructed of wood right on the ground. Whole families pile on these small ATVs; I have seen as many as ten people at once--without a trailer--riding on a four wheeler. Interestingly, unlike the village of Pilot Station on the Yukon River, people here do not refer to them as "Honda", though almost all of them are.
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Claire and the crying baby who did not want to leave her grandma. Once she stopped crying, she never said a word. Wouldn't tell us her name or how old she was. She just sat on Claire's lap and stared silently out the window. Fortunately she was not fighting us, and did not seem mad any more. Probably just scared at being handed over to strangers. When we found her mother in Bethel, she said the baby's name is Michelle and she is 3 years old. By the time we left the waiting room with our luggage, she was running around with several other children, laughing and talking a mile a minute in both Yupik and English.
