Housekeeping

Perhaps it is because I am an Aries—you know, not a lot of patience with the details. Whatever the reason, housekeeping is just not my strongest suit, either in my actual house or on the blog. As long as things are reasonably tidy and mostly clean, I’m good with it. But some chores take me forever to get around to, despite my best intentions. Like repotting the plants. I’ve been promising them new dirt for a year now.

When it comes to blog housekeeping, the equivalent of repotting the plants is updating the blogroll. I want to do it. I need to do it. I just never get to it. Having more than a mild case of HTML-phobia doesn’t help.

For several weeks now (OK, months) I’ve been lurking at a half dozen new (to me) blogs and enjoying them thoroughly. I’ve planned to write a post encouraging TMD readers to check them out, and to add them to the blogroll. But my recent bout of blog ennui has seen me reading without mentioning them, or even commenting much on their blogs. Enough of that.

All of the following seven blogs came to my attention via my friend #1 Dinosaur at Musings of a Dinosaur, who I am proud to call my friend in Real Life as well as in the blogosphere. Dr. Dino definitely has a finger on the pulse of blogland (or would that be a toe?). Thanks, Dr. D!

I think it started with Ambulance Driver (AD) at A Day in the Life of an Ambulance Driver. He writes well, he handles volatile subjects gracefully, and he has a kick-ass sense of humor. When he posted the story of his daughter with cerebral palsy, he had my heart in his hands. Precious few blog posts can bring tears to my eyes, but this one did.

AD and Dr. Dino both had mentions of a nurse in Georgia named Babs, the blogger at Living Single in the Buckle of the Bible Belt, so I had to mosey over and check her out. Wow. A smart-and-sassy Southern blonde; I felt like I had found my blog sister (we share three out of four of those, but she is way sassier than I am). Her blog is now called Just Peachy, which is a lot easier to say than LSITBOTBB.

I am a sporadic reader of comments on other people’s blogs and hadn't been keeping up recently, so I was taken totally by surprise when AD and Babs made a Big Announcement last week. Read his version here and her version here. And congratulations to you both! I just love that Awwwwwwwww factor. I am so happy for you; you both deserve that finding-your-soul-mate joy. It is a wonderful thing to have.

AD also has frequent references to his friend Matt, who blogs at Better and Better. Matt is a small-town police officer in the Deep South who writes with compassion. Recently he and AD and Babs created a beautiful joint effort: each of them wrote a story from their individual perspectives—the responding officer, the ambulance driver, the ER nurse—about the events of a single night. They each posted their sections on their own blogs and pointed readers to the other two blogs to get the whole story. I was quite taken by the creativity of the idea and the beauty of its execution; and deeply touched by what they wrote. If you haven’t read it, do. Matt’s part. AD’s part. Babs’ part.

The two new ER nurse bloggers I am now reading and being highly entertained by are Monkeygirl at Musings of a Highly Trained Monkey and the eponymous blogger of ERnursery. Both are well-deserving recipients of the Thinking Blogger award. Both have the right balance of wit and snark to be amusing and thought-provoking at the same time. Both have many good posts, so rather than point to one, I’ll let you browse for yourself—and do!

Another friend of AD’s (that boy really gets around!) is the LawDog, blogger of The LawDog Files. Another small-town cop who writes well and tells a good story. And I love his hundred-year-old granny; she is five years older than mine, and cut from the same cloth. I’d love to meet her; even better, I’d love for my grandmother to meet her. It’s not so far from Alabama to Texas.

And finally, there is the Medblog Addict—a lawyer—at Addicted to Medblogs. I love her ever-changing lawyer-joke-of-the-day in the sidebar. And I was ROFLMAO when I read the August entry for her Doctor-of-the-Month Calendar. Yes, no other than the estimable Dr. Dinosaur! Both MA and Dr. D are in top form for this interview. And the revealing photo of Dr. D—what beefy cheesecake--breathtaking. I immediately wrote to the dinosaur and suggested an avatar change.

And speaking of the Thinking Blogger award, I was immensely pleased and very proud to have this sought-after crown bestowed upon my own head by Dr. Dino some months back. I did not mention it here at the time for two reasons. I mostly don’t blog about blogging, and I couldn’t figure out how to do the html-thing to get the TB icon in the sidebar. Pathetic, I know. But thanks, Dr. D! I was, and am, honored.

So there you have it. Next thing you know I’ll be posting my results on the Rate Your Life quiz that was all the rage five minutes ago. And house plants, look out! Your repotting is near.

Berry Picking on the Yukon River

The primary subsistence activity of the Yupik Eskimos in July and August is picking berries. The vast tundra of southwest Alaska is literally covered in berries in late summer—salmonberries, blueberries, blackberries and redberries, the Native people love them all. Berries are the main source of vitamin C in the traditional diet, and are usually either made into jam or frozen for later use. Last year I wrote a post on berry picking here.

Berry picking is not an idle or a casual activity. It is pursued with a focus and intensity that is surprising to the uninitiated. Whole families travel by boat or four-wheeler to their traditional sites for “berry camp” and spend weeks at a time camping on the tundra and picking berries all day long. We have sunlight for about 18 hours a day right now, which makes for a lot of picking.

The entire family takes part, men included. Berry picking is not “women’s work.” A family of six or eight people will hope to bring home at least twenty gallons of berries to be put away for winter. As most of the berries are tiny, less than a centimeter in diameter, it takes a lot of berries to fill a five-gallon bucket.

And picking them gets to be back-straining work after a while. All the berries grow on ground-cover type shrubs which are about six inches tall. Picking requires walking slowly, fully bent over at the waist with hands moving quickly. It is no wonder that we see more people in clinic for backaches this time of year. If the picker comes across a thick cluster of berries, he or she may kneel to pick for while or even sit down and pick around themselves. Some elders carry little camp stools with them to make it easier on backs and knees.

Last week I had two extra days off, which I had not made any specific plans for other than simply being available for life. Henry had family visiting from the Midwest and was off camping with them; Joan and the boys were downstates visiting her family; Dutch does not get nearly as much time off as I do, and he was working. So I decided to make a quick trip to Pilot Station, the small village on the Yukon River for which I am the assigned provider. I had two goals in mind: to take a steam bath with my friend Alice, and to pick berries.

Since this was not an “official” trip, sponsored and paid for by the hospital, I did not plan to do patient care; but any time the people of the village find out that I am there, a few always request to be seen. It costs about $200 round trip to fly between Bethel and Pilot Station, and the folks without Medicare/Medicaid or other insurance must pay their own transportation; if I can see them in the village, it saves them money. I agreed with the health aides that I would spend two half-days seeing the patients who most needed it.

Even short trips to the village require a lot of baggage. Since this was not a hospital-sponsored trip, I did not have the big silver trunk full of supplies or the pharmacy case full of medications. But every visit I bring sleeping bag/pillow, grub box of food, small cooler, rain gear with boots, steam bath supplies (four towels, large basin, hat, washcloth, toiletries), and a case or two of fresh fruit as a gift to the people of the village. This trip I also brought a dozen loaves of fresh bread for the health aides. Even with judicious packing, it was well over the weight limit and added $50 to the price of the ticket. When I see the kids’ eyes light up at the sight of the case of apples or oranges, it is totally worth it.

The flight up was quick and smooth, with a tailwind that took five minutes off our flight time. The company agent met the plane and hauled me and my luggage down to the clinic just as the health aides were leaving for lunch. I used the hour to put stuff away and eat a quick sandwich, and was ready to see patients for the afternoon by the time they returned. A phone call to Alice in the afternoon confirmed my first goal: she was delighted to light the steam that night.

The village clinics all close at 4 pm, and the health aides are usually anxious to get home. They all have families to feed and chores to do. At the hospital we routinely work until 6 pm or later, so finishing the day at 4 always seems early to me. To my great delight, the clinic’s four-wheeler (a.k.a. “Honda” as all four-wheelers are known in Pilot) finally got new tires and is back in service. I was handed the key and instructed in the quirky requirements for getting it started—quirky since some kid tried to start it with a screwdriver in the ignition and really screwed up the keyhole. A little jiggling was required, but I managed to get the hang of it. Gas in the village is $7/gallon, but I was happy to fill the tank and have easy transportation. I joined the numerous Hondas buzzing around the village, joyriding just for the fun of it.

Alice came by the clinic to find me about 8 pm. She had been out on the tundra picking berries all day and had just come in. One of her sons was chopping wood for our steam bath, and she needed to get home and cook up some salmon for them to eat. “The bath should be ready in an hour or so,” she said as she cranked her Honda and sped away. Perfect timing.

She was still cooking when I arrived, so I sat down and watched. Most Yupik food is either baked or boiled. But Alice is a modern woman—she has an electric skillet. One of her boys had brought in two silver salmon, and she cut the heads off and removed the guts and egg sac intact. Then she cross-cut the fish into steaks, dredged them in flour and fried them in a half-inch of oil. She cooked the egg sac the same way. Her husband and three sons ate fish almost as fast as she could cook it. Pilot bread with margarine and blueberry jam rounded out their meal.

The steam bath was crackling hot. Alice had invited one of her married daughters and an elder woman to join us. I knew them both, though not well. We had a delightful time talking and telling stories, and time flew by. Before I knew it, my watch read well past midnight. I jumped on the Honda and was back to the clinic in a flash.

Alice had said she would meet me the next morning around 11 to go pick berries. I saw patients for about two hours, and then donned Gore-Tex pants and knee boots. The weather was sunny and clear, but tundra is often wet and boggy and the trail is known for being muddy. I had the Honda fired up and ready when Alice showed up with another elder I knew, Annie, riding behind her. The daughter who had steamed with us was also coming, along with her husband who would be our protection. He had a rifle loaded for bear—literally. Black bears have been seen recently in the area we were going to.

So we took off on three Hondas, and I would soon be glad that I did not have a passenger. It was some really rough riding to get far enough away from the village that the berries were untouched. We were traveling on open tundra, up on high bluffs overlooking the Yukon River. Over hills and through valleys, bumping over tundra tussocks and squishing through hub-deep mud bogs, the trail lead us steadily downriver for over an hour. Often the bumping and dipping made it more comfortable to ride the Honda standing up with knees bent to absorb the motion.

Eventually we got to the spot Alice wanted and scattered out to start picking. Her son-in-law scouted the area and reported no bears present. Annie found herself a promising spot and sat down amongst the berries to pick from a seated position. The rest of us walked and picked, walked and picked. It was a beautiful spot, so I was taking photos as well. We had come so far downriver that we could actually see the village of St. Mary’s in the distance.

After a few hours of picking I needed to start back, as I was catching the late plane home that afternoon. My one-gallon bucket was less than half full (I’m not a fast picker) and I was happy with that amount. But Alice insisted on giving me all the berries she and her daughter and son-in-law had picked also; she wanted me to go home with a full bucket. I was delighted and grateful for her generosity.

The trip back was just as rugged as the trip out had been, but did not seem as long. I was more confident in my Honda-riding skills by then, which helped, though still glad not to have a passenger. The experience reminded me of riding a mechanical bucking bronco. It was huge fun, and I can’t wait to do it again. That will probably have to wait until next summer; the berries are just about gone for this year.

My Yukon berries filled a one-gallon freezer bag with about a quart left over. I froze the gallon and made blueberry cobbler with the quart. Since that trip, Dutch and I have been picking blueberries on the tundra in front of our house, and I have to brag that they are just as big and juicy as the Yukon berries. We put a second gallon in the freezer and the rest have gone directly into use. Last night I baked a blueberry pie, and this morning I made blueberry pancakes for breakfast. We easily have another gallon of berries out front; I may have to call my grandmother for her jam recipe. It is a good thing that Dutch loves blueberries as much as I do.

Photos by The Tundra PA

1. Detail of tundra growth.

2. Alice's daughter. Classic picking posture.

3. Open tundra berry fields. St. Mary's in the distance.

4. Alice and Annie.

5. Annie picking berries.

6. Loaded up Honda. I've seen as many as 8 people on one at once.

Pulling Teeth

Writing has been like pulling teeth for me these last few weeks, as evidenced by the dearth of posts on this blog. Life is full and busy, I just haven’t been inspired to write about it. This is not so much writer’s block, as I have numerous ideas for topics I want to write about; it is more like lack of writer’s discipline—an inadequate supply of “bum glue”, as author Elizabeth George phrases it.

This is not a new problem for me. Writing has always been something I have done in waves: big output followed by long periods of not writing at all. When I started the blog a little over a year ago, one of my reasons was to create a tool that would improve my discipline about writing. And it has definitely done that. In the first year, I pretty consistently posted two to three times per week. For the last month or two, though, I seem to have hit a trough.

Recently I read that there are now estimated to be over 77 million blogs on the internet. When I first started there were around 40 million. With such an explosion of blogs, there is plenty out there to read. Way more than most people have time for. To those of you who are loyal Tundra Medicine Dreams readers, thank you. You certainly have plenty to choose from, and I am honored that you choose to read my work. To those of you who are also commenters, thank you even more! Like all bloggers, I love comments. The great beauty of this format of publication is the ability of the writer to interact with his or her audience. That alone is a powerful motivator to keep writing.

I never intended to take a blog vacation, and that is not what I am calling this current phase. I’m thinking of it more like the trough before the next wave, which will come. In the meantime, my creative writing mind is traveling more often to the fantasyland where my first novel is gestating. It, too, is about life in Alaska.

More as it comes.

Enjoy Grand Rounds at the Beach

Grand Rounds is posted this week at Eye on DNA. Our host, Dr. Hsien-Hsien Lei gives us a lovely beach house setting for a large collection of interesting posts from around the medblogosphere. I was pleased to be included in this week's edition; it is the first time I have submitted a post for consideration since January. It is nice to be hanging out with some of my favorite bloggers again. Stop by for the weekly pot-luck.

A PSA Story

He was the last patient of the morning, and as usual, I was running about an hour behind by the time I got to him. He had a twenty minute appointment for abdominal pain. He was the third abdominal pain patient that morning; the first two had been women of reproductive age who also had twenty minute appointments.

The first thing he told me when I walked into the room was that he had to make his 3:00 check in to catch the last plane home. He had borrowed the $200 plane fare from his village council to come in for the appointment, and he couldn’t afford to stay over. He barely had money for lunch.

A bandy little man in his mid-forties, Evan (e-VAN) might weigh 135 pounds with all his clothes on and his pockets full of pennies. His round face and full cheeks proclaimed his Yupik Eskimo heritage. His English was good, so we didn’t need an interpreter.

I reviewed his chart before going into the exam room. I know several of his family members, but had never seen Evan before. He has had complaints of lower abdominal pain and dysuria (painful urination) for several months. He came to the hospital about two months earlier and was seen by one of the physicians in my clinic. Her work-up included a clean-catch urinalysis (CCUA), which showed more than five but less than ten white cells, and a few red cells; a complete blood count (CBC) with slightly high white cell count at 15,000; and a prostate specific antigen (PSA)--drawn before the prostate exam--of 11.6.

What? 11.6?? Holy cow. The top end of normal is 4, and the highest PSA I’d ever seen (not doing a lot of men’s health) was just over 7. But 11.6? Wow. She documented a normal and unremarkable prostate exam and diagnosed prostatitis. He was given a six-week course of levofloxacin and told to follow up in two months. Unfortunately, no urine culture was done.

The day before I saw him, he had gone to the village clinic and reported that he still had the abdominal pain, it still hurt to pee, and he was tired of how long this was taking to get better. He took all those pills the hospital sent out, so why wasn’t he any better? The health aide reported him to me during radio medical traffic; I did not have his chart in front of me, but said what I always say in such cases: any time the patient does not get better, he or she needs to come back to Bethel for a re-check. Especially for a complex complaint such as abdominal pain.

“The problem,” the health aide told me, “is money. He has no income, he lives by subsistence. He is uninsured.” Meaning no Medicaid to pay for his travel. As an Alaska Native, his health care and all his medications are free to him; but the transportation to get to that care is up to him. I asked her to see if his family or the village council could loan him the money to fly in, but did not know the outcome until the next morning when I saw his name on my patient schedule. I was relieved to know that he had made it.

Before I went in to see him, I had my nurse draw his blood for a PSA, ask him to void spontaneously for a CCUA, and then straight-cath him to get a post-void residual. She did; he had 300 milliliters of retained urine, which is high for a relatively young man.

He looked quite well. He had normal vital signs and was sitting comfortably in the chair. I had watched him walk in from the waiting area, and he moved easily. His manner was shy and soft-spoken; he answered questions clearly and was an excellent historian. He confirmed that he had taken every single one of those big antibiotic pills for a full six weeks.

“Even I took them,” he said, “I never got better. It stings when I pee, and it is poking pain down here.” He gestured to the supra-pubic area.

His abdominal exam was benign, no mass, no tenderness. His genital exam was normal. His rectal exam revealed a normal rectal sphincter and vault, with no evidence of an abscess. His prostate, however, was huge.

Now, the caveat here is that I have not done all that many prostate exams. I know boggy from firm, and normal from enlarged, and I have felt an asymmetric prostate. But I have never felt a prostate nodule, and I could not begin to estimate gram-weight based on my digital rectal exam.

Evan’s prostate was the biggest I had ever felt. With him bending over the exam table, my finger went straight in and then straight up. The consistency was firm and the shape seemed symmetric. He had the usual discomfort with the exam that most men do, but no remarkable level of pain. But then, on the left lower side, I noted a difference in texture. More hardness. Was it a nodule? I wasn’t sure. It caused him no additional discomfort when I pressed it.

With the exam over, Evan went to have lunch while we waited for the lab to report the CCUA and the PSA. Once I had those results, I would call the urologist in Anchorage for a consult.

The CCUA came back quickly, and showed thirty to fifty white cells, ten to twenty red cells, and positive nitrites. He definitely had a urinary tract infection. Since he reported no improvement with six weeks of levofloxacin, it was probably the same infection, resistant to that antibiotic, and now worse. Since a culture was not done, we can’t know for sure.

I waited all afternoon for the PSA result. My nurse called the lab several times and was told it wasn’t ready yet. While I waited, I talked to my favorite consulting physician, Dr. H. He is a family practitioner (FP), and one of the smartest docs I have ever worked with. I also just like him a lot, and enjoy learning from him.

When I told him about the physical exam and my concern that I had felt a nodule in Evan’s prostate, he held out his arm with the wrist extended. Pressing the bony prominence just distal to the radial pulse, he said “prostate nodule.” Pressing the large muscle at the base of the thumb, he said “normal prostate.” Pressing the space on the back of his hand between thumb and forefinger, he said “boggy prostate.” Okay, that was definitely a nodule that I felt.

Three o’clock came and went and Evan left to fly home to his village. Finally, about 4:30 I called the lab to find out what the delay was on the PSA. The lab tech apologized for the delay and said that he had never had so much trouble running this test before. He had to do multiple dilutions in order to get the machine to give a result. He had just finished the final run, and was reporting Evan’s PSA at 38.9. My heart sank.

I dialed the Alaska Native Medical Center in Anchorage and asked for the urologist on call, glad once again for the excellent specialty consultation and referral service we have available around the clock. He was on the phone with me in less than two minutes. I presented Evan’s case to him, and after hearing all the details, he gave me reassurance.

“A PSA that goes that high, that quickly, is highly unlikely to be cancer. If it is, then it is exceedingly aggressive, and the patient has an extremely poor prognosis. Much more likely is that this is prostatitis caused by a bacteria resistant to levofloxacin. Too bad a culture wasn’t done last time.”

He wanted more definitive imaging before speaking to the question of the nodule I felt. He asked if our ultrasonographer could image the prostate trans-abdominally; he knew we do not have a trans-rectal probe. I checked, the answer was no. He wondered if Evan might have a prostate abscess; he has seen very few of those in Alaska, but it is a possibility. He also wondered how well Evan would do with self-catheterization four times a day. “As much as patients don’t like it, it is the best thing for them when there is that much residual. It will allow his bladder to cycle, and keep him from re-infecting.”

“Start him on Septra, and then adjust according to sensitivity when the culture result comes back. Call me in a few days when you have that information,” he said.

Though it was after closing time for the village clinic, I called and was happy to find one of the health aides still there. I told her to call Evan and ask him to come by first thing in the morning to pick up the medication. I trust that he will, and that he will take every last pill we give him.

What I keep thinking about is that through this entire two months, Evan's complaint has always been that he has pain, never that he feels sick. He has never had fever, been nauseated, had a change in appetite or change in stool. His prostate is certainly large enough--swollen?--to cause the "poking" pain he describes.

But despite the reassurance, I am still worried about him. I know I felt a nodule. Regardless of infectious issues, he needs to go to Anchorage for definitive imaging of his prostate, and appropriate follow up with the urologist. When I spoke to him about possibly going in, he said that he could not go alone. “I’m not a city boy,” he said. “I’ll get lost.” The look in his eyes spoke volumes. He doesn’t have $500 for his own plane ticket, much less $1,000 to bring along an escort.

Somehow we will see to it that he gets there, and gets the care he needs. Stay tuned for the rest of the story…