Sunday, May 07, 2006

A Memorable Elder

Since I wrote this story last week, spring has arrived in full force. The snow is melting rapidly, the temperatures are holding mostly in the 30s—though still below freezing many nights—and the geese are beginning to arrive in much larger numbers. More about that in a coming post.

April 29, 2006

Despite the fact that it is nearly May, southwest Alaska is still firmly embraced by the cold arms of Winter. The tundra landscape is solid white, snow continues to fall every few days, and I awaken to a thermometer hovering in single digits (positive ones, at least, since last week’s minus two degrees). The Eskimos are whispering excitedly about the first few sightings of geese returning—a sure sign of Spring—but so far the high-flying V’s are passing us over in their search for bare tundra with tender new growth. We are poised at the edge of transition, and SO ready for it to happen. After seven months of winter, my eyes long to gaze at green landscape and feel warmth from the sun.

One of the inherent dangers of transition is that the warm and sunny afternoons cause a fair amount of surface melting that refreezes overnight into a treacherous slick of ice. Walking becomes a precarious exercise known as the Eskimo Shuffle—taking small, careful steps with body weight poised directly over feet, hands out and ready to break the fall should one go down. Even with good cleats on (Stabilicers are widely considered the best here), remaining upright and in forward motion can be quite a challenge. If the wind is blowing it is twice as hard. Falls are very common this time of year, and we see a variety of upper extremity fractures in the Family Medicine Clinic as a result.

One morning last week, I paused at one of the windows in the clinic and a deep sigh escaped as I watched yet another few inches of snow falling. Time for this to be done, I thought. The pager at my waist vibrated; the health aide in my assigned village about twenty miles downriver needed to talk to me.

The lead health aide in Napaskiak, Irene, was calling me about an elder who fell outside her home a few hours earlier. Her arm was obviously broken, and Irene wanted to send her up to the hospital. The question was not about whether she needed to come, but rather about how she would get here. The small planes commonly used for village hops were flying despite the snow falling outside, but her patient hates to fly. The trail up from the village is in good shape, but it is too drifted in for trucks to be driving on the frozen river, and her patient refuses to travel by snowmachine. She is willing to let her grandson bring her up by dog team.

“Do you think that’s OK?” Irene wondered. “She seems stable, she’s alert, vitals are fine, and she’s refusing any pain meds except Tylenol.”

I quickly checked the computer, scanned her health summary for the active problem list, chronic medications, recent visits. She is an amazingly healthy elder, on no meds except occasional Tylenol. “No loss of consciousness?” I asked.

“No,” said Irene.

“Full memory of the accident?”


“Sounds like it would be OK to me. Are you comfortable with it?”

“Yeah, I am. She’s my grandmother, I wouldn’t let her go if I thought it wouldn’t be safe. My cousin Golga is a very good dog musher and his dogs are reliable.”

“OK, then. Be sure she’s well splinted, firmly swathed, and warmly dressed. And ask her not to eat anything before she gets here. I’ll be watching for her.”

Two hours later they arrived.

The trail up to the hospital from the main river comes over a small rise and emerges into the clearing around the building. I watched as a well-moving dog team cleared the rise and trotted toward the entrance somewhat away from the snowmachines. I knew this had to be my patient and her grandson. The driver was a compact, energetic Eskimo man in his 30s, but it was his sled that was a sight to behold. It was an old-style wooden basket sled (a rare sight around here anymore), about nine feet long, pulled by ten powerful-looking Alaskan huskies. Enthroned on a fur-covered seat in the sled was a tiny elder wearing the most beautiful fur parka and mittens I have ever seen.

The musher parked his team as close to the door as he could get, and then helped his passenger out of the sled. She was dressed in furs from the ruff around her face to the mukluks on her feet, but it was clear from her movement that she was injured and needed help. She moved slowly, with care and dignity, her eyes narrowed and her mouth set firmly. The two disappeared through the front door, and I headed for the nurse’s station in the clinic to order her x-rays.

In less than an hour (a minor miracle) she was registered, screened with vitals taken, imaged, and sitting in my exam room. I had never met this woman, but I had heard of her; she is one of the matriarchs of her village of 375 people. She is both loved and revered by her extensive family. She is a moving force in the village; though she doesn’t sit on the Tribal Council any more, no important decision in the village is put in place without her blessing.

The tiny woman who sits before me is a marvel. Her name is Anutka. Seventy-nine years old, she stands 4 ft. 6 inches tall and weighs less than a hundred pounds. But for all her small stature, she has a powerful presence. Her face is as brown and wrinkled as a dried apple. She has an almost regal bearing, sitting quietly in the chair with the injured arm in a sling. Her beautiful fur parka is carefully folded and placed under her chair; she wears a traditional Yupik kuspuk, an overshirt with large front pockets and a hood. Her long gray hair is contained in a handmade beaded hairnet.

I had already reviewed the x-rays before going in to see her, so I knew that she had a comminuted, angulated, displaced both-bone forearm fracture; I also knew she would be going to Anchorage for probable surgical fixation. I just needed to get the details of the story before contacting the orthopedists and teleradding her x-rays.

Sharp black eyes snapped with impatience as she endured my history-taking questions about how and when the accident occurred. Her grandson Golga, the musher, translated my questions into Yupik (not really necessary, as she understands English fairly well) and her answers into English (totally necessary, as I don’t understand Yupik at all). She had spent the night before at her granddaughter’s home next door, helping give nebulized albuterol treatments to the two babies with RSV bronchiolitis. When the sun rose about 6:30, she walked back home, avoiding the deep snow drifted between the two houses by staying on the boardwalk. She said ruefully that she should have gone through the snow.

One of her sons heard her cry when she fell and rushed to help her. She held her broken left arm to her chest with her uninjured right arm as he brought his snowmachine around to drive her to the village clinic. Eskimos, as a people, are the definition of the word stoic. She never complained about the pain as the village health aide splinted her arm and advised her that she had to go up to the hospital. She needed x-rays, maybe even surgery to fix this arm. Anutka agreed, but was adamant that she would not travel by snowmachine. “Too noisy, too smelly, too bumpy, too fast.” Her grandson smiled a little at me as he translated this. It is clear that this tiny little woman is revered by her family, and her wishes are law among them. She would travel by dog team. After talking it over with me, the health aide had called Golga and told him to start harnessing his dogs.

A well-trained dog team pulling a moderately heavy sled will travel about ten to twelve miles per hour and can go all day at that pace with intermittent breaks. The trail from her village to the hospital is mostly on the river, which is still solidly frozen with a four-foot thick sheet of ice. We have had so much snow this year (over 90”, which is a lot for us), the trail is fairly smooth and soft and easy to follow. Golga and his dogs were able to get her here in under two hours. A snowmachine could make the trip in under thirty minutes, but it is a hard, teeth-jarring ride sitting in a homemade plywood sled being pulled over river ice behind a snowmachine going 60+ miles per hour. And getting regularly smacked in the face by the ice balls kicked up by the snowmachine’s track. I did not blame her one bit, preferring the quiet beauty and slower pace of a dog team to the loud and bouncy speed of the snowmachine.

After carefully removing the sling, her arm looked as bruised and swollen as I expected it would. She had a mid-shaft fracture, displaced about 50% and only mildly angulated, so the arm didn’t look grossly deformed. Her hand was warm and the nailbeds had brisk capillary refill. She had good sensation in the hand and could move her fingers.

A quick phone consult with the orthopedist at Alaska Native Medical Center who had reviewed the images sent electronically by teleradiology. He agreed that she needed to come in, preferably this afternoon; remain NPO, as he would want to take her to surgery right away.

I explained to Anutka that she needed to go to Anchorage, her arm needed surgery to fix the broken bone. She closed her eyes briefly, then looked at me and nodded. She expected it. She truly hates going to Anchorage ("too many people!"), but she knew it was necessary.

I filled out referral forms and travel forms and sent the patient to pick up her plane ticket to Anchorage, 400 miles away. I also called her daughter who lives here in town; Golga could not escort her, he had to take his dogs home. Anutka has Medicaid, which will cover the expense of travel for her and her escort. By mid-afternoon she was boarding the Alaska Airlines jet for the one hour flight to the city. I’ll see her next week when she comes through on her way home.

Before she left the hospital, she held my hand briefly and looked closely at my face. “Quyana cuk nuk,” she said quietly. Thank you very much.



Blogger Barbados Butterfly said...

A beautiful post, thank you.

Tuesday, May 09, 2006 4:03:00 AM  
Blogger Unknown said...

There is a vigorous discussion about out of hours care on a UK doctor's blog and one of the threads in that discussion is how reasonable it is to expect people to travel to receive medical care depending on the perceived urgency. Your extraordinary post offers a remarkable perspective on that.

Regards - Shinga

Tuesday, May 09, 2006 8:12:00 AM  
Blogger Ex Utero said...

Welcome to the blogosphere. A really wonderful piece of writing.

I think you are going to get a lot of visitors.

I did a few med. flights up to Alaska while I was a ped.s resident in Seattle. I was something of nut for neonatal transports but I did a few ped.s transports during an elective rotation that I practically had to kill my residency director to get to do. Tell me, do they still use Lear jets to get people down to Harbor View?

Tuesday, May 09, 2006 1:26:00 PM  
Anonymous Anonymous said...

Fascinating story! I can just see that tiny matriarch all bundled up on the old fashioned sled.

Nice job!

Tuesday, May 09, 2006 1:33:00 PM  
Blogger The Tundra PA said...

Thanks, all of you, for leaving comments (and such nice ones).

Yes, shinga, travel is a huge issue here. It is expensive, and sometimes not even possible, depending on the weather.

Ex utero--you were Medevac-ing patients from Anchorage to Seattle, I'm guessing. My involvement is a step removed from that. We Medevac from the villages to Bethel by helicopter or fixed wing. From here, patients may get Medevac'd to Anchorage by helicopter--sometimes Black Hawk--or by Lear jet. The Anchorage to Seattle piece I am not involved in, so can't say.

Peg--thanks for your support! You have the honor of being my very first commenter. When I sat here at the far edge of civilization wondering if anyone would actually read my writing and respond, you calmed the early butterflies. Quyana!

Tuesday, May 09, 2006 11:23:00 PM  
Blogger Aisling said...

Beautiful post.

Some patients, even though the interactions are brief, touch us deeply. Such is the wonder of medicine...

On a lighter note, that's amazing that she took one tylenol for a comminuted fracture. Reminds me of a pregnant Tibetan woman we took care of a few years back who declined all pain meds and proceeded through her first labor without a peep.

And 79! What's the avg age expectancy out there? I'd have thought it much lower...

Saturday, November 25, 2006 8:50:00 PM  

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