Archive for June, 2010

On B12, fatigue, malaise, and clinical experience.

June 30, 2010

For patients feeling malaise,

B12 is a blood test that pays.

      Don’t look at the blood cells

      Just check on the B12

And treatment’s a penny a day.

A patient came in with vague symptoms a week ago and gave me permission to give some information.  Having had a gastric bypass a number of years ago, about a month ago the patient noted fatigue and malaise, just an overall lousy feeling, gradually getting worse.  I ordered the usual panel of tests: CBC, sed rate or ESR, Chemistry 14, B12, folic acid, thyroid stimulating hormone or TSH, mono spot, 25 OH vitamin D, and for men, a testosterone level. 

Our reference lab says that levels of 20 to 30 are vitamin D insufficiency, above 30 is normal(some literature supports 40).  This patient’s level came back at 8. 

We didn’t learn much about Vitamin B12 in med school.  It’s important, we were told, because of pernicious anemia, but chances are you won’t see any problems with it.  And don’t even bother to check if the patient is under 40 and has normally shaped red blood cells.

In residency I diagnosed an elderly patient who had tingling of the hands and feet with B12 deficiency; her level was 199 and the lower limit of normal was 200.   She felt much better the day after the first injection, some of the other docs felt because of the placebo effect.

Years later, in private practice, and I saw a 38-year old who didn’t feel good with large red blood cells.  Her B12 level was low, and the patient felt much better after the first injection.  Over the next three months I lowered the age bar on the basis of experience, and when the 19-year-old artist came up with a lower level, I abandoned age as a decider.  The youngest one I’ve found so far was 11.

In the days before online physician communities, I sought out the hematologist,   someone who should know more than me.  When it came to B12, he didn’t. 

I’d been  pondering for a month, getting what I could from books, when I ran into a neurologist in the hospital parking lot.  No age limit, he said, and don’t both with further testing after a low level.  If they give their own shot, it costs $3.50 for ten months treatment.  And if the person is over the age of 60, has symptoms and a level under 400, treat them.

Which sounded a little radical, but within three months the reference lab started sticking on a caveat that said 10% of those with a level under 400 benefit from injections.

A patient, who did not do well, came to the hospital with a B12 level of “undetectable.”  The red and white blood cells were perfectly normal.  An extreme case which I will never forget; a CBC is a lousy way to decide to check for the problem.

B12 only comes from animals (seaweed is close enough).  Strict vegetarians eventually have B12 problems.  Most people who lack the vitamin eat plenty of meat, but have lost their ability to absorb it.  And with the growing number of people on acid reducers (think purple pills), more and more people can’t absorb B12 at all.

The patient with the gastric bypass has fingertip tingling and a level of 357.  If not for the previous medical history, and my previous clinical experience, I’d be willing to give her vitamin B12 pills in large doses with a recheck of the level in 6 months.

Ninety percent of the patients I started on B12 injections in the last 20 years gave their own injections; I never wanted to have a reputation of being a “shot doctor.”  Nor did I want my motivations questioned.

I have found three cases of B12 deficiency and three cases of B12 insufficiency in my four weeks in Barrow.

Nalukataaq, Inuit for Whale Festival

June 28, 2010

Man, the whalers are pumped.

Going up in thirty foot jumps.

     After what they have done

     They are having their fun

And no one is down in the dumps.

Most people here who speak Inupiak and English will tell you that Nalukataaq means Whale Festival.  But you can’t understand anything without understanding its context. 

Imagine living in Barrow where the sun disappears for months at a time.  The preparation starts in June,  hunting the bearded seal and preparing the skins, sewing the skins onto a homemade wood frame to make the boat called an umiak.  The crews start in March, clearing trails with pick axes across the sea ice to open water.  When the trails are ready to handle snow machines, the crews set up camp at the sea ice’s edge.  When someone spots a whale, the boat is launched with the minimum of noise, the crew paddles without speaking till the whale is intercepted.

 Not everyone can handle a harpoon, and not everyone can fabricate the explosive head of the 8 gauge shoulder gun, and the entire season usually boils down to exactly one shot.  All that work rides on one man in a homemade boat with a bunch of his buddies paddling. 

Bowhead whales weigh about 30 tons, the largest being 45.  When a mortally wounded creature like that dives, the crew ships paddles noiselessly and nobody talks.  When the whale breaches again he is usually dead, trailing blaze orange buoys attached to the harpoon. 

Then the work starts.  The animal must be towed to the edge of the ice and pulled up with a block and tackle.  The crew works literally day and night till the animal has been dissembled into pieces small enough for one person to move.  The snow mobiles pull homemade trailers full of blubber. 

If you ask a whaler hunter, he will say that the best part is the sharing, bringing the meat and blubber to the village so that elders and others who don’t hunt can have some. 

Food prep takes about six weeks, and the whaling crews, led by a captain, celebrate by feeding the town.  Caribou, duck, and goose soup, along with whale served raw as muktuk or fermented as mikiuk, prepared in five gallon increments and distributed to anyone who comes.  The city sets aside a parking lot and with a wind break of 2×4’s and sheets of plastic

The “blanket” of the blanket toss is made out of seal skins from one of the umiaks.  If a new captain gets a whale, he donates the skins from his boat for the ‘blanket’. 

Imagine the synthesis of a year’s worth of preparation and backbreaking work, imagine you are the captain of a successful crew.  Wearing you best parka with wolverine on the hood, you take your place on the blanket and the hands gather and in short order you fly thirty vertical feet into the air.  Below you, thousands of faces look up.  You see the entire town and the Arctic sea stretching away towards the North Pole.

Mine was one of the faces looking up.  Before the captain jumped he yelled, “YEAH!  TOP O’ THE WORLD, BABY!” At the peak of his trajectory he threw candy over the crowd. 

Before I left he had jumped three rounds.  An expert every time, he danced in the air, yelled with the same enthusiasm, and never went fewer than six jumps.

Nalukataaq translates to English as Whale Festival, or Blanket Toss.  But not well.

A sax solo forty years in the making

June 27, 2010

It’s finally my summer vacation

My saxophone sings with elation

     Forty years’ decompression

     Has found an expression

I don’t need any more inspiration

It is an early summer day in Barrow, Alaska and I am performing with a small band for an audience of forty-five. 

Behind us, three hundred yards on the other side of the double-pane windows, the ice that had covered the Arctic Sea has broken up, leaving ice floes drifting south in front of a north wind.  Above the ocean with white ice floes, white clouds scud across the deep blue sky.

We are playing for the annual hospital staff barbecue, an audience of doctors, nurses, pharmacists, x-ray techs, lab techs, maintenance and clerical workers, administrators and their assistants.  The housing adjoins the hospital.  We call the exercise area at the right angle juncture of two hallways the Knuckle.  A rowing machine, a treadmill, an elliptical trainer and a stationary bicycle stand under a vaulting ceiling while the crowd mingles and eats. 

We let three of the apartment complex kids, age 7 to 9, sing with us.  We run through Itsy-Bitsy Spider, When the Saints Go Marching In, and It’s A Small World.  At the insistence of the kids to do one more number, we allow them to read in on a Johnny Cash number, Folsom Prison Blues, and enjoy the irony.

I am singing well, I fit in with the guitarist and our leader, Mac, the trumpeter/vocalist.  The fact that I am singing in public yet people aren’t fleeing still makes me smile.

We send the kids away for All Blues, a Miles Davis song with lyrics that talk about the sky, the water, and ‘her’ eyes as “all blue.”  I am intensely conscious of the sun flooding the area, and the glorious context of where I’m playing.

When the guitarist finishes Mac turns and drawls, “Let’s do Summertime.”

I start frantically leafing through my loose-leaf binder.  I protest, “I can’t find the music.” Mac says, “Steve, you don’t need the music.”

With the way he says it, I know he’s right.  In the month that I’ve been in Alaska I have brought proficiency back to my playing.  In sudden realization, I know that all I have to do is have the opening note and I’ll be OK.  I put my soprano sax to my lips and I start on a B natural.  I play from the heart.

The last time I played this number in public I was part of another trio; we had a drummer and a pianist and in the summer of 1968 we were sure we would make musical history.  We lacked the knowledge of basic economics and its application to the world of music.  We made solid jazz that needed maturation,  but the reality of a world in turmoil caught up with us. 

From that summer till this, for becoming and being a doctor I have not had a real summer vacation.   I let the decompression of forty years carry notes and riffs that I hadn’t imagined till just now.  I am making beautiful music in a spectacular setting and for an eternal few minutes my consciousness enters a different level.

The sea ice broke up, the eczema responded to propranolol, the young respect the elders. And don’t use possessives when you talk about whales.

June 25, 2010

I’m learning the Inuit tongue,

Enjoying respect from the young.

     It’s a terrible loss

     To get hurt blanket tossed

These are wonderful folk I’m among

I have permission to give the following information.

A teenaged patient with eczema, severe to the point of disability, came in a couple of weeks ago.  For reasons clear to me only at the time I did a thyroid test and his TSH was slightly low, indicating an overactive thyroid (the current primary thyroid test, the TSH or thyroid stimulating hormone, measures the brain’s demand for thyroid hormone; low levels indicate excessive circulating thyroid hormone).   A week or so ago I prescribed propranolol.  The eczema is markedly better today; the patient looks happier and is sleeping better. 

Next time I have a patient with poorly controlled eczema, I hope I remember the patient who had been to multiple dermatologists for years and got better with propranolol.

The patient was happy, the relative was happy; I could see things had turned out well, and I came away with job satisfaction. 

The young people treat me with great respect.  I commented on that to a knot of early twenty somethings.  They smiled at me with grandchild-like love and talked about how reverence for elders is part of the culture.

I got to talk to two people with critically low vitamin D levels, in the single digits, today.  Both have diffuse bone pain.  I explained how calcium doesn’t get absorbed or used properly without vitamin D, and in compensation the calcium in the bones gets mobilized.  Which keeps the circulating calcium up at the expense of skeletal strength.

Alas, one of the two uses narcotics recreationally; I hold confidence that I’ll make the bones better but I harbor no illusions that the narcotics seeking behavior will stop.  I hope I’m wrong.

The sea ice broke up in the early hours today.  This morning, working on the elliptical, I watched white ice flows on blue water floating slowly south, pushed by the winds. 

We’ve seen the first Nalukataaq injuries.  I’m a person with enough sense to say that blanket tossing looks like fun for the young but not for me.  Not everyone agrees with me.

My Inupiak language acquisition program is progressing.  I’m in the stage of echolalia, where I can repeat short sentences but I don’t know what they mean.  I was able to say “Good morning.  How are you?  I’m fine.  My name is Dr. Gordon.”  But my head is not in the language and the language has not taken root in my head.  I am, however, working on it.

Seeking to get a better handle on the grammar, I asked one of my informants how possessives are handled.  I got a blank stare.  I have a limited number of nouns in my vocabulary, so I started with whale, agvik.  “How would you say my whale?” I asked.  I got another blank stare.  Finally the informant said, “You wouldn’t say that.  You never say my whale or your whale or even our whale.  You just say whale, ahagvik.

You can either be right or you can be happy. You can’t be both.

June 25, 2010

There are times to be strong

There are also times to sing songs

     Those who are bright

     Don’t like to be right,

In fact we enjoy being wrong.

You can either be right or you can be happy.

My Iowa next door neighbor, Kent, gave me that piece of wisdom.  It’s only true 99.4% of the time.

If you know someone well enough to have conversation, being right usually entails someone else being wrong.  That which diminishes someone close to you diminishes you as well. 

Pessimists are right more often than optimists, but optimists are happier.

A crucial part of my job is to think of the worst thing possible. 

Yesterday I referred five patients to the Alaska Native Medical Center in Anchorage; three were sent out by medical transfer plane because I thought of worst case scenarios.

Alas, I was right.  One of them is in surgery as I write.  My heart goes out to the entire family.  And because I cannot reveal data about the patient without consent, I cannot say why I feel such personal sympathy.

I would have preferred being wrong.

Morning clinic went well.   

I am not a surgeon; my medical forte is more cognitive that procedural.  I am willing to do surgery on the skin, and today I started off by removing a sebaceous cyst from a patient’s face.  I was able to take out the glistening sac and its cheesy, smelly contents intact. 

At noon the North Slope Borough Risk Management team came in to talk to us about Workman’s Compensation.  (Alaska has boroughs, not counties.  The North Slope Borough, roughly the size of Wyoming with one fiftieth the population, has between 7500 and 10000 residents, 900 of whom are employed by the Borough government.)  We talked about Work Comp law and procedures while we munched mediocre pizza (two pizzerias in the whole Borough) and fresh fruit.

We talked about the problem of lack of physical therapists, and the fact that the preferred referral center is Fairbanks.  Some of the fine points of Alaska Work Comp law got brought up (example: the employer has to report all on-the-job injuries within 8 hours of occurrence) 

Clinic was slow in the afternoon because most people are at the Nalaqutaak (whale festival and blanket toss). Business picked up shortly after I said, “Gee, it’s slow.” 

Respiratory problems and pain in the bones, joints, and muscles predominated.

At the time of this writing one of the patients is en route to Alaska Native Medical Center for surgery. 

I hope I’m wrong.

At the end of the day I walked over to the guitar player’s house.  Mac, our trumpeter and band leader is in Wainwright and won’t be back till tomorrow.  We played for an hour and a half, and had a good time.  At this stage of our musical maturation our egos have mellowed and we don’t mind giving artistic control over to our leader, who in turn works on bringing out our best musicianship.  Then we can just play and we don’t have to worry about who’s right and who’s wrong.   The guitarist and I agreed that as long as Mac mushes, we don’t mind being the dog team.

Five referrals south to save life and limb, getting fingerprinted, and an ice cream bar from home.

June 24, 2010

I’m just trying to keep folks alive

My off-slope referrals were five

     At the station I lingered

     While cops printed my fingers

At the end of a leisurely drive.

I just finished a twelve-hour call shift, which is not an excessively long call. 

Out of respect for the patient I won’t give identifying details of the day’s first patient’s bizarre presentation.  I can say that between the time the patient came in and the time that the patient left, I could see in the face a sense of wellness returning.  It required a good amount of work on my part with several phone calls, a consult from a colleague, and five forms to fill out.

“I sent five patients off slope today” is not something you will hear said anywhere but the North Slope of Alaska, and the linguistic device reflects a cultural thought process.  The Brooks Range runs more or less east-west across the top third of Alaska.  The land slopes gradually downwards and northwards to the Arctic Ocean.  The North Slope is close to the size of Montana, the population is less than 10,000.  Barrow is the largest town at 4500.  The roads that connect the rest of the world only come to Prudhoe Bay; the well publicized Ice Road is a temporary phenomenon that ends with spring.  Commerce between settlements can be by plane or boat or snowmobile, depending on the season.

I was instrumental in sending five patients off slope today, away from the unique cultural assumptions of the North Slope.  Three were sent by Medevac, two went by commercial jet.

ATVs and snowmobiles are necessities of life here; they are the vehicles that feed the towns.  With so many of the two passenger gas burners around, no wonder people get hurt with them. 

Barrow lacks CT, and we send a lot of patients to places like Anchorage where CTs are common.  They can find diseases and conditions that endanger life and limb.

In the middle of the steady intensity of ER coverage, I had to go get fingerprinted. 

My employer here is the Arctic Slope Native Association, or ASNA, which is a bureaucracy.  Though run by Inuit, it is subject to the vagaries of all bureaucracies.  For unknown reasons, they wanted four sets of my fingerprints. 

The police station is four blocks from the hospital, and one of the hospital’s expediters drove me in one of ASNA’s vehicles.  When I left the ER, I checked out to a colleague one of the patients in the middle stages of being Medevac’d out.  I left the hospital wearing scrubs and a white coat, into 40 degree fresh air.  The police station maintains an anteroom for those waiting to be fingerprinted.  I waited in line and I didn’t fret about waiting

My clinical duties were being handled while I was away from the clinic.  I was in the service of my employer and I had time to breathe.  It was a good break.  When the policeman called my name I shared my relaxed attitude.  He took my prints professionally and we had a good time chatting. 

I’m no longer the boss.  I enjoy my position as an employee.

Back at the clinic, I arranged transport out for an injured patient.  Supper was the best corned beef brisket ever, but I ate dessert first.

It was an ice cream sandwich from Wells Blue Bunny, just north of Sioux City.

Shotguns on a four-wheeler parked outside the library. Where else but Barrow?

June 23, 2010

A four wheeler’s shotgun’s on guard

At the library.  I got a new card.

     With the price out of reach,

     I bought not a peach,

And gasped at the price of the lard.

The whale festival, the Nalukaataq, is this week.  It should be quite a celebration.  The whalers brought in fourteen this year.

One of the perks of my job is that I get to talk to whalers. 

I’ve seen five whaling related injuries so far this year, all from whale processing, and none related to the actual hunting.  I understand from my colleagues that the run-up to whaling season brings in a lot of injuries.  The crews put in incredible hours making trails on the sea ice.

The docs here also talk about the injuries we’ll see from the Nalukaataq blanket toss; people are thrown 20 feet into the air and for the most part land upright and standing.  Occasionally they miss the blanket.  Some of my patients haven’t been blanket tossed for years and are still dealing with the injuries.

The clinic morning went long; I admitted a patient over the lunch hour.  I started seeing patients shortly before one and did my best to keep things going in a timely fashion.  At the end of the day I had found three more hyperthyroids and a B12 deficiency.

The patient with the strange neurologic findings came back looking vastly improved.  Now that he’s on the right medicine he’s feeling better and he’ll probably make a full recovery.

After clinic I walked the dike between the two lagoons, across the tundra to the library, in the process seeing another furry brown lemming dashing through the grass.

The library is a very nice facility adjoining the Heritage Center.  I was issued a card today, and I checked out two DVD’s on Alaska, one of them about Barrow.  In the library parking lot was a four-wheeler carrying two gun cases and a goose decoy.  I didn’t get a chance to interview the driver.

Here in Barrow I am not a Senior but an Elder.  The term carries considerably more respect.  Without even thinking about it, the community gives reverence to the aged.

I crossed the gravel permafrost road to the grocery store.  Nectarines were on sale at $3.88 a pound, comparable to the worst midwinter prices in Sioux City, and I got two pounds.  With peaches closer to $8.00 a pound, I decided I really liked nectarines more.  I bought celery, a red onion, mayonnaise, mustard, olives, pickles and grape juice and paid $40.  The price on meat products is like the scenery in Alaska: breathtaking.

The hospital community is organizing a barbecue on Saturday, and I’ll be making potato salad on Friday night.  Of course I’ll have to get potatoes, a knife, a cutting board, a bowl and a pot.  If requested by the readership, I’ll give the recipe (leave the request in the comments).

Our band’s next gig is the hospital get-together.  Our trumpeter is covering the clinic in the far distant outpost of Wainwright, till Friday and the guitarist and I will be getting together on Thursday.

An evening colloquium: Why we love it here. After a hard afternoon.

June 22, 2010

You don’t get both money and time

Somewhere you must draw the line

    It’s all about tradeoffs

    I’ll not be a Madoff,

Which is good.  I won’t even whine.

I’m starting my 4th week working here; so far I’ve found a thiamine deficiency, three overactive thyroids, a dozen vitamin D deficiencies, three whale-related injuries, a testosterone deficiency, a folic acid deficiency, and a thyroid deficiency.  I have arranged five Medevacs.  Each one happened to a unique human being in a family context.

I have written six prescriptions for narcotics (something I don’t do much in Sioux City); each one has an absolutely horrendous reason to be on long-term addictive drugs.

I told a patient that, in his particular situation, marijuana is less destructive than alcohol.  I can do that because here alcohol is as illegal as marijuana, and, besides, I could smell the marijuana smoke on his clothes.

I’ve seen more treatable ear infections (otitis media) in the last three weeks than I have in the last two years put together. 

My Inupiak vocabulary grows; today I learned the proper pronunciation for grizzly bear, which uses a consonant common in Navajo but absent in English.  I can ask where something hurts, and I know the words for bodily waste products.

Rheumatoid arthritis, TB, and Hepatitis C run rampant on the North Slope. Constipation is more common than healthy bowels.  Many seek narcotics, multiple sclerosis is rare.  Marijuana abuse is as frequent as alcoholism; I see twice as many recovering alcoholics as I see active drunks.

 People who have survived unspeakable trauma against all odds come to me with the terrible problems related to the aftermath.

Most people here don’t believe in global warming.  They uniformly grumble that by this time last year the grass was green and the sea ice was gone.

I do not understand why people from tropical countries would come to Barrow and stay, but they do.  People started coming to Barrow at the beginning of the pipeline construction, and they remain here to this day.  No one complains about the cold, no one complains about the twenty-four hour sunshine.

People here are very well-travelled and they talk freely about where they’ve been.

The morning was very easy; one of my five scheduled patients showed up.  The afternoon got serious and went long, finishing after 6:30.  The cafeteria had set aside my meal and stayed open an hour late.

The hospital food exceeds my expectations; the dietary staff cooks with love and imagination. 

This evening in the commons room we got together and talked about what a great place this is to work.  It doesn’t pay as well as another venue we discussed, but the pace of work is reasonable, the food is good, the commute is short, and the esprit de corps is strong.  One doc and I fell to discussing how free we are, and how the sense of freedom blossomed when we decided to leave the most recent job.  Both of us love our work and loved where we worked, and both of us knew when it was time to move on and slow down.  One of the other docs has just come in from Kaktovik, a village of 480 with no internet and no cable.

He had a great time.

Atraumatic pediatric exam and a show at Pepe’s North of the Border

June 20, 2010

I play with the kids, I don’t fight

I show them the otoscope light

     The child will freeze

     I don’t have to say please,

I just have to leave out the fright.

I have the patient’s mother’s permission to tell the following story.  When I walked into the room the toddler looked at me and started to scream.  I Purelled my hands, greeted the mother, set down the paper chart and took out my yoyo, while the child wailed.  The volume diminished by less than a decibel while I ran through Sleeper, Walk The Dog, Rock The Baby, and Split the Atom.  While I was playing with the yoyo I interviewed the mother about the child’s draining ear:  when did it start, what color, is there fever, has the appetite gone down, what about cough, any allergies, any smokers in the home.

After that I sat down and played peek-a-boo with the patient.   To play really good peek-a-boo, hold a visual barrier (such as the chart) between you and the child, move the barrier and say “peek-a-boo.”  Over the next seven or eight rounds of peek-a-boo, the volume of the crying diminished, ceased, and was replaced by a smile.

I fished the otoscope from my pocket.  I showed the child that the instrument was not to be feared by touching the mother’s hand and showing him where to look.  Then I touched the patient’s hand and said, “Hand”.

Children in the language acquisition phase will freeze if you touch them and name the body part.  I usually get enough time to examine the ear without restraining the patient, but I rarely get more than eight seconds.  Rewarding the kid with applause, he turned his head without being asked.  

We played our way through the examination; he resumed crying when it was over.

All in all, covering the outpatient area yesterday didn’t strain me. Patients came in twos and threes; the clinical mix was interesting but not overwhelming. 

When I note tremor, high blood pressure, weight loss, heat intolerance, thoughts racing, insomnia, and pulse over 90, I think about hyperthyroidism.  If the patient looks too much like the textbook description, though, I’m usually wrong.

One of our colleagues, another locum tenens doc, agreed to cover for me starting at 4:30 so our band could play at Pepe’s North of the Border, Barrow’s Mexican restaurant.

We have a guitarist, a trumpet player (another doc), and me on saxophone.  All three of us sing.  The guitarist and I agree that the trumpeter should be the leader; he does a good job of organizing and encouraging us.  He gets us the gigs, he organizes the practices, and he picks the tunes.

We play Celtic, old standards, fifty’s rock ‘n’ roll, and country. 

We opened promptly at 5:30 with St. James Infirmary.  We don’t try to overwhelm the crowd or get them to pay attention; we like to see heads bobbing while people eat. 

At 7:00 a group of ten sat down directly in front of us while I was soloing on Summertime, which brought out my latent attention deficit, and I had to ignore the sheet music and improvise.

I condensed six months worth of emotions, seasoned it with the triumph, tragedy, drama and irony of the patients I’d seen that day, and I played about my freedom.

The number drew applause from a tough crowd.

In the last half hour the room was packed; our harmonies worked, our improvisations soared.  We played beyond the allotted time and nobody objected. 

The gig was over when the band leader had to bolt to work the emergency room.  He’ll be gone this coming week, covering the isolated village of Wainwright. 

Our next gig is the hospital barbecue, next Saturday.

Wernicke without the Korsakoff, don’t hold the thiamine.

June 18, 2010

I tell you in Barrow there’s a need

For independents of the medical breed                         

     And, what is more,

     They need a drug store.

Do I have to appeal to greed?

Labs this morning included a folic acid deficiency, another hyperthyroid, and a hyperparathyroid.

Folic acid deficiency should be as rare as snowy owls eating black-footed ferrets but it isn’t.  Left untreated, folic acid deficiency is fatal.  Treatment runs a few cents a day for a simple pill.  I find the diagnosis and treatment of this problem very gratifying; not only do I get to save the patient’s life for little money but I get to make them feel better.

A call from Anchorage led to a discussion of Wernicke’s encephalopathy.  Neurologic problems happen from thiamine deficiency and carbohydrate excess.  As all food stuffs containing flour have thiamine supplementation, the worst carbohydrate with no thiamine (one of the B vitamins) is distilled alcohol.  A person has to drink very hard and keep a strictly rotten diet to get Wernicke’s.  Thiamine deficiency more often gives rise to Korsakoff’s psychosis, where a person loses short-term memory.  Med school vitamin discussions featured Wernicke-Korsakoff syndrome, and in med school I learned but I scoffed.  I shouldn’t have.

Vitamin D deficiency gives rise to hyperparathyroidism which in turn gives rise to osteoporosis, and the vitamin D level on the patient with the abnormal parathyroid is pending.  I will be very surprised it the vitamin D level is normal.

For reasons of confidentiality I cannot go into details about the people the abnormal lab results are associated with, but they are living, feeling human beings who suffer and who hurt; they live in families; they make good decisions and bad; each one has stories to tell, full of drama and irony. Each wants to be done with illness and move on with their lives.

I still had paperwork to fill out for my hospital appointment, the deadline loomed, and the completion took up much of the time freed by clinic no shows. 

The Indian Health Service started the hospital in Barrow.  The Arctic Slope Native Association took over the operation in 1995, and in the process started delivering health care to the non-Natives.  I suspect that out-of-pocket expenses for an Urgent Care visit are like prices for everything in Barrow, that is, very expensive.  The non-Natives come for work physicals, workman’s compensation, coughs, colds, and the occasional head scratching mystery.  Sometimes they require services that are not available in the entire North Slope, and arranging follow-up becomes very difficult

Barrow would also be a good place for a doc to open up shop and serve the non-Native population, almost all of whom have very good insurance.  Such a doctor would do well here from first day.

It won’t be me.  I’m having too much of a good time being an employee, not being an owner, working at a reasonable pace.

A retail pharmacy would also do well here.