Interesting morning rounds: botulism, alcohol, and narcotics.

The problems our doctors have faced!

The Natives have developed a taste

For foods they call stink

And eat with a wink

And can’t be prepared in great haste.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

This morning the main topic of rounds continued to center on botulism.

Alaskan Natives have a taste for fermented foods. The proper way to prepare whale, I learned in Barrow, is to put the meat and blood in 5 gallon buckets in the living room and to stir it every day for 6 weeks.   In some parts of southern Alaska, the locals bury a burlap bag of salmon heads at high tide line and come back a week later.  Other meats, such as beaver tail, walrus fin, or seal blubber, get placed in a grass-lined hole in the ground, covered with dirt, and consumed when the fermentation process goes to completion.  Those who grow up with these foods regard the flavor as intense and incomparable.

Plastics food containers exclude oxygen, allowing the formation of botulism toxin, the most powerful poison known.

I don’t know why this area owns most of the country’s botulism when so many people in the rest of this very large state prep similar foods in a similar manner, but it presents so much of a problem that the hospital stocks the anti-toxin.

We have had three outbreaks since I arrived.

In fact, without alcohol, narcotics, and botulism, morning rounds would be done in ten minutes rather than an hour.

I keep learning more about botulism. The poison irreversibly binds to the connection between the nerve and the muscle (neuro-muscular junction, or NMJ) and prevents the nerve from triggering a muscular response.  Things don’t start to work again till the NMJ regenerates, which can take 6 to 12 weeks.  Those who have respiratory paralysis spend that time on a ventilator.

If the gut loses the NMJ, swallowing becomes difficult, vomiting ensues because the stomach doesn’t empty, and the small intestine blows up as if obstructed because it doesn’t move. People will complain about dry mouth first; the experienced docs here don’t wait for double vision or respiratory weakness.

Some of the patients have insurance, some of the insurance companies don’t want to pay for 10 days observation. Today the discussion centered on how to get past Those Who Serve Only To Deny.  “If you get a doctor on the phone,” I said, “Point out that no one in the country has had as much experience with botulism as we have, and that the insurance company’s doctor has never seen a case.”

Spring has come early. We have been slogging through mud for the last week when we go outside.

I got a chance to talk with a wildlife biologist who specializes in walrus. A nearby beach draws males who haul out of the water on average of a day and a half out of 5.  Walrus cams placed at the beach take pictures every hour, and revealed that some of the walrus go to the top of a bluff to look out over the sea, forget they’ve reached a height, and move straight to the water, taking a fatal plunge in the process.  The biologists regularly police the area to remove ivory so that the Natives don’t come by in skiffs for the same purpose.  The US Fish and Wildlife Service sells the ivory regularly to coastal Natives, who carve it for sale, mostly to non-Natives.

I found the conversation fascinating.



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