Archive for April, 2016

Of Red Tide and dead walrus

April 16, 2016

We went for a very short ride

And found acres exposed by low tide

Which brought within reach

Clams of the beach

And other things people eat fried

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. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

An intestinal virus with violent vomiting and profuse watery diarrhea has dominated my clinical work for the last week. It hits the toddler-to-middle school age range disproportionately, but it still struck a lot of adults, and struck them hard. I can’t do anything for the basic disease process; people tend to heal on their own. But if dehydration sets in, I have developed a routine that calls for 2 liters of IV fluids (if you must know, Normal Saline, the same as 0.9% Sodium Chloride) and 8 mg of ondansetron (trade name, Zofran).

When I hear of vomiting and diarrhea starting at the same time, I tend to think of food poisoning. But food poisoning will strike a household all at once, where this virus hits family members in sequence.

I had to consider, also, the shellfish problem.

The people on an island with 25-foot tides like to go out at low tide for mussels, clams, cockles, whelks, abalone, crabs, and octopus.

When the water ebbed out 3 feet lower than average this weekend, Bethany and I went to explore the beach.

We found the water’s edge a hundred yards past where logs drifted onto beach grass mark the high tide line, on a beach of whispering tranquility, surrounded by towering evergreens. We picked up a dead sand dollar, and saw holes where a clam spade would have brought a tasty morsel. A mother with her two children came out exploring. The adults had a delightful conversation, and one of the kids picked up an abalone. I had never seen a live one before.

Which prompted me, the next day at rounds, to ask my colleague about the posters we’d seen warning of Paralytic Shellfish Poisoning. He explained that some algae contain a toxin that filter feeders, like clams and mussels, concentrate, and which, if consumed, cause a very ugly paralysis. Those algae blooms, known as the Red Tide, in the warm weather, especially in El Nino years, and more often when the temperature goes up.

I asked about walrus, the sea mammal that eats mostly clams. I recalled the large walrus skull I saw on the wall of friends who live in Southwest Alaska. While out sport flying, they spotted a walrus carcass on the beach, landed, and wrestled the ivory-bearing head into the plane.

While the algae blooms won’t happen for another month, some bivalves, like mussels, retain the toxin for years after a bloom.

First day in Metlakatla

April 12, 2016

I set off in the down-pouring rain

To the clinic, a small House of Pain

I started up with a smile,

Because that’s my style

And it’s easy for me to sustain.

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. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

On Sunday we took the ferry from Ketchikan to Annette Island, a ride of 45 minutes. We arrived in a pouring rain.

People call this area of Alaska the Panhandle, it juts southeast along the Pacific coast. It receives an average of over 100 inches of precipitation yearly.

About 2000 souls reside in Metlakatla, the town on the west part of the island. WWII brought an influx of defense personnel, who did not leave until late in the 20th Century; the majority of the inhabitants are Natives. As Alaska’s only Indian Reservation, license plates and driver’s licenses are optional, and ATVs run street legal.

The clinic assigned us to a cozy apartment less than a half-mile walk from the clinic, and I did my initial morning commute on foot in a torrential rain.

My first day on the job here started with morning rounds.

Talk of tides and fishing dominated the conversation before the clinical discussion. I mentioned the poster warning of paralytic fish poisoning I’d seen on the front door, and those present assured me that the problems wouldn’t start for a month or so.

The doc who had call opened the discussion with a rundown of the weekend ER patients.

I spent the morning in orientation and getting my ID badge and entry card, and I took care of four patients in the afternoon. I used RPMS, an Electronic Medical Record (EMR) system developed by the Veteran’s Administration.  Far from perfect, I find it the best one of the 9 I’ve learned in the last 14 months.

I talked to a relative of the first Native to be drafted by the NBA (that unique individual has a lot of relatives on the island).

I saw the first of what would be a string of patients with violent vomiting and diarrhea, ranging from infant to middle age. Almost certainly viral, we have no treatment aside from oral rehydration, or, in extreme cases, IV rehydration.

But we are a clinic with an ER and no hospital; we don’t keep patients overnight. I will have to weigh the risks of a boat ride if I consider sending a patient for further diagnosis or treatment.

At the end of the day, we arrived back at the apartment dripping from a walk in the driving rain.

Well, if you can’t take the rain, stay out of the Panhandle.

Ketchikan to Metlakatla

April 12, 2016

We came across on the ferry

At leisure, and then we could tarry.

Some food we bought more

With a trip to the store

And we found some good prices on dairy.

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. So far this year I worked assignments in western Nebraska and southwestern Alaska; I just arrived in southeast Alaska.  Any specific patient information has been included with permission.

We took the ferry from Ketchikan to Annette Island, the only Indian Reservation in Alaska. In 1887 an Anglican missionary, motivated by doctrinal differences, led a thousand Canadian Tsimtshians on a search for a new home.  They found this island, moved legally, and in 1906 petitioned for, and received, reservation status from Congress.

Fortunate enough to have no mineral wealth that economic interests wanted to steal, they maintained their reservation more or less inviolate until WWII, when they got an air base, and a promise to build a road to the other side of the island so as to link up with the Alaska Marine Highway system. The road took eleven years to build and finished 8 years ago.

We learned these things from the Security guard who drove the 15 miles from the clinic to pick us up, and also took us on a tour of the town.

Falling timber prices shut down the logging and sawmill operations.  The salmon cannery, the casino, the school, and the clinic provide the most jobs.

We passed the gas station, the schools, the churches, but no bars or liquor stores.

Perhaps because of fewer freeze-thaw cycles, perhaps because of better maintenance, the roads lack the crater-grade potholes we find back home in the spring.

The guard helped us drag the luggage up the stairs to the apartment. We unpacked briefly.  We ate the snack that Bethany had the foresight to bring, then we walked to the grocery store.

We hadn’t expected a well-maintained, well-stocked, brightly-lit facility.  The prices, a big higher than Ketchikan’s, didn’t look so bad compared to what we’ve paid for the last two months.

Then we settled in. We tried the TV and found no service, and we had no idea whom to call about the Internet password.  We played Scrabble, ate some salmon we’d brought, and found ourselves exhausted when the sun went down.

In the same time zone, but we definitely faced jet lag.

Overnight in Ketchikan

April 10, 2016

Up here, it’s one of the sights

When present it cheers up the nights

I regretted quite loudly

That the sky was too cloudy

To see the great Northern Lights.

 

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. After 2 months in western Nebraska, then two months in coastal Alaska, I’m now in the Alaska Panhandle.  Any specific patient information has been included with permission.

 

After an overnight in Anchorage, we arrived in Ketchikan, Alaska’s first city and never Alaska’s capitol.

Contrast is the essence of meaning, and Alaska’s hugeness makes for a lot of contrasts. After overlooking an arm of the Bering Sea from a coastal plain with mountains 30 miles distant, mountains here rise abruptly from the salt water, with not a single swath of tundra to be seen.

Technically in the same time zone, we crossed 24 degrees of longitude to get here, as many as you cross getting from New York to Chicago.

Ketchikan built its airport on an island, and, I suspect, built the island for the airport. One takes a ferry to town.  Anticipating problems with luggage, transitions, and inadequate support for the profession of skycap, the airport offers free luggage carts.

We found Ketchikan’s mood much like other tourist towns in the off season. The gold rush over and the timber prices low, tourists won’t start arriving by the literal boatload till May.  The other industry, salmon canning, stays small to stay sustainable.

The town features large on cruises of Alaska’s Inside Passage, and last year more than a million tourists filtered through.

We stashed our cooler full of salmon in the Best Western’s freezer space. The hotel’s service amenities include a van that drives people around town.

We went grocery shopping, knowing the high prices found on any island, especially an Alaskan island. We walked back to the hotel because we needed the exercise, exploring the Marina and the parking lots off Tongass Avenue, the main drag.

On the advice of a ferry passenger, we went out to the Lodge at Cape Fox, a first class restaurant run by a Native Corporation.  We enjoyed a spectacular view of the harbor and Halibut Olympia, while we discussed a weight loss strategy for our upcoming stay.

The news predicted great Northern Lights. After dark, I went outside to look up and find dense cloud cover.

Easter Sunday in the ER

April 10, 2016

Readers:  Connectivity problems slowed the flow of posts.  To preserve the sequence, this is a week late.

It could have been nothing at all

With the cold and a sudden snow fall

I thought I would try it

It was 6 hours of quiet

This Easter when I took ER call

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.

When the Russians took possession of the part of North America we now call Alaska, they enslaved the indigenous people but had more interest in furs than in land. But they brought their religion, and it stayed when they left. Thus this town celebrates Easter at two different times. And this year the Orthodox Easter comes almost a month after the Catholic Easter.

If one of my colleagues celebrates a religious holiday that I don’t, I do my best to take call for that person, thus I find myself this morning in the Emergency Room.

0750AM: Arrived in ER to find no one here. I sat down in the doctor’s corner, fired up my computer, and started looking through the inpatient census.

0800: Spoke with a helicopter pilot in follow up and got to quizzing about the other professional’s job. I learned about darting wolves and moose. I found out what can happen when a compressor goes out and the engine fails between 60 and 600 feet up, what the helicopter pilots call the death curve. At such altitudes the helicopter can fall hard enough to kill, but can’t build speed enough to use the rotor as a brake. The problem being, of course, that most helicopter work involves just those altitudes.

Spoke with the doc who had taken call for the 12 hours previous. Not much to report.

0830: Started inpatient rounds on three patients. I can’t write about individuals, and, in this case, writing about disease states might identify people who didn’t give their permission.  But I can say that I dealt with the respiratory system and the gastrointestinal system.

Newton’s laws of physics don’t account for certain large parts of the universe, but one of those laws says two things can’t be in the same place at the same time. And human bodies suffer in consequence. If the person damaged by that inescapable reality lives in a small village accessible only by air or water, the consequent injurious effects ripple throughout the community.

10:00 AM Heavy snow fall started. Nap time.

10:20 AM One of the inpatients worsened. I got information and facts straight before I called the consultant at Alaska Native Medical Center (ANMC) in Anchorage. The light-hearted interaction brought me new information. The decision to send a patient out in a Medevac plane brings risks, especially in a snow storm.

11:00: Watched YouTube videos on Eskimo Scouts, racist Cold War Propaganda, but sympathetic to the people of Shishmaref outside of Nome.

11:45AM Called my wife to meet me for lunch in the cafeteria. The soup was excellent.

1230: Phone call requesting a medication refill. I said yes to a blood pressure medication with multiple uses and no resale value. I put a note in the electronic health record, but didn’t see the patient face to face.

13:00: Colleague called. Church finished. Take your time, I said.

14:00:  Colleague arrived.  Left in a slush flurry.