Fishing and electronic medical record systems: one is a waste of bait, the other is a waste of time.

The computer is a drag on my brain

I would rather the cold and the rain

While I’m up in this state

It’s more fun to waste bait

Is it really that hard to explain?

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

Bethany and I booked a fishing charter on Sunday. We slept poorly and had the magic moment together of loading the car in the darkness and setting out well before light.

We drove into Homer, immortalized by Tom Beaudette in his literary series as the End of the Road.  It sits on Kachemak Bay, made famous by the TV reality series on Alaska homesteaders.

We shared the charter with a party of 4 from Anchorage: 2 doctors (an OB and the only pediatric orthopedist in the state) and two public defenders.

The morning brought much rain and no nibbles. Bethany and I napped intermittently and the young professionals chatted and waited for fishpole ends to dip, while the captain kept the boat trolling back and forth.

In the afternoon the spell was broken when a doc brought in a very nice salmon, about 10 kilos or 25 pounds.

Pacific salmon spawn once and then die.  The king salmon, also called the chinook, reach the biggest weights and carry the most fat of all the species, even more if you get them in winter, before they make changes for breeding.

The sun came out in the afternoon as we trolled back just off a glacier that sent strong chilly winds.

No one got seasick, and no further salmon showed any interest in the baits.

Perhaps we didn’t catch any salmon, but we saw lots of sea otters, loons, eagles, and a seal.

We went out to eat in Homer at a Mexican restaurant; I showed off my Spanish and told a couple of jokes with the hostess from Guadalajara.  We saw a moose on the way back.

The next morning at orientation, I could still feel the boat rocking.

My computer training started in the afternoon.

I don’t like what computerization of records has done to American medicine: stolen physician time from medicine to data entry.  Few of the quality metrics improve patient care.  New studies are finding examples of patient harms from the electronic medical record.

My experience with this particular system goes back a couple of years, and crosses state lines.  Every update promises improvements and brings functional deterioration.

Such systems hurt the basic functions of health care but aid administration.  Report generation and billing get easier.  Bad systems requiring frequent retraining provide employment.  The government keeps expanding the suite of quality metrics that does not help patients but demands more administration, which now tops the list of American medical system price increases.

I whined for a while.  My trainer didn’t disagree, then I went back to learning.

All in all, if I’m not taking care of patients, I’d rather be fishing.

 

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Back in Alaska

To come back we both felt the push

To Alaska, this time, not the bush

We see cars, we see trucks,

But never mukluks

You could say that life’s rather cush.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

 

We have now flown so many times to the 49^th State that we managed to arrive at our destination the same day we left.  Still, we traveled for 17 hours.

We got here shortly after the “spring forward” time change, which sends the entire country one time zone east.  We dealt with that problem by going three time zones west.

Coming to Alaska till now has meant “the bush” to me: places accessible only by air or water.  High prices, consistent foot traffic, ATVs and snow machines on the streets at all hours.  Life in those places resembles life on islands, with a close sense of geographic identity and an almost  complete lack of theft.  You don’t need driver’s licenses or license plates if you have a vehicle there.  And most people don’t.

The majority of the patients I’ve cared for in the bush have been, well, Alaska Native.  Specialist care means flying into Anchorage (in one place it meant a boat ride to Ketchikan), with all the implied hazards, not to be undertaken lightly.

And now we find ourselves in a metropolitan area with a couple of movie theaters and a really great selection of grocery stores.  The main thoroughfares have traffic lights (that work).  We haven’t seen a single ATV on the streets yet.

The hospital architecture resembles that of the hospitals of western Iowa where I’ve worked, but the directory here lists dozens of doctors, including at least one surgeon.

It’s still Alaska.  Restaurant prices and portions befit the largest state in the Union.  We found a pile of moose droppings five steps from where we parked the car.  The sidewalks show the ravages of multiple, radical freeze-thaw cycles.  The Walmart parking lot pavement consists mostly of chuck holes.  Ravens dominate the skies, eagles come a close second, and the drone of small aircraft continues throughout daylight hours.  When clouds clear, you can see breath-taking mountains in more than one direction.

Summation of a month in the Arctic

The alk phos kept coming up high

And the local docs can’t tell me why

And the TSH low?

It’s just part of the show

Like the constantly cloudy sky.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia.  Any identifiable patient information has been included with permission.

I finished in Arctic Alaska the Friday before Thanksgiving. I found the pace  leisurely, sometimes to the point of frustration.  I enjoyed my most productive days, 14 in 12 ER hours and 11 in 8 clinic hours, but the day 5 patients spread over 8 hours I filled the empty minutes with Continuing Medical Education (CME), email, Wikipedia, and naps.

I found 6 mildly low TSH (thyroid stimulating hormone) assays out of 9 that I ordered. Out of the 12 alkaline phosphatase (an enzyme found in liver and blood) tests I requisitioned, 10 came up mildly high. When asked, the clinical director confirmed that, yes, those two tests came back abnormal more often than not, but had no good explanation.

I covered the twelve-hour ER shift four times, coming into contact with 2 patients with dislocated fingers. I got to follow, from afar, the progress of the sickest patient I saw, sent out on a plane to a surgeon and hospitalized for the better part of two weeks.

I never worked more than 44 hours in a week.

I bought Rosetta Stone Inupiaq, the language of the Inuit, only to find it wouldn’t work on a computer using any software newer than Windows XP.

The major plus of the assignment: great leadership. The major minus: the housing (supposedly built from recycled cargo containers) which promoted isolation.

The rainy weather that greeted us promptly froze 4 days after our arrival, when the snow started. Cloudy skies prevented a good view of the Aurora Borealis, and the wind might have shifted direction a few times but never went under 20 mph.

During the month, a baby seal strayed through a breathing hole in the ice and appeared at the foot of an apartment house stairs. A week later, a caribou showed up at the hotel, looking lost.  Three days after we left, I got a video of a herd of caribou running on the sea ice outside the same hotel.

Inspired by the high cost of food, both Bethany and I lost weight.

I bought a hat made of beaver fur and a letter opener of mastodon ivory.

We never quite made it to the gym but we took lots of walks in the cold and the wind.

Bethany substitute taught Special Education, and found herself paid a good deal more than she’d expected.

Would we return? Absolutely!  But we would have to ask, When?

 

 

At the end of another Arctic assignment

After the lessons not learned

And the good advice has been spurned

Sometimes slow, rarely quick,

People get sick,

I do my best though the bridges are burned.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I just finished a month in the Arctic.  Any identifiable patient information has been included with permission.

Aside from well child checks, perfect people do not come to see me. Most of my patients have made a lot of decisions they regret, and, whether they realize it or not, when the consequences add up they get ill.

In my years in Community Health I learned that schizophrenia, bipolar (formerly called manic-depression), and substance abuse overlap so much as to be indistinguishable.

Sometimes patients are difficult to talk to. Schizophrenia, for example, can rob the face of expression and make speech slow and monotonous; Parkinson’s disease can do the same thing.

Alcoholics, marijuana abusers, smokers, meth heads, and narcotics addicts get sick more often and more severely than those who lead orderly, substance-free lives. Leaving the start line with mental illness that hampers learning from experience gets compounded with substances that do the same thing.

I do my best to focus on my job: fixing what can be fixed and preventing what can be prevented. Bringing up a person’s past mistakes brings nothing good to a medical visit.

Every day I attend patients in desperate circumstances. I do my best to listen to what they say, and what they don’t say.

When I start to fall into the trap of judging people who have come to the inevitable consequences of reality avoidance, I remember the many mentally ill I’ve cared for who tried so hard to stop the voices in the heads. Because it’s easier not to judge if the person has a diagnosis.

I sit and talk to someone who has burned a lot of bridges, brain cells, and assets using recreational chemicals, and I do my best to tease out the story from a wandering narrative. I nod and look into the face of devastated youth and beauty.  I listen to speech patterns that some find annoying, and when the patient finishes talking I ask the right questions.

I do my best to get them to the correct medicine. Often the patient requests drugs that will make their problems worse, not better, and I explain the rationale for avoiding them.  Mostly they follow the logic, sometimes they don’t.

A lot of the people here have asked me if I’m staying. I don’t plan to, but I’d like to come back.

Inevitably, I don’t get along with some people.

But then, perfect people don’t come to see me.

 

 

Winter Alaska Life: really cold and dark

Consider the price of the meat

What you get at the store can’t be beat

But up here, to be blunt,

The price of the hunt

Makes the comparison sweet

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

In the northern hemisphere, the sun sets later daily from June 21 till December 21, the Winter Solstice. At points on the Arctic Circle, the sun doesn’t rise at all that day.  The winter I worked Utkiagvik (then called Barrow) I arrived a week before dawn; if I had come early enough, I would have experienced night from November till January.  Here we have about 72 hours when the sun doesn’t show itself, and that won’t happen till after we leave.

When the sun sets, it will set in the south, not the west.

I find myself now so far west that I can watch the sunrise at lunch.

+*+*+*

For the most part ER mornings run slow, with late afternoon surges. I hit the cafeteria early, before noon and at 430PM.  Not only the aging eat so early; I did so in residency when I worked ERs in Wyoming.

I cover ER not out of passion for the genre but out of obligation as a team player. Still, the set up here has brought me no more than 9 patients per clinic day, and the ER has brought me no fewer than 10.  Thus ER here has brought me more professional satisfaction.

I would prefer shifts shorter than 12 hours.

+*+*+*

I love languages. The North Alaska Native Association (NANA) partnered with Rosetta Stone and in 2007 brought out two versions of Inupiaq, Coastal and Interior.  On previous Alaska trips I tried but failed to get the product.  This time, though, the local NANA office had the item for sale, and on a rare day off I tramped through a light snow and bought it.

But I couldn’t get the software to install. Yesterday, in another rare day off, I called RosettaStone.  It took 90 minutes to find out that the program can’t be used with my current software (Windows 7 Professional).  The phone rep cheerfully told me that I could add another language, and which language did I want to buy?  After 3 tries he still didn’t understand that, working with Inuit I wanted to speak their language.  He just thought I wanted to add to my inventory.

+*+*

The price of hunted meat, including license, travel, fuel, and ammunition, makes the end product unjustifiable from an economic perspective. Here, however, where food either comes by airplane or comes into the area of its own accord, pursuit of game animals and fish brings in the cheapest calories.  “Stew” in the lower 48 means the meat flavors the vegetables.  Here, with potatoes running $3/pound, one flavors the meat with the vegetables.

The town has 3 grocery stores, all of them expensive. One sells reindeer meat.  On my day off I bought a couple of pounds at breath-taking prices, and cooked up a stew.  Delicious, but it really needed 4 hours of simmering rather than the 2 ½ hours I gave it.

 

 

 

When is influenza Work Comp?

A recurring problem, I fear,

Is the flu I get every year

Am I a jerk

To say I got it at work?

I don’t want to be a pain in the rear.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

Friday I worked but not very hard. I saw more people off the schedule than on due to the number of no shows.  I attended as many people with respiratory problems as with bone-and-joint problems.  As the day wore on I felt, more and more, the aching from yesterday’s 3-hour walk on the ice-covered road leading out of town.  I resolved walk more.

After work Bethany met me in the hospital cafeteria for the weekly prime rib dinner. As Iowa beef snobs we rarely leave home to eat it.  We made an exception; it turned out to be very good, and my piece of meat came large enough to overwhelm.

But my cough, gradually improving over the last 8 weeks, came back stronger than ever on the short walk back to our apartment, and I realized that my tundra-seeing expedition couldn’t account for the ache in my upper back.

I started to shiver, my nose started to run, and my cough worsened. At 9:00 PM I called the Veteran’s Administration for permission to go to the local ER.

I spent 40 of my prepaid phone’s 200 minutes on hold.

My fever and aching worsened, I took Tylenol, I broke into a sweat and I felt better. Which I told the nurse when she answered.

The nurse had no concept of Alaska’s vastness.   She asked if I could get to the VA facility in Palmer, Wasilla, or Anchorage; I told her that I was a good deal closer to the Russian border than  to any of those places.

She knew more nursing than geography.

Eventually she advised fluids, rest, and Tylenol.

Every year I get the flu shot; it’s about 50% effective at preventing flu but it’s 90% effective at preventing death from the flu. And every year, I get the flu.

I got sicker on Saturday evening and went to the ER. I anticipated and got a flu test.

During the wait for results my chills cycled with sweats twice. I took my first oseltamivir (Tamiflu) pill before I left the ER.

But as I had signed in, the slip of paper wanted to know if the problem were work-related.

So many times in the last year I asked sufferers who sought my advice if they wanted the problem put onto Work Comp (or, in Canada, onto the WCB, Workman’s Compensation Board). The vast majority refused; some feared being fired in reprisal, some didn’t want to hassle Human Resources, and some felt their regular insurance would take care of things.

I have almost no social interaction outside the hospital, and I deal with the infected on a daily basis. Until now, I understood the perspective of the self-employed: fear the Work Comp insurance rates will go up.  This time, though, I stood in the shoes of the employed.  And I understood the hesitance.

I didn’t check YES or NO. I wrote, Let’s talk.

A Halloween parade seen from the ER

The children went trick-or-treat

While Anchorage was shut down with sleet

Thus diverting the flight

With the time growing tight

But the end was alright, it was sweet.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

I like to be flexible in my assignments. While I prefer to concentrate on outpatient work, I enjoy the intensity of inpatient.  And I’ll cover ER to keep things running smoothly.  So for the last two days I’ve worked the Emergency Room.

Of the three morning patients, one turned out a good deal sicker than anyone could have foreseen.

The nursing staff prepped for Halloween, scrounging odd props for impromptu costumes. We found a red rubber half ball manufactured with a valley down the flat side so that the proper pinch would keep it on the face as a clown nose; with the addition of a hood used for positive pressure in the event of severe respiratory contagion, it made for a really creepy visual.

The kids started showing up at 3:30PM in costume. The hospital distributed large sacks of candy to each department, and three distributors took their places at the end of a corridor, just outside the ER door, giving out miniature candy bars.

Inside the Emergency Room, while the costumed kids paraded past, severe illness worsened in front of our eyes and we dealt with the rippling waves of back stories of drama, irony, and dysfunction. I danced back and forth with increasing urgency as the notorious Alaska weather complicated the patient transfer, past distraction and into improvisation.

By 5:00 PM, when I went into the corridor to snag a bite of junk food, I found the nurse jauntily giving out the treats by the handful.

“I thought we were supposed to give out candy one at a time,” I said.

“I’m tired of this,” he said sotto voce, “I want to go back to work.” And he kept greeting the kids in costumes with laughter.

Just after 6:00 PM I hot-footed down to the cafeteria; the kids had finished trick-or-treating but the Halloween decorations remained on the doors and bits of black and orange crepe paper littered the floor. I got the last 4 pieces of fish and returned to the ER.

Missing food, sleep and human affection leads to burnout. Large paychecks cannot make up for the inability to eat a relaxed meal.  Bolting bites of fried cod between talking to patients did not give me a break but it kept me from impatience.

During one of my status checks I found the patient double thumbing her phone’s keyboard. “Have you put everything up on Facebook yet?” I asked.

“Oh. Yeah,” came the off-handed reply.

I finished at 8:30 PM, full of adrenaline. When I got back to the apartment, Bethany told me that the three foxes which live beneath the school hadn’t been relocated yet, thus the children missed recess. “I know,” I told her.  But I couldn’t tell her why.

 

 

A procedure I couldn’t talk the patient out of

I looked down at the big toe

To see how the nail did grow

It sure wasn’t right

And it hurt day and night

So I fixed it, but not for the dough.

 

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

Medical school and residency merely start the process of lifelong learning required of my profession.

In residency, I saw one ingrown toenail removal before I did three under supervision. In the Indian Health Service, a podiatrist said, “This is the procedure that’s going to put your kids through college!” and gave me some tips on speed.  In the 90’s I did quite a few, but by the time the century turned, despite a large financial motivation to the contrary, I figured out how to get the patient taken care of without shedding blood.  A bit of cotton, an orange stick (a wood implement widely used to rearrange cuticles) and a bit of povidone dione (marketed most commonly as Betadine), with patience and about a week, can usually move the flesh away from the nail a millimeter a day.

Over the summer, researching the problem while in Canada, I came across the concept of a nail spreader, which can flatten out a curved nail over the course of several months.

But the patient yesterday (who gave permission to write more than I have) had already tried everything I had to offer, yet the problem persisted.  And I couldn’t talk  the patient out of the procedure.

Finding the right equipment takes up more than half the time of an office surgery when neither the physician nor the nurse knows where anything is.

I got trained to not only take out the nail plate, but scrape away germinal matrix (the tissue that makes the nail) down to the bone with an instrument called a curette, then apply a chemical, phenol, so destructive to human tissue that the nail would, hopefully, never grow back.

We had no curette, and no phenol, and I didn’t mind: less work for me and a good deal less blood loss.  At the end, I used a stick coated with silver nitrate to burn the heaped-up inflammatory tissue growing over the nail.

During the procedure we talked about high school sports (very important in small-town America) and music while outside, the gentle snow fell.

6 afternoon patients and an evening power failure.

With a light do you send out a scout

To see what the problem’s about?

For it gets pretty dark

And the prospects are stark

Up here when the power goes out.

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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

On my first Friday back in the Arctic, I got to talk with a Native about village life.  After getting through the medical agenda, I asked about fishing.

The village in question right now does it a lot.  And, with freeze up coming, the Natives are working the set nets.  Soon the caribou migration will start.

But the whaling grabbed my attention.  We talked about a village that brought in their entire quota of 10 bowheads last spring; in times past the villagers sometimes had to make do with as few as 4.  In the process, we talked about making the bombs necessary for the complicated harpoon that the Natives use.

***

I had the thrill of making two people better before they left.  One I helped with massage and spinal manipulation, one with an exercise I saw on YouTube.  “YouTube?”  the patient exclaimed, “You mean I could be a doctor from YouTube?”

I said, “You want to learn to put in a chest tube or do a cricothyrotomy?  Go to YouTube.”  And, in fact, you can find instructions on almost any procedure.

***

Still learning, or relearning, the Electronic Medical Record system here, I only had 6 patients scheduled for the day, 2 in the morning and 4 in the afternoon.  I’m just getting the hang of sending the prescription to the pharmacy before the patient leaves, and finishing the remaining documentation later.

The docs here meet with staffers for morning report, much like we did during my time in Barrow (now called Utqiavik).  Shortly before the meeting started, I realized I’d brought the wrong cell phone, the one with no local signal.  Yet, wonder of wonders, I had two bars of service and updated email.  I texted Bethany to not text me on either phone, attributing the miracle to sun spot activity.  She didn’t get the message; I have no idea if solar flares were responsible.

***

We had settled in for the night when the power failed, and moonless Arctic nights have a deep, Stygian darkness.  We have had power failures everywhere we’ve gone, and for the most part we can laugh it off as part of the adventure.  But our all-electric housing has no alternative to combat the cold, and while I searched out flashlights and head lamps (a total of five) I started to worry about making it through the night.  While the hospital has emergency power and we have long underwear, here we lack the cold weather sleeping bags and tents residing comfortably in our basement in Iowa.

The words power outage take on new meaning in an unforgiving climate.

This year’s first Arctic day seeing patients

The one forty-five didn’t show

Perhaps the wind and the snow

Made him think twice

About going out on the ice

Where a fall can be the stop of your go
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, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic. Any identifiable patient information has been included with permission.

I started in to seeing patients this morning after rounds. The first patient of the day would have presented more difficulties if I didn’t speak Spanish with considerable tolerance for dialectic variation.
I got a chance to write when my 1:45PM patient didn’t show.
In less than 72 hours the weather went from overcast and rainy to snowy, then clear. When snow falls, people become the unwilling slaves to Newton’s 3 laws: A body in motion remains in motion absent external force, a body at rest remains at rest absent external force, and for every action there is an equal and opposite reaction. Friction can conceal those laws from our consciousness, but put dry powder snow onto black ice, and people slip, slide and fall. And then they come to see me.
The real heart of a medical visit, though, lies in evaluating what the illness means to the patient. And each patient so far today arrived with unique circumstances with a fascinating back story.

Consider the overall Alaska picture.  Natives have seen tremendous change, and many have been engulfed by linguistic upheavals.  In the memory of people younger than me were the trips onto the winter sea ice, camping in igloos to hunt seal with harpoons, using dogs to find the holes in the ice where the seal come to breathe.  Most non-Natives moved here from somewhere else, and each one finds themselves in the middle of a personal odyssey.  Of the small number of non-Natives, born here, most have moved around, a lot.  Each move has its own tale of motivations, losses, and gains.

Those, like me, who keep coming back to the 49th state, have their own epics.  This time I’ve found two people I’ve worked with before in other places on the Alaska coast, and a third is soon to arrive.