Archive for the ‘Alaska Life’ Category

New Year’s Day, walk on the beach

January 2, 2017

We went for a walk on the beach

To see what the ocean could teach

Then the tracks of mink

Made us question and think

As the eagles in cedars would screech.

 

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. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

 

Being a couple of well-established party vegetables, we retired New Year’s Eve at 9:30, only to be awakened by fireworks at midnight. We could see most of them from the bedroom window.  Bethany opened the curtain, we put on our glasses and lay in bed, watching.   The display went on for a quarter-hour.  Bethany drifted off to sleep.

The sun rises late here, not till after 8:30. We went out for a walk on the beach with one of the pharmacists.   The island has diverse geology, and resistant rock outcroppings break up the strand.  Pacific flotsam dots the high-tide line; the most colorful parts I found were ropes, nets, and plastic containers.

We spotted an immature eagle soaring. We walked on the sand when we could, but mostly we slipped and slid over shingle, the pebbles and cobbles on their way to becoming sand.  We clambered over interesting layers of granite, layers turned vertical by unspeakable geologic forces.

People walk their dogs on the beach here, we expect to find canine and human tracks in the sand. But we also found a lot of lynx tracks, and we could read a dramatic story of a large cat stalking a very small deer, but the novel’s end got lost where the sand merged with the broken rock.

We heard the skittering, high-pitched call of an eagle in a towering cedar, but couldn’t spot him.

And we came across the distinctive, delicate marks that mink paws make in the sand. In one spot we found the shell of a sea anemone apparently retrieved from a tidal pool at low tide by a mink and consumed on the spot.

Then we found 3 drag trails, each paralleled on one side by mink tracks, each coming up from the jumble of stones and puddles of water and erratically but inevitably leading up the beach, past the high-tide line and into the rain forest and muskeg. We followed as best we could.  Though I track well for my age and demographics, I couldn’t follow the trail on the rock or on the spongy floor of the forest.  We wondered how many mink constituted the party, and what they had caught.

When we had gone as far as our aging knees, ankles, and backs would take us, we turned around. The wind died down, the sunshine warmed us and we unzipped our jackets.  Against an astounding blue sky we spotted eagle after eagle, gliding from the water into the trees.

 

First week back in Metlkatla

December 22, 2016

With parents, so strong, warm and brave

To them the praises I gave

Imagine the joys

In a room with 3 boys

And all of them stay well-behaved.

 

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. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

MONDAY

Normally, I cruise right through jet lag, but with plane delays, sleep disruption on the way here shattered my usual techniques. The schedule wisely gave me Monday morning to get up to speed with the EMR, but no one to help me.   I used this system here and elsewhere in Alaska before.  Open –sourced from the Veteran’s Administration, it has functioned well for the last couple of decades.

The sun rises late and sets early here, short days mean I walk to and from work in the dark. I wake up early, more or less at the time I got up in Iowa.  But my office and the exam rooms have windows giving onto spectacular views, with evergreens and towering, snow-capped mountains.  Sometimes, during an examination, I ask patients whether they get tired of the scenery.  Uniformly, they don’t.  People move back from the cities to live here.

TUESDAY

Our clinic does a lot of treatment with nebulized albuterol, IV fluids and Zofran (ondansetron), a potent anti-vomiting drug. So far everyone needing albuterol smokes or is exposed to smoke.  Dehydration,  with the need for IV fluids, can come from a number of sources.  I get a charge when a patient feels better because of fluid replacement or breathes better because of albuterol.

Wednesday

I’ve given out a lot of Zofran since I started here three days ago; I enjoy the change on patients’ faces when the drug takes away the nausea..

Today I have call.  With the upcoming holidays and a number of permanent staff on vacation, the usual Wednesday afternoon meetings got postponed, and no one bothered to reschedule patients.  I didn’t want to face an afternoon with no work, and, as it turned out, I didn’t have to.

We have limited diagnostic and therapeutic capabilities here, and I don’t mind. With no CT, very limited lab chemistries, and no ultrasound, we send a lot of blood tests out.  If time frame permits, we make arrangements for transport by ferry for specialist consults.  But more than one person so far has required Medevac via boat to Ketchikan

THURSDAY

More permanent staffers have left on vacation. Mostly I do Urgent Care with a chance of follow-up, but sometimes I take care of people with long-term problems.

Today a family came in, both parents and three sons under the age of 10. The boys stayed well-behaved and quiet, without interruption, during the entire visit.  When not watched, the oldest took the opportunity to hug his brother.  I saw similar patterns of behavior in other families with three sons when I worked here in April: oldest hugs middle, middle hugs youngest.  At the end of the visit, I thanked the parents for the treat of caring for their children.

I didn’t say, but I wanted to: “It’s a pleasure to work in a community where families maintain such a high level of functionality.”

 

.

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.

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.

March 23, 2016

When it came to the blackened entrée

I hardly knew what to say

The salmon’s the surf

But the moose is the turf

And the wind blew the high heat away

 

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.

Friday we drove out to a potluck at the house of one of the other docs. I brought an Asian salad, Bethany made bread.  Other treats included sweet potato casserole, Spam fried rice, Philippine corn nuts and peanuts and pork rinds, bean salad, potato salad.

While the temperatures this winter have hovered around freezing, the mercury started to plunge last week, into the single digits. The Bay froze over, and the wind picked up.

The host faced a culinary challenge: cooking outdoors when the wind chill sucked so much heat that he had to construct a windscreen.

The entrée consisted of the unique surf and turf of this area of Alaska: blackened moose and salmon. At the end of the party I asked for and received tips on the process of blackening.

Monday the snow fell and fell hard, and I had something I very rarely have, a slow day. I perused my email.  I did some online CME, but mostly I sat.  My tally for the entire day stayed in the single digits.

Today during rounds I heard a doctor referred to a patient as a “high liner.” Too much of an outlander to have heard the term, I waited till I cared for a commercial fisherman later in the day to ask, and I learned the term refers to the best commercial fishermen, the ones who consistently bring in large catches.

One of the first patients of the day came in with a neck lump. In short order I diagnosed a sebaceous cyst, a collection of cheesy, smelly material that happens when one of the skin oil glands gets plugged.  With an apparently open schedule, I agreed to cut it out right then.  We gathered the gear, I wiped the area with alcohol, prepped it with Betadine, and draped it with a sterile towel.  Then I couldn’t find it, nor could the patient, nor the resident.  David Copperfield could duplicate the trick, but I had to repeatedly plead that I had no idea what I’d done.

In the afternoon, a young patient arrived to follow up on a shoulder injury, and I very quickly found range of motion loss. In a culture such as this, where everyone hunts and fishes,  incapacity of a shoulder can have terrible consequences.  After the x-ray, while I awaited contact with the specialist, I used an osteopathic technique called muscle energy.  I brought the arm to the barrier, and using my own muscle power had the patient perform an isometric contraction away from the barrier for 5 seconds.  I instructed in a relaxing breath, got 10 degrees more of motion, and repeated the process.  Then I showed the patient how to do it without me.  That person left with better range of motion, and I finished the day euphoric from making two people better before they left.

They both gave permission to publish more information than I have.

 

Athabascan languages and radio traffic

March 11, 2016

Today’s limerick at the bottom.

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.

I learned to speak Navajo in the early 1980’s in Canoncito, New Mexico. My teachers asserted ability I didn’t feel and made me speak for myself.  My first sentences stumbled at two words in length.  The language has 32,000 tenses and no regular verbs; I pretty much kept to the simplest of the present tenses.  I could make myself understood, and the people showed great generosity in their tolerance.  Despite my lack of grammar and vocabulary I had good pronunciation.  Sometimes my patients or the staffers would burst out laughing because, they said, “You sound just like a real person.”

Navajo language belongs to the Athabascan family. Those cultures call themselves Naa Dine (or something very close), meaning People.  The men practice mother-in-law avoidance.  Women run the society. They potlatch: every few years those who can throw a massive party for the purpose of redistribution of wealth.   Those peoples mostly call the North Pacific area home.  Anthropologists have a lot of interesting theories about why the Navajo and the closely related Apache live so far from other Dine.

The area of my current assignment includes several villages of Athabascan speakers who call themselves Denaina. Today I asked a Denaina speaker if the language were close to Navajo.  “We have a lot of the same words,” the person said, “but they mean different things.”  Struck by the universal truth of the statement, I laughed out loud and asked to use the quote in my blog.

***

The Alaska State Legislature is currently debating Bill #98 to regulate telemedicine. Docs out here in the wilderness have been doing telemedicine for decades under the old law, which demanded an examination before any prescription.  The remote hospitals trained Community Health Aides (CHAs) to do examinations and dialogue with doctors via radio.  Now with good telephones connections  and cell phones we still call talking with the CHAs “radio traffic.”  At this hospital, each physician has an ongoing relationship with a number of villages.  And every village has a clinic with a limited pharmacy.

The new law lacks consideration for good patient care and the reality of life in villages accessible only by air or by water. One of our docs went to Anchorage to testify against the bill, and I wrote him this limerick:

We work in places remote

You can to by plane or by boat

We rely on description

To make our prescription

Please, for this bill, do not vote.

 

Nobody in the audience laughed.

 

 

Referrals to Anchorage and Rembrance of Reye’s

March 6, 2016

We’re much further out than is rural

Logistics would make your hair curl

I don’t know the choice

But there’s burnout in voice

When I need to make a referral

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.

Medicine has always been a team sport, none of us alone is smarter than all of us put together. Our profession has always relied on specialists.

You can’t drive to where I work from anywhere but here. Nonetheless, 21st century American medicine requires referral to specialist from time to time.  They come here on regularly.  Ears, nose, throat (ENT), for example, flies in for a week every two months and has a packed schedule.  Cardiology comes four times a year.

We have a system for getting referrals down to Alaska Native Medical Center (ANMC), which starts with a simple call to a Case Manager, always a Registered Nurse (RN). All three RN nurse managers have a firm grasp of realities of Alaska life and the way inherent logistic problems color the provision of medical care.  Occasionally, the problem at hand demands a close time frame, which is when I have to speak doctor to doctor.

On two occasions so far I have made such calls. The neurosurgeon spoke from or past the brink of burn out; he would not yield to any attempts at cheeriness or optimism.  The cardiologist’s voice showed more resilience.

I remembered another Indian hospital, in another state, in another century. The adoloscent came in with intractable vomiting and personality change; I needed less than 5 minutes to make the diagnosis of Reye’s syndrome, a malady that disappeared when we got out the message not to give children aspirin. But we didn’t know the link then; we knew the liver turned to mush and the brain swelled and sometimes the child died, and we didn’t have much in the way of treatment.

After the first five minutes, I had to call the lab tech in, and midnight came and went while I awaited biochemical proof. Once I had the diagnosis solidly confirmed, I called the University medical center an hour away and started working my way up the hierarchical ladder.  I presented the case to the student, intern, and resident.  By the time I got to the chief resident at 3:00AM I could deliver the presentation in less than a minute, but my nerves had started to fray.

I could hear the chief resident’s heart break in the sigh and the pause. Clearly overworked and sleep deprived, he sounded cornered when he said, “Well, I guess you’ve got to send the patient down.”

I can look back on my own burnout and I can empathize with the other doctors, but I don’t have a solution when we cannot make enough doctors to staff the system without working most of them more than 60 hours a week.

The neurosurgeon probably works more.

Power outages and head lamps.

February 18, 2016

 Sometimes, when down falls the snow,

Out the power will go

But what I use instead

Is the light on my head

Which in my pocket I stow.

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 winter, till now, has brought little snow to the area. Temperatures have consistently topped those at home in Iowa.

But today I trudged through fat, wet flakes the 250 yards to the hospital. Yesterday’s rounds lasted close to an hour, reviewing the significant cases that happened over the long weekend.  Today the presenting doc announced the expected death of an elder, and all action stopped for a moment.  The person’s passing will leave a void in everyone’s life.

Patient flow slowed to a trickle with enough snow to ruin driving but not nearly enough to make roads passable to snow machines.

At 10:00AM the lights flickered and went out. The laptops, running on batteries, glowed in the dark.  Then the emergency generator kicked in, and the fluorescent fixtures lit up again.  Business went on as usual.

With heavy, wet snow straining the electric wires, power went off and on the rest of the day. We kept working.

One patient gave a long, complicated, difficult to follow history, and if I’d had to hurry I would have gotten annoyed. But I didn’t, so I listened, and, after a while, I took notes.  The power flickered again, and I ordered some tests, the results of which showed serious pathology, bad enough I referred the patient to the ER and wondered whether or not the Medevac plane could fly in such snowy weather.

I took away a lesson I already knew: people get sick whether or not they can tell their story well.

A patient whom I’ve followed for more than a week came in after lunch. I asked one of the younger docs, with more surgical training, for help.  In the middle of the minor procedure, during the stitching, the lights went out and stayed out.

I carry a head lamp in the pocket of my white coat. When I first started private practice, LEDs had yet to revolutionize the flashlight industry, and head lamps stayed anchored to the wall.  A medical grade head lamp cost upwards of $200.  The one I have in my pocket cost $30 at Cabela’s, feels cheap to the touch, and provides better illumination than anything available in 1990.  I use it to examine mouths and other places where the sun doesn’t shine, to help during minor surgery, and to remove ear wax.  Today it helped finish the surgery.  Just as I cut the last suture, the lights came back on.

Then not much happened for the rest of the afternoon. I left outpatients early, and Bethany and I braved the roads to drive to the library.  I borrowed a couple of books.  If the power goes out, I’ll stay entertained.

Till my headlamp batteries go out.

Botulism, Napoleon, and a miracle

February 17, 2016

Towards death you might go to the brink

From eating the foods they call stink

Fermenting such fare

In glass with no air

And such poisoned eyes cannot blink

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.

We discuss significant cases in the medical staff offices every working morning; the collegiality makes us all better doctors.

We started out with a spirited discussion of Native foods and botulism.

A lot of Alaska Natives prefer fermenting foods to cooking them. The non-Natives refer to those foods as what they are, preceded by stink.  Thus fermented salmon roe are stink eggs, fermented salmon heads are stink heads, the choice parts of seals are stink flipper.  Usually fermentation lasts six weeks, and traditionally takes place in a hole in the ground lined with grass and covered over with dirt.

Bacteriologically, fully rotten foods carry much less danger than those partly decayed; bacterial toxins break down with time and the germs themselves die off. Problems arise when fermentation takes place without oxygen, permitting the formation of botulinum toxin, giving rise to botulism.  Thus the hole in the ground produces less risky delicacies than Tupperware, Mason jars, or Ziploc bags.

I learned today to ask about the 4 D’s: Dry mouth, Double vision, Dysgeusia (trouble swallowing) and Dyspnea (shortness of breath), in the context of vomiting or other gut disturbance after eating native foods, especially those prepared in modern vessels.

Few Gussicks (the Native word for non-Natives) realize that Americans eat a lot of fermented foods. Most everyone, for example, knows about stink cabbage (sauerkraut), but few think about stink milk (sour cream, buttermilk, yogurt, and cheese), and stink juice (wine, cider, beer).  The English love their hung pheasants.  And traditionally eggnog was allowed to sit at room temperature for 6 weeks.

Napoleon could wage his wars because a Frenchman patented a process of fermenting ground meat with lactobacillus to kill the pathogens, and in the process made botulism-free salami and other sausages.

And later in the day, I twice gave out my never-fail recipe for constipation, the prune water protocol. Put a prune in a glass of water, I said, leave it by the side of the sink, when you go to bed drink the water, eat the prune, and brush your teeth.  Repeat morning and evening.

Rounds ended with a discussion of a medical miracle. I cannot give details about a death sentence and a reprieve, but I can talk about the ripples of hope that spread through the family, the village and the medical community.

Brevig back to Nome

March 31, 2015


I flew out and back Bering Air
My clothes in layers I’d wear
I come and I go
In the ice and the snow
And a bag of dry fish I did share

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 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) I can get along with. Right now I’m on temporary detail to Brevig Mission from the hospital in Nome, Alaska.

I don’t sleep well the day before I travel, without regard to mode of transport. I rose early and showered and packed and ate.

Then I napped, for the best sleep I got all night. By 8:00AM I logged on to the computer.

I worked a steady pace through the morning. At noon the staff left for lunch. I stayed by myself and ate trek mix while I read a Jonathan Kellerman novel (I write better than he does, but he has the genre formula nailed down).

With but one afternoon patient scheduled, I had time to finish documentation. The Bering Air agent, who had showed up during a house call to check me yesterday, came in. The plane would be a little late, he said, flying from Nome to Wales first. He needed my weight. I offered to get on the scale (declined), and gave my best honest estimate. But he also needed weights on pharmacy and lab air freight.

Things had finished when the staff asked me to add in another patient. I looked at the clock. Plenty of time before the 4:00 departure. Sure, I said.

And I said that for the next three patients as well. I luxuriated in unhurried patient care. And each time I entered the data into the computer in a timely fashion.

I told the staff what a great time I’d had. They told me to come back in summer for prettier scenery. I looked out at the snow-covered hills and the frozen Bering Sea, and wondered how things could ever get prettier. They assured me they would. And they talked about how Brevig never sleeps in the summer, how the place bustles with activity. And about the fishing.

I said that I would have like to have tried dry fish.

The staffers looked at me in dismay. I should have spoken before, they said. And I saw how my shyness, from not wanting to impose on my hosts, appeared as standoffish. And all that announced at 3:50PM.

A Community Health Aid (CHA) bundled up faster than I could imagine, and jumped on her ATV.

It takes me a good deal longer to get on my arctic-grade bib overalls than the CHA’s near instantaneous preparation. As I mounted the ATV behind a diminutive staffer, we saw the plane coming in from the northwest.

The CHA on the ATV passed us on the hard-pack snow of the village street, and the staffer in front of me took the bag of dry fish from her without slowing, as casually as if it happened every day and as smooth as the railroad used to pick up sacks of mail. Approaching the airport, we saw the only truck in town, a 4WD club cab pickup.

I needn’t have worried about keeping the plane waiting. We pulled up before the pilot, working on his documentation, killed the engines.

Wearing my arctic layers let me confine my baggage to 1 day pack. I sat as instructed just behind the passenger in the co-pilot’s seat.

After a 5-minute flight to Teller we deplaned one passenger who had flown from Nome through Wales and Brevig to get home.

Ice melting into puddles astounded me when we arrived in Nome with a temp 20 degrees higher than Brevig when we left.

Contrast remains the essence of meaning, even when just barely above the melting point.