Posts Tagged ‘snowmobile’

Munchausen in the morning, narcotics seekers, and long distance snowmobile back pain.

February 10, 2011

Here’s an intelligence spark

To keep doctors out of the dark.

     The information we share

     In the hour we spare

About which patient is seeking which nark.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

The doctors’ mornings in Barrow start with an hour-long colloquium.  We discuss patients by name, talk about history, physical findings, and differential diagnosis (the list of possible diagnoses).  We talk about problem patients, consultations we’ve received, and interesting lab findings.  Every admission, delivery, and transfer gets discussed.

I keep my presentations short. 

When I worked in radio, and I could sell a commercial to a sponsor, I never got more than a minute to get the message across.  I learned to distill the communication to its essence, keep my sentences short and not repeat myself.  If you can’t say it in less than a minute, I used to lecture trainees, you’re not sure of what you want to say.

I named a patient and described an injury at morning rounds today, and how the patient copped an attitude when I refused a prescription for the requested narcotic.  As soon as I said the name the room erupted into spirited groaning.  A Munchausen, my colleagues said, who diverts the pills to a (named ) household member.  Then they told me about the self-inflicted injuries they’d seen.

Munchausen’s syndrome got its name from a fictional character in a 19th century play who went from doctor to doctor, making up symptoms to get attention and treatment.  In the 21st century, a patient with the diagnosis of Munchausen or Munchausen’s syndrome has demonstrated a willingness to injury him or herself, feign symptoms and alter lab findings.  Most of the pathology comes down to attention-getting and narcotics-seeking behavior.

I’ve had Munchausen patients in other places.  One’s (I won’t say where, I won’t say when) skills at feigning an abnormal neurologic exam were so good that a previous doctor ordered a seizure drug intravenously.  The drug went into an aberrant artery, instead of a vein, that ran on the inside of the elbow, and the patient lost a hand.  The tragic story unfolded over the course of a week, and as I used the telephone to close in on the truth the patient signed out of the hospital, against medical advice, never to be seen again. 

I talked about three other patients, I received advice on whom to call at Alaska Native Medical Center (ANMC), and learned some fine points about bush medicine.

The other docs with more experience here discussed what to expect during Qiviuk, the Messenger Feast that started today. 

Several hunters, who had been out for meat to provide for the feast, came in with medical problems related to their activities.  One had back pain from riding hundreds of miles on a snow machine in the pursuit and retrieval of a caribou, and gave me permission to write about it.  I’m sure if I’d been that long on a snowmobile I’d have the same physical findings.

I told him my thoughts on the importance of hunting to Barrow, how it sustains the people nutritionally and how it gives the men in particular and the town in general direction.

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Snow machine excess, cold injury, and wolverines

January 19, 2011

Some people, they smoke and they drink,

Some trap the otter and mink

     But the story’s been told

     That Barrow’s so cold

You can’t open your eye if you wink.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  To avoid burnout, I’m transitioning my career, and while my one-year non-compete clause expires, I’m working in exotic locations, traveling, having adventures, and visiting family and friends.  Currently I’m in Barrow, Alaska, the northernmost point in the United States.

I’ve been back on the job for less than twenty-four hours, here in Barrow.  I’ve seen several cases related to snow-machine use.

In Barrow, one avoids the terms sled or snowmobile in favor of snow machine.   The people here use them, not for recreation, but to do necessary work.  People hunt from snow machines, so that hunting injuries are almost synonymous with snow machine injuries.

Most, not all, caribou migrated south past the Brooks Range when the days grew too short.  Herds of up to five hundred remain, grazing on the tundra.  In temperatures so cold that alcohol freezes, in the Arctic night when the sun doesn’t rise and the moon doesn’t set, subsistence hunters go after them with firearms ranging from .22 magnum handguns to 7mm Remington Magnum rifles.

A lot of parkas here sport wolverine fur on the ruff. Unique in that breath frost won’t stick to its fur, hunters eagerly seek the “skunk bear.”  The creature has such a nasty disposition that it acts like a serial killer, slaughtering everything in its path for fun and eating for necessity. 

The government issued a wolverine fur-trimmed parka to a person I know (not a patient) during the cold war, for work done in the Arctic.  To this day, the nature of the work and the circumstances of issuance remain clouded in mystery.

Hunters also go after wolves; polar bears occur as targets of opportunity.

Most of my clinic load, whether in Iowa or Alaska, has to do with damage from alcohol and tobacco.  Respiratory infections, cough, asthma, depression, fatigue and malaise, hypertension, high cholesterol follow from those two substances.  Counseling people to quit, though a good idea, rarely works.

When the patients come in with fetal alcohol syndrome and fetal alcohol effect, it’s too late.  With irreparable damage I just make the best of the situation.

I won’t say where, but I attended a set of fraternal twins, one of whom had fetal alcohol syndrome and one of whom had much milder fetal alcohol effect.  Some people are more resistant to alcohol than others, and such resistance starts before birth.

If most of what I see in any clinic has to do with drinking and smoking, the majority of the remainder has to do with the unique factors of where the clinic stands.  Barrow’s air is so dry that eczema here runs an order of magnitude worse than any I’ve ever seen.  Yet most people know the cold so well that frostbite comes rarely.

The first case of frostbite here in Barrow came my way today, very shallow damage, but not to fingers or toes.

Nalukataaq injuries continue, my wife arrives, and snowmobiles on the water

July 15, 2010

If there is pressure inside of a cast,

It must be bivalved, I mean fast.

    The noise and the sputter

    Of our deluxe cast cutter

Brought relief to the patient at last.

I’m still taking care of Nalukataaq injuries.  A patient (who gave permission to relate this much information) fractured an ankle during the blanket toss, requiring a trip to Anchorage for surgery.  Weeks later, the patient came in with pressure sensation at the ankle bones and the heel.

Pressure on living tissue inside a closed space like a cast prevents blood entering and leaving; a person can lose a limb that way and I can remember getting out the cast cutter on a snowy night in Navajoland when transport down the Interstate was impossible.

I had the nurse move the patient to exam room 5 where we keep the orthopedic equipment while I went back to my apartment to get my hearing protection.

In my short career as a (failing) rock musician I lost hearing and my ears are still ringing.  Loud noises don’t just annoy, they inflict pain.  Like many baby boomers I suffer from tinnitus. 

We cannot undo the mistakes of the past, but we can keep from making the same mistakes in the future.  Bethany bought me a nice set of noise cancelling headphones a while ago, with the intention that I’d use them on plane trips. I also keep a set of foam ear plugs in the case, and if I anticipate severe noise I use plugs and muffs at the same time.

I rolled the foam plugs and inserted them into my ear canals, then I put on the muffs. 

The circular blade of a cast saw vibrates at right angles to the plane of the blade and cannot cut skin, muscle or tendon though it can tickle like crazy.  While the patient watched, I touched the blade to my palm. 

To relieve pressure inside a cast, one has to make a cut up each side of the cast, turning something conceptually like a tube to something conceptually like a clamshell without the connection between the halves.  In the fissure made in the fiberglass, I inserted a specialized instrument called a spreader, applied pressure on the handles and the jaws spread, forcing the two pieces of cast apart.

The relief  spread over the patient’s face when I started to cut the cast padding with scissors.

***

Bethany flew in last night and I borrowed a truck to pick her up.  She wasn’t prepared for the chaos of carousel-free baggage claim.  We took our time on the way to the hospital, we drove around town for fifteen minutes.  We stopped at the guitarist’s house for carry out Thai and live Irish music. 

Much racket of two-stroke engines awakened us as we were falling asleep.  Bethany thought there were jet skis on the lagoon; we watched snowmobiles making circuits on the water in the midnight sun.

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.

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.