Forensic Ed (Reader Discretion Advised)

August 1, 2009

One of the best parts about working in a remote hospital is the opportunity to rub elbows with people who are doing work that would normally isolate them in some dank office downtown.

One of our physicians, Dr. M, is a young man with cerebral palsy. His spasticity prevents him from getting a license to do family practice in other states, even though it's pretty well controlled with a spinal shunt that infuses medication to help relax his muscles. He does not want to make the Arctic his permanent home, so he decided to become a forensic expert in child abuse. He'll start his 3-year residency next summer. In the meantime he'll continue to provide expert testimony on cases of adult assault and abuse of children here.

I thought I should take advantage of Dr. M's expertise while I could, since sexual abuse and domestic assault are so pervasive here. Alaska has six times more child abuse than the lower 48 and here in the Northwest Arctic Borough, the highest rate in the state. I was spoiled while working in Minnesota as St.Paul has the world-class Midwest Children's Resource Center, where I referred all suspected cases of childhood sexual abuse during my 20 years of practice there.

Although I feel the need to be more knowledgeable because I am working on the front line here, the basic practice rule stays the same: if the story sounds plausible, the nonspecialist like me needs to send the victim right on to the child abuse specialist because of the chance of contaminating the story by leading the victim. A clinician's innocent blunder can ruin a court case. As Dr. M explained to me, there are volumes written about how to extract the story and analyze the physical evidence in order to elicit the truth about what happened. Generalists don't make time to study those tomes. Except maybe the most curious or perverse practitioners. Seven percent of doctors are psychopaths, so who knows what they study in their spare time.

Dr. M was preparing expert testimony for a trial the following day and invited me to join him as he made a last pass through the evidence. This case involved an adult instead of a child, but I was eager to learn more about the physical manifestations of assault as it would help me hone my powers of observation during routine exams. Well-practiced medicine is after all a matter of astute sleuthing.

Dr. M read me the report he wrote based on the interview of a young woman who was strangled to the point of lost consciousness and then raped. The accused is up for rape and attempted murder charges. He proceeded to show me 180 pictures of her injuries as well as normal skin findings taken the night of her assault. He quizzed me as we went. I used my common sense but was sometimes clueless as to the signs he was showing me. The story is registered on the skin like the print on this page to those who can see.

Ninety-nine percent of rape here involves a woman who has lost all judgment and control from alcohol. I feel vindicated. Several of my female colleagues have told me it's unsafe to wander around town alone. So I can walk around town any time of day or night -- just as long as I'm sober.

We scan her arms. The paw prints on her arms are easy to decipher. The initial grab.

Two symmetrical bruises on the mid inner thigh? Cunnilingus. But which direction is he facing? Shouldn't his body be smothering her in case she wakes and resists? No, Dr. M says, the other way. He is stabilizing her legs with his thumbs to keep her from moving suddenly. Good hunch though, as women usually do come to during the rape.

When we get to the detailed photos of the vaginal area, I feel a comfortable sense of familiarity. During a pelvic exam there is a tendency to look comprehensively but briefly. Now I stare and study in a way that would be inappropriate with a live patient.

There is a vertical tear in the posterior fourchette, which is below the labia minora or inner lips. He tells me this is critical, classic evidence of forced entry. Like the cracked glass of the back door in a burglary.

He uses a colposcope, a microscope tailored to exploring human epithelial anatomy, to search the vagina for more evidence. Once, he tells me, he found a hair left by the perpetrator. This single piece of DNA-encripted evidence put the guy away for forty years.

We move up to the neck. There are bruises but not as impressive as I imagined they would be.

He had forced a kiss on her. She remembered that because it occurred before she had lost consciousness from strangulation. I made conjectures about the abrasions on her chin and lips and how his teeth or chin may have caused them. Dr. M appears at a loss at this point. He says, not too self-consciously, that he isn't much of an expert on kissing. I joke about my own knowledge and proclivities. What a strange moment, talking to this sweet, spastic, drooling man, who is 25 years my junior, about our respective experiences and acumen in the area of kissing.

Now we come to the most crucial piece of evidence. It is a centimeter-long superficial laceration along the jaw line. He asks me about its significance. I squint, cock my head and shrug. Jubilantly, as only Dr. M can be, with his infectious laugh that lasts just a beat too long due to his spasticity, he says, "Self-inflicted from her own fingernail, it proves that she was trying to pry his hands away from her neck as he was strangling her." They weren't playing a sexual game of asphyxiation as the defense will surely suggest.

We are just wrapping it up with a few pictures from inside her mouth when Dr. M points excitedly at something he missed before. There are petechiae (minute exploded blood vessels) on the inside cheek -- evidence of prolonged strangulation. This will help support the attempted murder plea because it suggests a greater degree of asphyxiation indicating an intent to do serious harm. This is important, he explains, because this is this perp's fourth victim in a town of 3500 people.

Although Dr. M assures me his job is "one hundred percent non-biased" as an expert witness, he wasn't exactly exuding neutrality at this moment, or throughout the examination. Instead I saw passion, and mission, and utmost seriousness. I can't help but think that all the childhood punishment he must have received for being a weird-looking spastic boy had to have made its mark on him. And what a functional if arduous way to get back at the dark side of human behavior.

Alaskan Animal Stories Amid a Little Night Music

July 30,2009

Dear Friends,

Last night after a hectic day spent in radiotraffic at Maniilaq Hospital in Kotzebue, I headed over to my friends' house for some R and R. Wendell Stalker and his wife Mary have a small beachfront home laden with animal skins, garlands of artificial flowers punctuated by pots of the real thing, pictures of family everywhere, and 5 or 6 guitars huddled along one wall of the living room. I detected as before the faint odor of dog, the scent of its rearend apocrine glands subtly wafting across the room.

Mary, who is usually the first to give me a big hug and big smile, hung back while Wendell, a gentle small Inupiat man in his fifties greeted me in his reserved way with a pat on the back and a mere meeting of chests. Wendell, pony-tailed, wears large glasses which allow one to track his very expressive eyes as he tells his stories in sotto voice. He met Mary five years ago in church where they began singing and playing guitar together. She's a down-sized Mama Cass, a California transplant who has spent her adult life in Alaska.

We started by talking about Wendell's music career. He and his four brothers taught themselves how to drum and play guitar. He played in an underground bar in Kotzebue in the 60's where he had a "chaperone" because he was underage afterhours in an alcohol saturated environment. After high school, Wendell took off for the Jobs Corps, a track many motivated Inupiat youth take to get work that pays. He started playing in a blues band and pretty soon he was making way more money than he was likely to make after graduating from the Corps with a technical skill. He and two other dropouts -- Native Americans from the West -- formed a band called The Local Blues Band -- and they got an agent and made some really great money playing all over the Northwest. He said, "Man, people in Missoula were only good for C and W until we came to town." No one up there knew how much they could like the blues. They made $15,000 on one gig -- gone getting high. Mary laughs then saying, "Yeah, we were all doing drugs, sex, and rock and roll back then." Wendell eventually played with Muddie Waters.

The Inupiat have a long tradition of partying for days on end after a successful hunt. It's like a prolonged carnivorous harvest celebration. Then they sleep for days. Wendell describes Thanksgiving homecomings in the 80's when all five brothers would stay up Thursday through Sunday playing music. "That's how many songs we knew back then." Now two of his brothers are dead and those are bygone days.

A break in the conversation, and Mary tells me that four days ago someone shot and killed Hunter, their 7-year-old dog she raised from just 4 weeks. She starts to tear up and says "I am so mad and I don't want to be mad." Somehow Hunter got out onto the road and when the neighbor children found him he was floating in the ocean face down. I looked blankly at her and asked why anyone would do that and she said, "it's fishing season." I just held her hand and said how sorry I was because a dog is as close to your heart as a child. And I knew too that her oldest son was killed in an auto accident in Fairbanks.

I said,"Well there's nothing like music to raise the spirits -- how bout you guys playing me some songs?" Then they dueted on "The Sweet By and By" and several Christian songs that seemed somehow familiar but I couldn't have named them. And it worked and before you know it they were telling me stories about living "at camp," which means the tundra, wild tundra of northwest Alaska.

Wendell reminisces about the years he and his brothers left their home in Kotzebue to help their aunt and uncle with chores on their homestead in Point Lay, a windy, forsaken settlement on the Arctic Ocean west of Barrow. They squatted in the abandoned sod homes, eventually building new places for themselves. It was a hard place to live for long as the wind never seemed to blow less than 35 miles per hour, 70 to 80 mph being the norm. Two of his brothers stayed on, married, and brought their wives to live there making it a tiny settlement without any amenities in the 80s.

"So," I asked Wendell, "tell me the truth about bears. How dangerous are they really?" The two of them then told me the story of their trip out to Wendell's family camp in a remote part of the tundra two years ago. They only had a tent and a fish-drying rack so this wasn't like a second vacation home. It was spring and a good time to hunt ugruk (bearded seal) from an immobile ice flow, shoot migratory ducks and geese, and fish.

They chose a fishing spot about a thousand yards from their camp where two streams meet forming a little peninsula. About three hours into an idyllic afternoon, Mary, Wendell, and their friend, Roy, spotted two grizzly bears moving aggressively toward them on the peninsula.

"They looked hungry," Mary said. Mary and Roy were very frightened. Wendell said he knew he could not let their fear enter him. He started yelling loudly in Inupiat telling the bears he would kill them if they ventured across the stream. He yelled at them for a very long time. He shot his duck rifle in the air to show them he meant it.

Wendell explains that he had to intimidate them with his body language, his vocal inflection, his eyes or they would surely cross the stream and attack the three of them. He described it as a very spirit-driven confrontation. Underlying it was a fierce cultivation of mutual respect between man and wild animal.

The problem was they had no weapon adequate to kill the bears. Now Mary talks about how stupid she was to have come unprepared. She left her Magmum 375 in the tent and her handgun had no ammo because she had removed it for safety reasons while on the bush airplane. She says this was the only time in all her years in Alaska when she wasn't prepared. "I let my husband down," she said, her disappointment in herself still palpable in the retelling of the story.

The bears turned around and ambled up the hill a ways. Then they turned back again and lay down facing Wendell, and watched and waited for 4 hours. He explains he couldn't retreat or they would have attacked. Mary by that time had rejoined Wendell with her Magnum 375. But they didn't want to kill the two bears except in self-defense. Killing them meant skinning and gutting them without proper equipment or the means to get them home. And a true Eskimo hunter never kills an animal only to leave it there to fester. This is considered deeply disrespectful to the animal's spirit.

Finally the bears went up and over the hill and soon the humans heard a great deal of squalking in the distance as the bears plundered the duck and geese nests, gobbling the eggs and the birds that remained to protect their young.

I asked Wendell how many times he had encountered bears in his life. He said about 15 times -- always with other male Inupiat hunters. I asked how those encounters were different. He said "The bears always ran away."

At the end of the evening I asked what happened to the brothers who stayed on in Point Lay. Wendell said one was eaten by a polar bear. I didn't have the courage to ask about the other.

Cultural Considerations

March 2009 Stint in Kotzebue, Alaska

Dear Friends,

I am a fish out of water - which may explain why I felt bad when I pulled my first sheefish out of a hole in the Chukchi sea ice last week, watching as it flailed about gasping for air for 20 minutes. My fishing companion and instructor, Chuck Luck, said "absolutely not" when I asked if I could throw all 15 pounds back down the hole.

The strangeness of my surroundings gets me to thinking about what's acceptable and what's not. How propriety evolves according to the needs and desires of people living in a specific place with its own unique cultural history.

As I flew from Anchorage to the Inupiat village of Kotzebue on March 1, I sat next to the a 12 year old boy who is an avid hunter. Mostly Arctic hares so far. But he's pretty sure his uncle will take him inland to find wolves - to thin them out as there's too many of them this year. For the record, Eskimos don't hunt wolves but wolves do eat their beloved caribou so I thought he might be telling me the truth.

He thought they could kill 40 wolves, maybe more. He's never gotten a caribou but soon enough he thought he would. I found myself encouraging him, thinking about other interests a young teen can have up here - mood-altering substances, sex, tobacco, and racing around on a snow machine without a helmet.

The truth is there's not much to do up here for children or teens. If a kid doesn't like to wrestle or play basketball, he or she is out of luck. There aren't any organized activities at the boys and girls club because it's hard to find people who have the time to volunteer who don't have some sort of criminal record. Kids don't take lessons up here. There's no baseball diamonds. Not even an ice-skating rink even though our lagoon could be made skating ready. Cross-country skiing? Nope. No bowling alleys. No swimming pool. And you can forget dance lessons. There is a small park near the cemetery equipped for the under 10 set.

So children learn to hunt early in life. During a sports physical last week, I found myself asking a 9 year old if he locked up his shot gun when he was done with it. His dad told me that once it's deployed there aren't any more bullets left. That's how much I don't know about guns.

Hunting up here is a cultural affirmation. Maybe even a kind of therapy, an appropriate way to release the destructive emotions like pent up anger. Better to kill to feed your family than violate your family. Better to pass on this cultural competency to the young. A suitable violence.

And fur attire only makes sense in this cold place. Wolf or wolverine ruff is best for keeping one's breath from condensing on the glasses and mustaches. Many of the women are able seamstresses making hats from seal skin or everyday leather and using beaver or fox fur for the earflaps and to warm the forehead. Animal rights activists would be laughed out of this place.

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Eskimos were hunter-gatherers until the late 1800s when white traders introduced items like rifles, tobacco and alcohol. The simple but brutal life off the land gradually became a mix of cash/carry and subsistence.

Now there are those that do some "subsistence" and those that don't. This word, subsistence, seems like a euphenism that some anthropologist made up in order to show respect for people who have until recently lived off the land. These "simple" people have a stoic core, a propensity for doing - not analyzing - that made it possible to survive in this hostile environment.

The material life didn't pass the Eskimos by any more than it has any other people who've had the option to indulge themselves. But now they must hold jobs in order to buy gas for their "snowgos", having abandoned their dog teams for the ease and power of zipping along on a machine fit with skis. Electricity, piped in water, and sewers are costly. Mushing is now a sport for the few people who have the desire,time, and money to do it. Hard to believe the inhabitants of Kotzebue illuminated their homes with seal oil and and then kerosene until as recently as the 1960's.

As I was leaving the small village of Shungnak a few weeks ago, the health aide who had driven me on her snowgo to the airstrip reminisced about life before bills. She wished she could go back to the old days. Much simpler then. Everyone knew what they were supposed to do. Now that she works full time as a health aide, she doesn't have the time and energy for hunting. As we looked out to the distant mountains, she told me their names -" Beautiful Lady" with her sculpted breast and abdomen and "Old Man Mountain" with his rugged face.

Mostly it's the elders who crave the caribou flank, muktuk (whale skin with its blubber), seal ribs, and muskrats. I met the director of the hospital's program to provide wild animal meat to those who can no longer hunt. He explained that the younger still hardy men are paid to go out to make the kill. Given the 10 dollar a gallon gas, this is a necessary compensation.

I struck up a conversation with a woman I met at the Nullagvik Hotel where I live this time. She told me about caring for her mom with Alzheimer's. The doctor had told her at the Alaskan Native Hospital 600 miles away in Anchorage that her mom was going fast - maybe 1 or 2 weeks to live. She brought her home and made all the old time foods - chewed her caribou meat for her, made her the soup she loved from childhood. Triumphantly she said, "Mom made it 2 more months!"

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The first Inupiat word I learned on the job was nuvuk - snot. There does seem to be a preoccupation with nasal discharge up here. When I work in radiotraffic advising the village health aides about children with plugged up noses, I try to delicately inquire about congestion relief. There are mothers and grandmothers who suck the snot out with their mouths and those that don't, preferring the blue bulb that is dispensed at the hospital on discharge of mom and babe.

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As a white medical professional I have recently learned a hard lesson: I am not Native, therefore the statements I make about unhealthy health habits can be misconstrued. I received an overhead page a little after 6 the other evening. My medical director had a letter in hand from a patient I had seen that day. He reported that I had said that Natives are drunks.

An elegantly dressed older man had come into walk-in clinic for his narcotic refill. Because a policy for prescribing controlled substances has been recently created so as to dramatically reduce the use, abuse, and sale of prescription drugs at our Bush hospital and clinics, I am allowed as a temporary medical provider to give no more than a 5 day supply of medication. This gentleman had received a 2 week supply with 5 refills of 2 very potent narcotics in January -prescribed by a temp internist who is now back in Seattle.

I took meticulous notes outlining the history of his chronic pain syndrome and response to medications. I asked him about past or current substance use, and he gave me a detailed history of his alcohol use starting at age 11 when his father handed him two beers. He emphasized his sporatic use as an adult. I talked with him casually about the relationship between substance abuse and reduced pain threshold and the genetic vulnerability including ethnicity to alcoholism. We talked of many things, and I never detected a note of hostility. I explained the new narcotic policy and gave him a five day supply of his meds until he could see a permanent provider here next week for a larger supply.

Someone might say his accusation is an example of reverse racism. If I had been an Eskimo doctor (there are none here), he wouldn't have made the complaint. But my sense is this isn't about racism, reverse or otherwise. It's about pain. Individual and collectively as a culture.

White people have had a long history of misbehavior up here, starting with suppressing the local language, music and dance and continuing through much of the twentieth century with shipping Native children to the lower 48 to become "civilized", under the pretension of providing them a better education. It was shocking for Native teens to go from a private bedroom with TV (after it came in) back home to a cramped sod house shared by as many as 10 or 12 people with no electricity. Store bought food was a luxury here that could be a few days away or more if the weather prohibited travel. The teachers down south were less likely to wrap one's hand or denigrate the child who had a harder time sitting in his or her seat.

I have often wished I had a little more pigment in my skin where there aren't any freckles. I think it would have comforted all the people of color I've seen over the years. People seem to gravitate to people who are more like themselves. Trust is kindled more quickly. I've always been a contrarian in this respect - a little bored with people like me and intrigued by otherness.

Growing up in suburban Chicago in the 1950's, the only dark-skinned person I saw in my neighborhood was the occasional woman who came by bus from the city to clean peoples' homes. I have a very clear memory of driving with my family past a city pool filled to the brim with African-American kids. My dad made a disparaging remark to the effect that the water was not safe for swimming because of the Schvartzes - a Yiddish term that has thankfully fallen out of use. I knew that day there was something impure about what Dad said.

My high school in Indianapolis integrated in 1967. Kids with names like Darn were bused in from downtown. I remember how isolated those kids were. I saw the teachers' repulsion. The middle class Blacks - there were 3 girls I remember well - did ok, although I'm sure they experienced their fair share of discrimination. Even I was on the receiving end of a few teachers' discriminatory remarks and behavior. But it was still a heck of a lot better to be Jewish than African-American.

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Three mornings a week the medical, psychological, social, and nursing staffs meet to discuss problem cases in the hospital, community, or villages. Rushing into these 8 AM meetings, I strip off my pants and jacket as I go. It's the only staff meeting I've ever attended that regularly includes a weather report. The explosion of Mount Redoubt 100 miles from Anchorage has thrown a monkey wrench into the best laid plans, including the likelihood of flying home as people complete their stints here.

Local weather in the farflung villages we service is most important as it determines whether seriously ill or injured people will be "weathered in" the village without professional medical care or can be safely flown into our Bush hospital. The responsibility for medical care when the weather is foul falls squarely on the village health aides. I asked the aides in Shungnak the worst time they could remember having to care for patients who couldn't be flown out of town. It was 15 years ago when a man was shot by the Alaskan State trooper in the abdomen, and a woman miscarried and bled for 3 days. The two village aides took turns caring for the two patients over 72 hours until the medevak plane could safely fly from Kotzebue to get them.

After the morning rounds a Code Review is done if a cardiopulmonary resuscitation occurred in the preceding week. Last week two 18 years olds hit a truck while they were riding on a snowmachine at 70 MPH at 3rd and Lagoon in the center of Kotzebue. The ambulance brought them in where resuscitation was performed for at least an hour on the driver. He died but the code was judged to have been done efficiently and well, with just the right number of people doing the right things at the right time. His heart was on the right side of his chest. The doctor who led the code admitted they probably went on too long but it made the family feel better. There were some comments about how it was difficult working around both families of these two young men due to some logistical problems with the layout and design of the ER. The second man was taken by medevac to Anchorage with multiple grave injuries.

I can't help but wish they had a Code Preview. What can be done to stop all the injuries and deaths from accidents in this part of the world? But that would require a deep culturally- considered conversation.

May 24 , 2009 - A Suicide in the Village

A Suicide in the Village

Dear Friends,

I returned last week to the village where I had described in January the aftermath of a youth suicide. Here's an update.

The brother-in-law, whom I had described as depressed as a result of the suicide, died in March of metastatic lung cancer at age 50. His wife, Cheryl, who is a very astute village health aide, had said in January that he wasn't himself. He usually had dinner ready with a smile but instead she would come home after a busy day in clinic to find him lying in bed. After administering a Beck Depression Survey and interviewing him in January, I thought he was depressed. What I didn't know is that he had brain metastases from a rapidly lethal form of lung cancer. Even if I could have X-rayed his chest in the village, the tumor would not have shown. An MRI available only in Anchorage later showed the brain metastases that had begun to change his personality.

When I returned to Kotzebue in March I called Cheryl, who was back in the village, to express my sadness over her husband's diagnosis. He had returned from Anchorage to his home to die. The radiation to his head hadn't helped him much. His pain, she told me, was not well controlled, and she didn't know what to do. From my office and room in Kotzebue, I advised Cheryl by phone, ordering narcotic patches to help reduce his pain and restlessness. A small thing after missing the diagnosis, it helped me feel better about his dying. I remembered our conversation as we had waited for my plane to take me back to Kotzebue in January. She described him as far and away the best of her three husbands. That was before she knew he was terminally ill.

Now she was describing to me how he saw his dead mother. And angels. He kept telling them that he couldn't leave. He wasn't ready.

A week later he died. When I called just 12 hours afterwards, she described his final minutes. He said he had to go and he was going to miss her. He looked across the room and called out "Mom!" and then he stopped breathing. In the background I could hear her grandchildren laughing and elders talking. The house was full, the family a bulwark through all the terrible things that have happened.

Unbelievably, Cheryl's mother, who was raising the foster son who committed suicide, has metastatic tonsillar cancer. A double whammy for this most wonderful woman. A husband, and now her mother.

In January I had seen her 72-year-old mother for a chronic earache. We spent at least 45 minutes together talking about her foster son's suicide, she wondering what she had done wrong and how could she have prevented it. He had blown his face off in the next bedroom while she slept. Since I couldn't see anything to explain her earache, I referred her to an ENT who visits Kotzebue every three months. But while visiting Cheryl's husband during his stay at the Native Hospital in Anchorage in February, she saw an ENT who found the cancer on endoscopic exam. Wow. I was taken aback. This meant that two of the 55 people I had seen in January had had terminal illnesses.

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The May village visit is as busy as January's was, except I got a late start because it was too foggy to fly safely out of Kotzebue last Monday. I waited through the day to leave, grateful for the bush airline's conservative flying policy. Better late than never.

I see two children with cerebral palsy.

The first is a 15-year-old boy who looks 8. His semi-contracted withered limbs barely fill the pediatric-sized wheelchair. His mother tells me he is getting harder to lift. Dead weight. Although the state will pay for it, no one in this village of 500 people wants to be his personal care attendant a few hours a day to give his parents some relief. He has a very small head with eyes that tick horizontally. Nonverbal. Diapered. I ask the usual questions. I examine his childlike body, all systems on delay, delay. Not one sign of sexual development. Passively he permits my probing.

Luckily there are four healthy children at home. But I feel powerless to help this boy and his family.

The second child is 9 and much bigger, more functional -- enough to be rambunctious. He turns away as I examine his ears. He pulls at his white (foster) mother who looks to be about 60. She tries to keep him from jerking her too hard. He hugs and kisses her repeatedly. She tells me in a disgusted tone how she took him out of school a couple of years ago because the teacher was no good.

They spend every summer in Anchorage where he has physical and speech therapy five days a week. He can even swim. We both lament the absence of swimming pools in the Bush. When Governor Sarah Palin sent out a questionnaire to parents of children with disabilities, this mother described all the things that were done badly. "Oh yes", she said, "I'll complain to get my son the best education and care." He can't talk -- yet. But he can use a walker to ambulate on even surfaces at home and school. Although the village's gravel roads prevent him from walking, he can often make his way by bike.

He has a cold, and she worries he'll get aspiration pneumonia again. I am able to reassure her that his lungs sound good. But I have difficulty understanding her enthusiasm, her commitment. Even though I know it's what a good mother does.

I think about John Cassevetes' movie, A Child is Waiting, made in 1963. Using children with disabilities like Down's syndrome and mental retardation and his signature naturalistic style of directing, his movie explored the problems of educating disabled children who had previously been hidden at home. Children were being placed in institutions for residential education. Judy Garland is the teacher who tries to point out the problem with removing children from their families.

Fortunately, now families are given the support to care for their children at home and receive educational services, too. I can't help but wonder as I examine these two boys whether the pendulum has gone too far in the other direction, especially in view of the limited resources we have for all kids.

I ponder the enormous need for mental health services here. A place that has the highest suicide rate in the country and where so many young people are dying. We've figured out how to systematically address the needs of the disabled. But mental health is a morass. The problems are often hidden or denied. Yet they are as plain as day here -- as manifested by hangings and overdoses and a hideous rate of traumatic injury and death while under the influence of alcohol and drugs.

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After spending my days treating people with the usual chronic diseases -- diabetes, hypertension -- in comes the most amazing man. He walked 50 miles down the Noatak River from his log cabin in the wilderness to see me. He is 50 and, unlike many aging Inupiat, does not look the worse for wear. He hasn't had a drink or a woman in 20 years. He uses his dividend check to buy the essentials. He doesn't drive a snowmachine. He lives entirely off the land -- hunting caribou and small animals, fishing, digging up burdock (a spinach-like green) and picking berries -- cranberries, blueberries. When the mosquitos come he heads up into the nearby Brooks Range. They leave in mid-July after the rains and he comes back home. Then come the gnats and off he goes again. Unlike the caribou who amass to reduce the total surface area available to the voracious insects, he has to make a run for the mountains. He uses an REI whistle to keep the grizzlies away. The Good Book provides reading entertainment when he isn't whittling cutlery and implements in his spare time. Why anyone would live in town puzzles him.

His medical problem is one that may be hard to fix. But I don't want to tell him that on the first visit so I stall and tell him I'll review his medical records from the Native Hospital in Anchorage and consult a specialist if need be. But how will I find this man for our followup conversation?

I think to myself there is probably some significant reason why he's chosen to live his life far away from others. And despite outward appearances, he is suffering like the rest of us who are living more communally.

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I feel a great weight in my heart as I read the most recent progress notes in several of the kids' charts. They are handwritten and signed by Dr. Golub, a 53-year-old pediatrician who was killed in Kotzebue last November while doing his quarterly field trip from the Native hospital in Anchorage.

When I returned to Kotzebue in January this year, my ER physician roommate had told me the gruesome story. After coming up to provide pediatric specialty care for the last 18 years, Dr. Golab had an opportunity to go dog mushing for the first time, with a woman who works as an occupational therapist in Kotzebue's elementary school. An experienced musher, she had always rode by dog sled from her home 20 miles away to work a week at a time at the school.

Three miles out of town on a bright star-studded night, a snowmachine going 90 miles an hour hit them. They flew into the air like Santa and his sleigh. When they landed, his leg was severed and her dominant arm was mangled useless. They pleaded with the man and the woman on the snow machine for one to stay while the other got help. Scared and high on alcohol and cocaine (according to the Anchorage newspaper) they started back to town -- on foot -- because their snowmachine wouldn't start.

She couldn't stop the flow of blood from his leg due to her own injuries. An hour later he died in the snow.

Despite a weakened aorta, she returned to the Bush from her home town in New York after five months of physical and medical therapy.

I read his progress notes from November 19, 2008, the day he died. Then I looked up at the mother of a chronically-ill child he had seen on the day he died. As we speak of him, I think I detect embarrassment in her face.

This was a sobering event in the community. A Native killed a white man who had done nothing but good for the people up here. The Natives don't talk about it. The white people are quietly angry. A feeling of hopelessness pervades the story. It reflects fleetingly on all the problems that the culture is experiencing -- a complex web that no one seems willing or able to tackle.

Today is the day before Memorial Day -- a brisk 30 degrees or so with a steady wind. The sun is shining as it orbits around the town. The Lions Club is out cutting the Arctic willows that clutter the mounds in the cemetery. The snowmachine path is so close to the graves that some of the wooden crosses that bear the names and dates of the dead have been knocked over. Surprisingly, it's not the cold over the past seven or or more decades that has done them in. The volunteers bring tools to patch the two pieces of wood back together again and stick them back in the ground.

I am sorry to miss May in Minnesota but I will glory in June soon enough. I wish you all well and do write if you have time.

January 30, 2009 - Walk on the Wild Side

WALK ON THE WILD SIDE

I resolutely leave my second floor apartment each morning wearing several layers of clothes and insulated boots, telling myself I'm ready for anything. I've intentionally cultivated an Alaskan stoicism in regard to the weather. I pass the small general store with its cursive neon sign,"Uutikuh", and the orphanage, Pukyuk, making a right on Bison Street, Kotzebue's busiest east-west thoroughfare. I cut behind the Alaska Commercial Store and a barebones apartment building which everyone refers to as "the 29 unit" in order to avoid the snow machines and 4-wheelers on busy Bison Street. This may be the only place in the US where there are no posted speed limits, and snowmachines, people, ATV's and cars all share the roads.

My ER physician roommate, Sharon, told me about the Native woman in her 50's who was walking on Bison in front of the 29 unit and was hit by a snow machine a few months ago. When the ambulance reached her from the Emergency Services Building just across the street, they found her with her ankle touching the back of her head in a grotesque arabesque. The fractures of her femur and both lower leg bones were like china shards from a smashed vase. Busted her up so bad that gangrene set in, and she had to have an above-the-knee amputation.

Along the back "alley" behind the buildings on Bison lies the peeling wooden crosses of the cemetery where the Baptists and Catholics are buried - separately. A large swath of land next to the cemetery is a snow machine playground where young people tear around at 40 MPH.

One clear still night I was walking home about 9:30 PM and saw beautiful fireworks in the sky over the shore of the Chukchi Sea. The pyrotechnics looked professional. I walked mesmerized looking up over the cemetery. So strange not to be sitting on some blanket in a park, hot and mosquito-bitten. It was pure visual delight until I heard and then saw 20 yards in front of me two snowmachines traveling across the alley at least 35 miles an hour onto the big field nearby where they race. If I had been a minute or two faster on my journey home, I might not have made it.

Last week I experienced my first Arctic blizzard. Some of the medical people residing in my apartment complex called the B and D cab and got a ride for five bucks plus tip for the 4 block ride. I wouldn't spend the money. I'm just as stubborn about paying for parking in Minneapolis. I figure small economies add up.

I could hear the wind through the night from my bed. When I stepped out, visibility was about 10 yards. A few days before I had lost my goggles somewhere between the hospital entrance and my office after using them the first time. Now my unprotected glasses kept icing up from my moist exhalations trapped by the heavy Donegal-made Irish scarf that covers my face. I couldn't see well enough so I took my glasses off. But I coudn't see the uneven surface of the snow. So I decided I had to walk on well-ploughed Bison Street exactly where the woman had lost her leg. The wind was roaring, and it was hard to hear oncoming snowmachines. So I rotated around 180 degrees left and right like a periscope at sea, hoping to have time to jump away should a snowmachine suddenly bear down on me.

When I turned at Bison and 5th Avenue, Maniilaq Hospital, the biggest building in town, was gone. The wind was furious in the open intersection, so I bent into it like a biker racing down a steep hill. I could hear the wild flapping of the Alaskan and US flags in front of the entrance before I could see them.

What if the wind just knocked one of those metal poles over at the very moment I chanced by? I remembered the story of a friend of Mike's whose daughter was crushed by a falling cottonwood in an Oregon state forest. She had to hike two miles to be standing at that spot, at the precise moment the tree chose to fall. What were the odds for that? Or for anything like that happening to me in this wild frontier town?

I entered the warm hospital foyer, grateful to start my day's work.

January 30, 2009 - Radiotraffic

The Radiotraffic Room in Maniilaq Hospital in Kotzebue is the medical command and control center for all eleven bush villages that it services covering 3000 square miles of northwest Alaska. I had my baptism by fire there last week.

My on-the-job training the day before I was due to start was aborted after 40 minutes because they needed another body (unfortunately mine) in the Outpatient Walk In Clinic to see the hoards that were lining up at 3 PM. The doors shut at 4:30 (unless you happen to be a friend or family member of the receptionist or triage nurse) and whoever is there has to be seen. Because most people don't get moving in the morning, there's an afternoon rush most days despite the fact that we open at 10AM.

The reason I was nervous about working in radiotraffic is that I don't have any experience as a first responder. Medical providers who work in city clinics don't get the first call when bad accidents or potentially fatal illnesses occur - that's why we have ambulances and emergency room doctors and nurses. And physicians have heftier experience with the scary stuff due to their training and work in-hospital than nurse practitioners like me.

So I walked with trepidation into the Radiotraffic room that first morning. My job was to receive between 40 and 80 faxes as well as phone calls in an 8 hour period from the 11 bush villages. The faxes are descriptions of the medical problems that the CHAPs (Community Health Aid Program) are seeing. CHAP's are people with at least an eighth grade education who train for varying amounts of time in Juneau to become lay medical providers in their own villages. They have a book of algorithms that they follow. Some have been doing it for years and are pros. Others are still learning and adept at dealing with most problems. A few should be part of a Displaced Worker's Program but no one ever gets fired.

My job is to make sense of the CHAPs' patient evaluations and tell them what to do if they don't know, tweak or abort their plans and substitute one of my own, or approve their evaluation and plan. When I see patients in clinic I rely a lot on my intuition, using all my senses (except taste of course.) In fact I'd say I use myself - body language, humor, personality even - to tease out the information I need to cinch the diagnosis. However, in radiotraffic I must help make a diagnosis without the benefit of seeing the patient in person and laying on of hands. More difficult is not knowing the level of expertise of the CHAP making the report. And worse is wondering if I'm the person they should be consulting about potentially life-threatening injuries and illlnesses.

Judgement in clinical medicine is the sin qua non of practice. There's nothing like experience to hone one's diagnostic and treatment acumen and one's judgement. I was relying heavily on my confidence in my judgement that first day. For I was in the challenging situation of having to rely on clinicians whose judgement I didn't know I could trust with patients I didn't know from Adam with health problems I may never have addressed in my 27 years of practice.

The first day was a rollercoaster ride.

But the saving grace was technology. A year ago I wouldn't have believed I would be writing this. I am both indifferent and deficient in anything that involves a series of operations involving a keyboard and mouse. Access and verify codes used to obtain lab and record reviews on patients have cost me countless hours up here. I have used every breathing technique I know to maintain patience with twenty-something IT staff members who are supposed to be fixing systems-related problems without apparent success.

The video teleconferencing apparatus was spectacular. I got a call about an infant having seizures - every clinician's nightmare. Fortunately he was breathing and had just returned home from the Alaska Native Medical Center in Anchorage where he had a normal head MRI and had started an anti-convulsant medication. Knowing how a parent's fear, especially when a child has seizures, can sometimes distort their description of events, I wanted to be certain that the baby was seizing. So the CHAP and I turned on our respective video cams, and I was able to watch the baby in real time. He was holding his bottle while lying in his mom's arms and then his arms suddenly jerked and the bottle went flying. Exellent verification! By phone the neurologist in Anchorage gave me a nifty recipe for Valium (yeah the same stuff our mothers abused in the 70's) mixed with mineral oil and then shot into the rectum with a small syringe. Finding mineral oil in the village proved to be difficult until the CHAP remembered that she had some at home. We probably could have used Wesson Oil but I forgot to ask about it while I was on the phone with the neurologist. This method of medication administration works about as well as delivering the Valium intravenously and is far easier for our lay medical personnel to do.

I used the videocam for a woman with an unusal rash. As the video became live, she looked off self-consciously like someone who was in a movie she didn't want to be in. Her rash may have been a drug allergy to Ibuprofen or the disease systemic lupus erythematosis. I treated her empirically and tried unsuccessfully to reach her by phone to see if she was better. One of the great frustrations and weaknesses in this system is that it can be difficult to follow up to see if your hunch was right.

An inebriated man who crashed his snowmachine was a tougher case. I followed him by phone in between faxes and calls most of the afternoon as he slowly came out of his concussion and drunken stupor. The videocam pretty much showed a guy who was out of it. Not much help. He had post-accident amnesia, perseveration - asking what happened over and over - and a big headache. So the question was whether to bring him in by commercial flight to evaluate him neurologically or wait to see how he was doing. By the end of the day the flying conditions had worsened to the point where sick patients couldn't fly because the bush planes were grounded.

Changing flying conditions is an added pressure when trying to time when to bring someone to the hospital ER for medical evaluation. In this case I told the CHAP to see if his mom could do neuro checks through the night - waking him and peering in his eyes. The CHAP called back to say that his mother, who is mentally unstable, screamed at both of them to leave and not come back. At last contact, the CHAP was still looking for shelter for this homeless man with forty below outside.

More frightening was the baby with respiratory distress who also didn't make the commercial flight that day. I called in our emergency flight team to go get her. Our EMT/ pilots will sometimes fly when the commercial bush airlines cancel. It's dangerous for everyone. I was reading a protocol based on a symposium on managing head injuries in Alaska, in which it said that bush pilots die in plane crashes at a rate that is 5 times their counterparts in the lower 48. So what does that mean for the average villager who travels away from home, often to obtain medical care?

The CHAPs send us photos of rashes, eardrums, burns, and anything else that is better evaluated with a picture in addition to written descriptions. I pull it up on the computer, look, and fax back a diagnosis and medication suggestion. I suppose there are days when the visual communications would qualify as X-rated.

But most of the time it's the hum drum stuff of daily medical practice. I like talking to the various CHAP's, mostly Native women from the different villages. I try to use humor when I can -if I'm not too frazzled from hours of multi-tasking. I also use the interactions to teach the less experienced people how to think about the problems that they're consulting me about.

By my third day in the radiotraffic room, I was feeling more comfortable.

But I would still much rather see the patient in person in clinic in Kotzebue with the ER and its staff just a few steps away.

January 30, 2009 - Cemetery Hill

My new midwife friend, Yolanda Meza, and I walked to Cemetery Hill a mile outside of town today. The sky changed from grey and purple clouds to unobstructed sun and patches of baby blue sky. Pure turquoise met the orange sun-reflected snow on the foothills to the northeast. It was about 15 below zero minus a few more degrees due to the breeze.

The wooden crosses visible beyond the lagoon and up the berm looked like candles on a cake. The people laid to rest on this hilltop had a connection, deep or intermittent, to the Friends Church, the first missionaries who came to Kotzebue in 1897. The church building in town boasts 1887 but Eskimos have never been too careful about numbers.

Many more cars than usual passed us, turning to go up the hill. When we reached the top, people were leaving their vehicles carrying fresh bouquets from far away. I asked a friendly-looking man in his 30's who wore glasses and had a mouth full of perfect teeth whose funeral it was. "My Uncle Ray", he said. He introduced himself as Archie Ferguson, named after his grandfather who was Kotzebue's first and most famous entrepreneur.

When the North Star ship came from Seattle up the Bering Strait on its yearly summer voyage through the 20th century, it brought from the Outside all the items people would eat, drink, smoke, wear, and use to supplement their subsistence living. It brought along a few families from the southern part of the route so they could spend a few months with kin. Most of the cargo went to Archie Ferguson's various enterprises - the trading post, roadhouse, hotel, and air taxi service. Archie Ferguson was a star.

This was the one time of year when Natives living out on the tundra or "at camp" could be sure of work, unloading the barges that ferried the cargo from the ship 8 miles out in the harbor to the shallow shore. With their earnings they could pay off credit at the store and purchase luxury items like sugar and coffee or new necessities like rifles. Except that they were mostly paid in aluminum "bingles" with specific amounts etched on the coin, good only at Archie's.

We walked unobrusively by as twenty-some people stood in their best parkas with faces framed in fur ruffs and watched as several of the most able-bodied men lowered Ray's very fine casket into the ground using ropes. His was a prime spot at the top of the hill as befitted their elder and nephew of Kotzebue's most enterprising man of his time.

My feet were starting to freeze since I wore shoes instead of my 40 below boots which give me blisters. As we passed the gaggle of SUVs and late model pickups on the way back, my mind turned to the luck of being Archie Ferguson's progeny.

His vision, energy, and hard work guaranteed the good life for many who followed him. But seeing others in this remote northern town, people who struggle to pay their bills, and have little left over, I know not everyone is so lucky.

Jan 11, 2009 - Suicide

The first night during dinner break the temporary health aide, Grace, and I chat at the clinic's kitchen table. "I'm just here for a few weeks helping out while I'm off from the university. Cheryl's (the senior health aide) 15 year old brother, Elwood, commited suicide a month ago and I wanted to help support her. My son killed himself four years ago when he was 15." We don't discuss the details of either suicide. It's hard for me to make a response without sounding trite. I mumbled something like it's impossible for me to begin to know how difficult that must have been. Grace tells me she's working toward a master's degree in public health so that she can help develop a policy to prevent suicide among Alaska's Native youth.

During clinic the next day, Elwood's mother visits me ostensibly for follow up of her chronic medical problems. She is 74 years old. When I start the conversation by asking how she's doing, she says she is sleeping badly and feeling poorly. I gently ask if there is anything particular that is bothering her, and she tells me her 15 year old foster son shot himself last month while she was sleeping. She never heard the shot from her bedroom down the hall. Tears filling her eyes, she says "I don't know what I did wrong. I think and think. I don't understand why this happened. I adopted him when he was 3. His mom lives on the streets in Anchorage - using drugs and alcohol. He grandmother lives in a nearby village where she drinks all the time. He seemed always happy in our house. We have a happy house."

The following day, Grace, Elwood's foster sister comes in to see me. As a teacher's aide at the school, she saw Elwood daily. "He always had trouble with schoolwork. He was always failing everything. Paying attention was hard for him but this year (freshman in high school) he was doing better. I remember the day he killed himself. He had done well on an assignment the school tutor had given him. We told him 'way to go - we knew you could do it.' He seemed ok, happier.

He could be very moody with temper outbursts. He was always that way since we adopted him. Mom always gave him his way. Last summer he and his two friends were always in and out of the house, "the 3 hoodies" my mom liked to call them on account of their sweatshirts with hoods that they always wore.

One of the teachers said he had a girlfriend. He wouldn't talk details with her. One of the girls from school said she heard they broke up.

The night he killed himself he told Mom that he wanted the phone card so he could call his (biological) brothers and sisters in Anchorage and the one who lives in the village. But he never used it.

The other thing we remember is his last night he played with all the little kids (grand and great grandchildren) who were living in the house. Usually he'd pick up the toddlers and run around with them. But this time he held the 7 year old above his head and carried her all around the house.

I wonder if it was something to do with the girlfriend. None of us knew anything about her."

My last day in Noatak a 17 year old boy came in to see me. He muttered about a few things bothering him. A sore throat. The senior aide had already treated that. His hip hurt. And his friend killed himself. "Do you want to talk about it?" Silence. Staring at his shoes.

I started, "You know, sometimes when a kid kills himself he'll tell his friends before he does it that he's thinking about it. That's real common." His eyes flicked up to the level of my stethoscope and then back down. "That happens with adults too and you know it would be very hard for anyone, even a grownup let alone a kid, to believe that someone was serious about doing something like that." He made a low "hm". "Friends blame themselves afterwards - that they didn't do anything. And sometimes they feel so bad they think about killing themselves." By this time he is looking at me steadily. "Yea sometimes I think about just getting it over with."

By the end of the visit, after an analysis of his hip problem, he promised me he would see the village counselor and contracted with me not to hurt himself.

As I was waiting for the plane to pick me up at the airstrip, Cheryl, the energetic, upbeat senior health aide and Elwood's sister, and I chatted in the waiting room area. She said it had been hard on everyone in the family. Even her husband, who hunted with Elwood, was depressed for the first time in his life since the suicide. (I'd seen him for sleeplessness and poor concentration so severe that he didn't feel he could work at the power plant.)

"I'm doing ok though. I took a couple of years off recently. I was getting burned out again. So the time away helped." (The health aides share call, run the medical clinic,and see anyone in the village of 500 that wants medical help with backup from the medical providers in Kotzebue.)

"The hardest part was going into his bedroom to get his body. Mom wanted me to do it. His nose was blown away and his left eye was hanging off his face. Anyway, it's part of my job."

July 6 - The New Year Up North

Dear friends,

After a full day of post-New Year's travel sharing planes with exhausted and impatient infants and toddlers and their devoted if frazzled parents, I arrived in Kotzebue Alaska without my bags. I was too tired to have a care although it occurred to me as I drifted off to sleep that in the unlikely event that my belongings were not found, I really couldn't live up here for the month of January with one set of clothes that didn't include my snow pants, goggles, and boots good to 40 below. Purchasing new duds at the local Alaska Commercial Company would cost me my first week's salary. If I could even find what I needed.

As the Eskimo taxi driver took me back to the airport the following morning to retrieve my found bags, he commented that things were warming up - 22 below up from 40 below the day before. And you know it felt like 0! All that expectation of mindnumbing cold and this really wasn't bad at all.

It was strange to wake up after 10 hours sleep and it still be so dark outside. My whole life I have avoided getting out of bed before sunup. But that doesn't work so well wintertime in the Arctic unless you can afford to hibernate.

I had decided before I left the Twin Cities that I would make an effort to integrate more into the community this time. The only way to do that other than crashing someone's alcoholic bash is to go to church. There are no bars, clubs, or bowling alleys, and finding friends on the internet seemed preposterous in a town of 3500. I had called my only Eskimo friend, Wendall Stalker, before I left the Twin Cities and asked him where he went to church and what time did it start on Sunday. He is a marvelous guitarist and ivory carver who caught me a big she fish in the ocean last summer, and I was hoping to see him and his wife Mary there and maybe make some new friends.

The light was tourquise blue to the south as I walked the four blocks to the church at 10:45 AM. I looked into the windows as I drew near the door of the simple A frame wood stucture and saw no one despite the bright inviting lights. The minister, an elderly Eskimo man dressed in a caribou skin coat with wolf ruff, greeted me saying that it was cold out so people were coming a little late. NPR was on (the only local radio station) - first the news and then C and W Christmas music songs and still no one came. Fifteen minutes after eleven, the Caucasian church organist and an older Native man came in followed by one more woman at 11:30. Hymns were sung and readings recited with a weak congregational response. Unfortunately I was right at the front and it took me awhile to figure out when to stand up and sit down. When the one Inupiak song was sung, the older man in the back sang out for the only time during the service.

The minister wore a beautiful white gown with beaded sash. He gave a short sermon about a man (later revealed as the bishop of the church) who went to live away from his family in isolation in the wilderness out of alienation. He only had faith in the trees, and clouds, and wild animals. But then he came back and joined the community and became a Christian and changed his life. And then Wilford, the minister, made the point that New Years is a time to make a change in your life, to take a step forward - and then he made a step like you do in the children's game "mother may I?" - a long stride with his right foot and then his left foot joined his right one. And I was touched by the sweetness and sincerity of what he said.

A few minutes into the service, I remembered with some trepidation that Episcopalians take communion. Which means I could either take the wafer and wine, commiting an act of hypocrisy and disrespect that might get me bolted if Christians are actually right about what they believe. Or sit tight in my seat among that tiny congregation of 4 including me, in which case, they would know me for just what I am - a heathen interloper. I took a chance on their coming up with some alternate explanation of my behavior and stayed in my seat while everyone kneeled in front of me except the older man whose knees were shot so he kind of leaned over to get the body and the blood.

I did get to meet everyone when we did the Episcopalian hand shake and peace greetings. We tromped over to the tin building next door where there was a tiny potluck - made smaller by my noncontribution. There the older Eskimo congregant named Willie pointed out the pictures of his mother and father on the wall. They were among the long deceased founding members of the church. He gently complained about the three parties in the immediate vicinity of his house the night before that had kept him awake. The organist, a white school teacher who's lived here 30 years raising 3 biological and then 2 adopted children, sheepishly explained that her brood was sleeping in but she'd get them there next week.

Like most church gatherings, people spoke about uncontroversial things and listened attentively to each other. The organist drove me home and said "see you next week." Uh maybe. I was looking for something a bit livlier with more opportunities for social engagement. But I hate to hurt their feelings by not coming back. And where the heck was Wendall?

Tomorrow I fly to Noatak, a village about 150 miles away that hasn't seen a medical provider for 5 months. I'll be busy morning until night and I'm sure it will be interesting.

Happy New Years and enjoy that balmy lower 48 weather.

July 20, 2008 - Farewell for now

Dear Friends,

This is my last day for this time in the Polar North. I've spent the last two weeks seeing patients in two villages. They are a study in contrasts, which perhaps shows how isolation plus geography changes human behavior.

Point Hope is a whaling village of 800 people on the northwest coast of Alaska on the Arctic Ocean. It is thoroughly isolated with almost constant winds and cool temperatures. The town is uncluttered compared to most Eskimo villages. No rusting vehicles lying about. The ground consists of many layers of swept gravel making it about as hard to negotiate in places as sand on a beach. Little wonder the elders need a 2 block ride to their clinic appointments in the snowless season. I am intrigued by a house made out of an airplane. There's one sizeable grocery store and no neon anywhere.

The beach is a half mile from town which makes it feel forbidding as I finally leave the clinic to take in my surroundings my third night there. I see floating ice everywhere as I look up and down the beach. The midnight sun makes the light shine brilliantly off the icy sculptures. The water appears bluer than Kotzebue's brackish hue. An abandoned bike and a large pile of rusting 4 inch pipes litter the inland portion of the beach. I find part of a seal skeleton to take home. It feels spooky to me to be here alone. I've been warned about polar bears but I'm not about to carry a firearm, which is the only reasonable means of protection, whether you're one or ten. I think I have more reason to be concerned about human predators anyway.

The clinic is busy any time the door is not locked except from 2 AM to 9 AM. People here have learned to be dependent on the community health aides to fix all their bumps and bruises and worse. Many are accustomed to treating their aches and pains with narcotics. The changing flow of medical personnel makes narcotic abuse easier than some other places in the US. The health aides fax the request to the hospital in Kotzebue and whoever is managing the "radio room" where all the village consultations and refills come through decides based on very little information whether the med is refilled. The doctor who is supposed to oversee the clinic went to Iraq, returned, but not to Alaska yet, so this clinic is orphaned, rudderless, and it shows.

I see middle-aged people and older with lots of degenerative arthritis from hauling around seal carasses and whale blubber and no physical therapist to teach them better ways to use their bodies. So I listen, examine, and try to treat them humanely, knowing that I'm feeding a few people's addictions in order to help a few more get through the day more comfortably. It's the same dilemma many primary care providers face in the lower 48 except there's no pain nor rehabilitation specialist or

therapeutic swimming pool to recommend. I am doling out Lidocaine Patches and Neurontin (a non-narcotic pain med that is good for chronic pain) prescriptions in addition to judicious (I hope) narcotic refills. Ironically people don't use ice here!

The oldest man in the village visits me for prescription refills and regales me with stories about the village. It was moved in the 1960's 2 miles inland because of erosion. The original houses consisted of wood and peat mostly underground - very fuel efficient in this coldest of places. HUD then built houses on stilts - modern ones- in the relocated village and things began to change. Satellite TV and then internet came even as some subsistence activities like whaling were retained. Fuel bills skyrocketed.

The Native dividend money, food stamps, and other subsidies mean that young people don't have to work. Like the young everywhere, they want to be modern like the rest of the world, and the old subsistence ways don't appeal to them. The influx of marijuana in the 60's hasn't helped people's motivation either. People of all ages smoke it regularly, and it's not considered morally wrong nor a health hazard by most.

The clinic building has been heated for years by the excess heat generated by the diesel generator which provides the electricity to the town. The exThe furnace and water heating system is finally getting fixed. The contractor who's finally fixing the furnace and hot that young people didn't have to work so they started making more trouble. The parents don't provide structure for the children as that has not been historically part of the indiginous culture.water system, gave me a key the Whaler's Inn where he stays so I could steal a hot shower. I worry I won't make it out of town due to inclement weather and the bush planes don't fly on Friday the 4th of July. The chaos and unhappy feeling in the clinic make me want to escape on time. As I prepare to meet the plane, a mother stops me in the waiting room for a quick assessment of her child's facial rash and the aide asks for help to suture a child's face. I make my escape despite the last minute requests.

I came back to Kotzebue tired out. After a three day break I flew to Ambler, an inland village at the junction of the Ambler and Kobuk Rivers near the Baird Mountains in Kobuk National Park. We flew over the Kobuk Sand Dunes, which are striking after seeing spruce-covered tundra dotted with meltwater ponds and lakes for miles. The great thing about the bush planes is that they fly low so you can see the topography well. The planes fly 800 feet above ground going east and 2500 feet going west, which theoretically prevents mid-air collisions. Some of the pilots have the disturbing habit of looking down for many minutes at a time doing paperwork while on autopilot. They assume that everyone in the air is complying with the Alaska flight rules that are updated every 6 months. This is not defensive flying!

Ambler Clinic is run by an older health aide named Emily. She is a quiet, peaceful Native woman who exudes confidence and kindness. Although she manages any medical problem that presents itself most weeks of the year, she takes advantage of my presence during the week to check on a child's breath sounds or to evaluate a high fever.

from Kotzebue who is responsible for the village had given me a list of all the people who needed immediate followup for their medical problems. Many came in to visit me with a wide variety of problems.
Emily explained that people here do not disturb her in the middle of the night and only ask for the things they truly need. She attributes this to the fact that many still "live subsistence." I wonder if it's also because she's set clear limits on what is acceptable interface with the clinic.

I see the oldest villager who has a critically elevated potassium level. He doesn't have one physical complaint. He does express frustration and anger about the doctors who don't listen and treat the Native people "like dogs. Since the advent of ATV's, the status of dogs has really plummeted so he is perceiving a mighty disparagement here.

I do not get one request for narcotics even though I am seeing many older people with the same severe arhtitis and chronic pain problems as the people in Point Hope.

People are fishing on the river but many of the boats are grounded (as well as ATV's thankfully) because the town is out of gas. It's also had an electrical outage so all the vaccinations are spoiled. No one tells me whether more have been ordered, and I don't like to pointedly ask the question as I don't want to imply blame if nothing's been done.

Evenings I chart the day's medical notes in the kitchen looking up sometimes to see tree swollows, mountains, and clouds through the big picture window. In my bedroom as I drift off to sleep, I hear balls bouncing and childen laughing as they celebrate freedom from school, their biorhythms confused by the lovely summer light.

Tonight, Sunday the 13th is my last night in Kotzebue. As I wander Front Street on the ocean, I met a tribal doctor, a woman of about 62 whom I had seen as a patient in the hospital clinic. She chatted telling me about her parents who were reindeer hunters in the 1940's in a small village in the region. When the reindeer stopped coming, they had to move to Kotzebue. She pointed to the foam along the shore, much like that which forms along the Mississippi in spring, and said that it was a sign that the Beluga whales are passing by farther out to sea, and the foam was created by the blow hole.

I stopped along the way to say good-bye to my friend Wendell Stalker, who plays a mean guitar, carves ivory from fossilized mastedon and walrus, and fishes in front of his house on the ocean. He gave me my first sheefish, a favorite of the locals. Pointing to a nearby net which catches fish while the fisherpeople sleep and play, he said, "I get to have more fun with my rod and hook!" He is a truly joyful soul.

I will miss this place. My plan is to return in January, the season of darkness and cold. One our Physician Assistants was sitting in the doorway as I passed his apartment tonight and I asked him about the 5 years he spent at the South Pole. He said it is colder here in winter! The difference lies in the humid air here versus the dryness of the Pole. The tribal doctor promises to make me seal skin mittens and a beaver hat and it looks like I will need them.

Maniilaq Clinic

Dear Friends,

My first week in the Walk In Clinic at Maniilaq Hospital was stimulating and a bit chaotic. This is a governmental - Indian Health Service/Northwest Alaskan Native Association - institution. It has very a unique way of doing things. Instead of an infinite number of pharmacies and medication formularies (medications available for use), there is just one. One pharmacist. One list of medications. No exceptions. So there are medications I like to use - especially for chronic pain - that aren't available. No heating pads. No cold packs. There is an intricate web of politics that governs this place. I cannot fathom it.

The nursing staff are friendly but sometimes don't know the answers to questions. Many people, like me, are working here temporarily. Patients are put in rooms and the providers just pick a room and see the patient. There's no list of people who have checked in, so we keep going until the doors are closed at 4:30 PM and then see whoever is left in the rooms no matter how long it takes. In the winter, the last patient may leave by 8. There are fewer patients now so I'm done by 6 or so. Few people have a provider - NP,MD,or PA - that they call their own. No continuity of care. No regular office visit follow up - which baffles and frightens me. I have always relied on the fact that someone would be coming back to continue improving whatever problem(s) we are working on.

There are no optometrists, physical therapists, or specialists here. I can't measure lung function in order to diagnose asthma accurately. If someone needs to see a specialist, I have to use good judgement to decide what can wait and for how long. A few specialists come up periodically and their schedules fill up quickly. Many times people need to go to the Native Alaskan Medical Center in Anchorage (for an elective surgery for example)- which involves making travel arrangements. Probably the hardest thing is to remember to do everything while the patient is here because many folks come in from the 11 surrounding villages which are connected only by plane in the summer. I have to ask each one when their flight check in is and plan my time with them accordingly. If I forget a medication, they have to wait until it comes to them on the next day's flight. There's a bigger price to be paid for forgetfulness.

My medical colleagues are a good group of people. One of the physicians has cerebral palsy. He speaks with the intonation that is so characteristic of CP and what comes out of his mouth is absolutely brilliant. He is double boarded in Internal Medicine and Pediatrics with a master's in Computer Science - which makes me wonder if he felt he had to overcompensate for his physical disability. He's a bit of a character - has opinions and likes to share them.

The only female physician, Ella Derbyshire,will be going to the South Pole next year if she can finally pass the rigorous medical evaluations. After Dr. Jerri Nielson had to do her own breast biopsy in 2000 which was positive for breast cancer, the requirements for signing on as the only South Pole physican became more rigorous. Dr. Nielsen wrote a book about her experience called Icebound which I'm reading (just can't get enough "exposure" to literature about ice and cold). There is a gauntlet of physical tests and exams and approvals by specialists one must endure now before going to be the only doctor in Antartica. Ella's been here 3 years, and it is evidently not cold nor isolated enough here for her so she's moving on to a more challenging practice setting.

Chuck Luck, a permanent physician's assistant about 60 years old or so, is even better than his name. He has patiently ushered me through the x-ray retrieval system several times.(It's like 10 different mouse clicks before you get to see the image - but then you get to play with it - making it darker, lighter, reversing the image so that the bones become dark and the air becomes light. That's something you can't do if you're looking directly at the x-ray film itself.) My office mate and roommate, Sandi, is a nurse midwife who has to answer the phone in the middle of the night and stay for hours helping women labor and deliver. I feel grateful I did not choose midwifery - which was something I considered before deciding on family practice. I love my sleep too much.

I met a temporary ER doctor from Oregon here for this weekend only who told me at dinner that the medical staff who come through as intinerants or locum tenens are either very good or very bad. The bad ones don't get to come back. He said a few years ago a locum physician went home and killed his wife with a hatchet. As a new member of the medical team, I wish he could have filled me in on the details! Mike, as you read this letter, don't infer too much from this historical incident.

The Native people I see in clinic remind me of the people in my practice at United Family with a few differences. They vary widely in their modernity. The elderly are quiet and unassuming. They live with their children and grandchildren and great great grandchildren. One 60 year old woman who accompanied her 7 year old grandaughter called her "my daughter." The custom is to take care of family when it is called for. People refer to stepchildren as "adopted" children, which I think is a lot friendlier term than "step". Many adults have taken in children who are not theirs. This becomes difficult when the medical system needs the legal guardian to sign off on a minor's care as no one does adoption paperwork. This tradition stems from the frequent loss of life during the child-raising years among Polar Eskimos historically. This affiliative culture does what it takes. Now premature death is most often from alcohol-related violence,accidents, and illness whereas historically it was starvation and cold-related accidents.

The young people in their teens and twenties remind me of youth everywhere. Perhaps with a more rural flavor because Kotzebue is so remote. Many however, have been to Anchorage - the big city an hour and a half away by plane. They play computer games and some have cell phones that only work here. Many drink until they're drunk and have babies in their teens. I did my first pelvic exam here on a 13 year old from a nearby village who had had four partners in the last year. The young men were just over 16 so that would constitute (consensual) statutory rape but I decided not to call in the authorities. A word of advice, antibiotics, and a contraceptive prescription seemed the better approach. Alaska has the highest Chlamydia (a common sexually transmitted disease) rate in the country. This may stem from the Eskimo practice of sharing wives. The Vicorian sexual mores never made inroads here. Inebriation is of course a factor.

Patients have been surprisingly open at times with their difficult life stories. One woman who works as a health aid in one of the small villages came in with palpitations and as I was recording her heart rhythm on the EKG machine, she told me how her husband had tried to kill her with a hatchet 3 years ago but she put her arm up to block him. She showed me a 10 inch long scar on her forearm. She still loves him. He won't get out of prison in Anchorage for another 12 years. He won't be coming home.

The children are especially beautiful. People take great joy in their babies. And yet sometimes they do not monitor even the smallest's whereabouts. From my bedroom window, I watched a 2 year old run into the street 3 times, once while a car maneuvered out of his way. I was just getting up to investigate when a man came out of the nearby house to fetch him. People take the whold family on 4 wheel ATV's without helmuts - the infants are held on the driver's lap sometimes. A toddler was drowned two weeks ago in one of the villages - walked into the water unattended.

I live across from the PutYuk Children's House where children who have been abused or abandoned go, usually temporarily. It's not that someone from the familly won't take responsibility for the child but that many times those individuals can't pass a background check due to felonies, history of previous child or partner abuse, or other problems. I met a divorced Caucasian woman,the dental clinic administrator, who adopted a 3 month old from PutYuk because no one willing to "adopt" her qualified. She became mother to this now two and a half year old after having raised two children now grown.

I enjoy my daily walks along the water. The ice is breaking up and floating further down the Sound. It is mesmerizing in the midnight sun (my favorite time to walk.) Sometimes the ice floes crackle as they interface with one another - creating glass-like shards before your eyes. Sometimes the ice is gone - especially when the wind is up and the waves are white and high. They say the seals are coming - no one will commit to a day or date. Maybe something superstitious in this reluctance.The seals follow the herring which are being caught as I write this. The bowhead whales are passing further up the Sound on their way to the Arctic Sea, and the Natives are hunting them now.

Love and peace.

First day

Dear Friends,

I sit quietly in the hospital's maternity unit - using the computer here as I have no means of communicating from my general issue apartment. No one is delivering a baby in this Arctic town of 3600 so I am grateful not to be an intrusive presence.

I read about Polar Eskimos before I came - mostly about Greenlanders- but some of the information applies to the Alaskan Inupiat here I think. The two days spent in Anchorage at the Art Museum and Native Heritage Museums set some nice groundwork I hope for all I will encounter here. The ingenious adaptations to the cold and a subsistence existence were well depicted in the museums. Grass was used to make socks. Seal intestines were used for coats and to make windows as they are waterproof and translucent. Sunglasses made of driftwood (no trees up here) reduced snow blindness and helped to see far - the eye openings like slits - the way we squint our eyes to see far. Snot was used to start fires - along with moss. Concentrated urine was a great way to soften skins - a strong base - that made the eyes burn. And always, great respect for the animals they killed - the sea otter was especially revered - the organs alligned much like a human's - believed to have a human spirit - so they were never eaten. Every part of the animal killed was utilized. A naturally ecological people - to waste wasn't a good option in such an unforgiving environment.

As I waited for my flight from Anchorage to Kotzebue, the gate filled with people who greeted each other - sharing stories of their week away - to Seattle - or somewhere else usually in "the lower 48". I could see the professional white people grouping together and the smaller goggles of native people - a young couple - so serious - with their tiny infant. I sat next to a woman and her two small squirrely children - she would gently reprimand them for their normal rambunctiousness - maybe more for my sake than theirs. Very blond little girls - looked like little Minnesota children except they were growing up in a mostly native Alaskan village. Mom is a Registered Nurse at the hospital where she takes care of patients with every kind of problem - and Dad is a firefighter - both grew up in Fairbanks - saving money here these past 6 years - and eventually to go home and buy a house. Too expensive to buy one here. She laments how few permanent staff there are in the hospital. It's really a good place to be but people come, work, and go. Then she asks me about myself and I have to tell her I am doing exactly what she was just lamenting. She tells me that the Fourth of July is the big holiday so good I'll be here - there's a 5 minute parade.

As we land I can see leads (openings like rivers) in the ice , tidal mud flats, and the waters of the Bering Strait - Russia on one side, Alaska on the other. When we debarked, one of the passengers commented that it looked from her side of the plane like we wouldn't be able to land because of the fog. Evidently we made it just in time. Sometimes the plane goes to Nome or back to Anchorage to wait out the bad weather - and this is springtime!

The medical director's wife and a woman who heads up psychological services picked me up - tipsy but not too tipsy for driving she reassures me! - and takes me the 6 blocks to my apartment. I thought the town was "dry" I say and she says - actually it's "moist" which means you can't buy it but can bring it in.

The apartment has a barracks look about it - peeling brown paint - second floor - my roommate is a nurse midwife who is ready to get back to Oregon but she has two more weeks here. Her kids are grown and like me, she has a husband at home looking forward to her return. She's been working around Alaska in various native villages for the last 5 years mostly from what I can gather for money. No one will pay her as much in the lower 48. She alludes to the difficulty of having different roommates. I think she worries I will be wasteful as everything you buy here costs a lot - milk is 9 dollars a gallon. Gas is 5.50. So I try to clean up after myself and give her space. And use just the minimum of toilet tissue and dish soap. Fortunately she keeps the TV on low volume. That's my sore spot!

I look out my bedroom window facing south and see a stack of antlers leaning against a shed, 3 snow machines, pallets scattered about and in the distance Kotzebue Sound and the foothills of the Brookings range.(Where Into the Wild the movie took place.)

At ten PM - sun sets at 1:30 AM - I take a stroll around - starting on the ocean side. It's about 30 degrees out with a bit of a wind.There's still snow along the water's edge in places but mostly there is gravel. Nets lie haphazardly about. A truly amazing number of items in every stage of degradation litter the surfaces around the homes and indefineable other spaces. I feel like I could be walking at times in an art installation at the Walker except things just don't quite hang together well enough. I think I pass a gas station - a couple of pumps. Gas prices aren't posted anywhere in Alaska - too discouraging. All the pipeline oil is sent out of state. The roofs are corregated metal or plastic and the homes very plain. No window and door trim. Very functional. With the winds off the sound (the town is at the tip of a peninsula), this is probably an adapation made of necessity.

It's Saturday night and the main visible activity is young people riding around on 4 wheel ATV's - some looking to be no more than 12 years old - and no one wearing a helmet or seat belts. I look about carefully as I walk thinking about the odds of being hit by a child driving a vehicle 25 miles an hour. Like the suburbs, there's no sidewalks here. Then my thoughts move to the kind of trauma I am likely to see at the hospital given what I'm seeing on the little roads - mostly unpaved. Visions of cleaning road rash, suturing lacerations, using the Glasgow Coma scale - all of the stuff I'm not very good at doing - and really wishing they'd pass a helmet and seat belt law for drivers of ATV's. Fomenting for change, and I've only been here 4 hours.

Today I found lunch at the cafeteria - almost desserted except for a Somalian pharmacist from Minneapolis and the hospital's regulation specialist. She grew up near Anchorage and has lived and worked for several native corporations. She is the first person to tell me things that will help me understand how to take care of patients in 2008. My immersion in the Native Alaska predating statehood was clearly not going to be enough, and I have worried about making mistakes. She said the village people are like lemmings falling off a cliff. The suicide rate is horrendous, and the people don't take it seriously - nihilism? A 22 year old hung himself on a tree in town the night before last. He comes from one of the nearby smaller villages. There is no social or genetic history for arising early each day to go to work, to live within a schedule. The older order of subsistence living is no longer relevant. People used to hunt and fish during certain times and seasons and then spend weeks sleeping, relaxing, eating. Or starving. Hunting often occurred over days or weeks - a huge energy expenditure followed by rest. People still hunt and fish but starvation is never a threat. They own the land and the native corporation provides.

She tells me about the anger the Natives feel toward the white health professionals. Sometimes the patients are verbally abusive to the staff. The doctors don't know about certain cultural expectations. For example, when an adolescent has a baby, her mother or another elder will come to the office visit and will expect the medical provider to talk to the elder, not the baby's mother. If the doctor directs the questions to the young mother and she answers, she will be beaten when she gets home.

At the end of our conversation, she worries that she has discouraged me, and I reassure her that in fact I am very grateful for the information. Wouldn't it be good to have this information written and conveyed to the staff that come and go? She thinks perhaps that there is a way in which writing it down could be detrimental. Acknowledging the problems would perhaps accentuate them? Politically incorrect with the tribal leadership? Reduce expectations for positive behavior? I don't know.

Tomorrow I start work. I am looking forward to it. Take good care my friends and enjoy summer.