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.