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.