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.