Bethel, We've Got To Stop Meeting Like This

This is my last foray to rural Alaska before I start my new job in October, and I'm still amazed by the lovely greenness of summer.  All of my familiar icy landmarks have melted away into an unrecognizably verdant landscape of tall grass and bushes.

Some of the hospital patients, however, remain a little too familiar--for instance, the 49-yr-old woman who is frequently admitted for one of two reasons: alcohol intoxication or alcohol withdrawal.  She was just discharged last week, and she bounced back onto my service yesterday.  After multiple doses of ativan and haldol administered at regular intervals, the patient woke up this morning requesting a shower.  She was in that very narrow window between intoxication and withdrawal where she was fairly lucid and cooperative.  Hold her any longer and she goes into a full-blown and very unpleasant withdrawal.  Let her go and she finds enough alcohol to keep herself adequately inebriated to avoid withdrawal.  Since she has never shown any interest in detox or any other treatment, I discharged her and kept my fingers crossed that she would stay out of trouble for at least another week or two.  She beamed at me, looking rather raccoon-ish with her bilateral periorbital contusions, and I couldn't help smiling back at her.

Fog, Glorious Fog!

Having recently returned from a CME on hospitalist procedures in San Francisco, I must admit I kind of miss the fog that often rolls in as evening falls.  A lot has changed in my favorite town since I moved away, but many things remain the same.  Between practice sessions spent mastering the insertion of central venous lines in the right IJ and right subclavian veins of anatomical models (you know you hit the right spot when your finder needle aspirates windex-blue fluid), I was able to hop on the 38 Geary bus which whisked me away from Union Square and rolled all the way down to Land's End, where I took a lovely stroll by the Pacific Ocean during low tide.

Snip Snip

Have you ever completed a vaginal laceration repair shortly after a successful delivery, wondered, "Why is there a bandaid on this patient's R buttock?", and removed the bandaid (which was starting to peel off anyway), only to find a growth that resembles a small penile glans?  The texture was a cross between a stale marshmellow and a lipoma.  The patient's PMD had been reluctant to remove the growth, fearing it might be highly vascularized.  I anesthetized the skin around the lesion with a field block of 1% lidocaine with epinephrine, stuck a needle in it, and when no giant geyser of blood erupted, performed an excisional biopsy and sent the odd growth to pathology for further evaluation.

When All Else Fails, Hold A Sleeping Baby

One of the Yup'ik elders on my service has the dwindles.  He's 87, he has Lewy body dementia, and he has slowly been losing his strength and mobility over the past several months.  He was originally admitted for acute R gluteal pain that radiated down his leg, likely secondary to a herniated disc at L4-L5; but he soon stopped eating and drinking altogether.  He has an amazingly large and caring family, all of whom are deeply invested in his well-being.  I have had numerous conversations with his siblings, adult children and adult grandchildren about his prognosis all week.  We had a family conference by speaker phone yesterday so that family here at the hospital could communicate en masse with family back home in the village.  The ones who had been in Bethel all week by his bedside felt strongly that he should go home to familiar surroundings.  The ones in the home village were less certain and wanted to try more aggressive interventions (i.e. artificial nutrition by NG tube) in the hospital.  The patient's sons were on their way home from fish camp (everyone sets up fish camp by the river in the summertime, in order to catch and then slowly dry an adequate supply of salmon and herring to last throughout the winter).

This morning, it was decided that the patient would go home to be cared for by family.  I put in a special request for a "reverse medevac" because he was too weak to sit up for a commercial flight home. An Expected Home Death form was filed in his chart.  When the paramedics finally arrived (the flight time had been delayed several times due to regular medevac requests that pre-empted the reverse medevac), we all got a little teary-eyed.  The family graciously thanked me, and there were hugs all around.

After the plane took off, I tiptoed to L&D and sat quietly in a rocking chair for a few minutes, holding the baby I had delivered the day before, which somehow made me feel just a little bit better.

Implanon Is My New Best Friend

Listen up, teenage girls of the Yukon-Kuskokwim Delta region: birth control is a really, really useful thing!    Yes, I am talking to you, teenage primip being induced at 42 + 1/7 wks for postdates and oligohydramnios, crying between pushes.  And you too, 18-yr-old girl admitted for a septic abortion at 8 weeks EGA, getting IV doxycycline and unasyn.

Last night, I had a very long talk with the 18-yr-old about the pros and cons of all the birth control methods available in the universe and gave her a detailed educational handout with tiny pictures of everything we discussed.  This morning, she told the nurse, "I want my birth control.  When can I have it?".  Asked which method she had chosen, she replied, "The poke."  Poking could describe either the depo provera injection that's good for 3 months, or the implanon implants that are good for 3 years.  Luckily, she chose the fantastically low maintenance implanon which was inserted posthaste just before she was discharged home.

Dishes Are Dangerous

My pager goes off incessantly, and it's hard to predict whether it's the ER doc asking me to admit a sick child, a village health aide asking what to do about a man whose right index finger is almost completely severed after getting his hand caught in a flywheel, or the lab calling to report a sky-high INR value of 18.  When I saw the page from OB this afternoon, I assumed that my 23-yr-old G7P2 being induced for cholestasis of pregnancy was on the verge of delivering...but it was actually one of the OB nurses who whispered sotte voce: "This is not urgent, but I cut my thumb and I was wondering if you would take a look at it."  She had been washing dishes and accidentally shattered a mug, producing a curvilinear laceration that crossed the PIP joint of her left thumb.  The bleeding had stopped after she applied pressure, and her range of motion was perfectly preserved.  "Do you think I need stitches, or can I just keep it wrapped up in a bandage?"

Because of the awkward position of the laceration over a joint, I decided to give her a few stitches to hold the wound edges together during the healing process.  One of the other OB nurses broke into the surgical wing and gleefully returned with 4-0 nylon suture, 1% lidocaine with epinephrine, Adson forceps, and the most beautiful, delicate needle driver  I have ever seen.  "It's a Webster," she told me.  "It costs $300."  It took all of my willpower not to surreptitiously sneak it into one of the myriad pockets on my scrubs.  In the end, the injured nurse got 3 stitches and we all agreed she had to fabricate a far more swashbuckling explanation for the mechanism of her injury.

Of Maggots And Mental Status Exams

My most entertaining patient is a 67-yr-old monolingual Yup'ik-speaking man admitted for weeping ulcers on his lower extremities that were infested with maggots.  His legs are completely discolored with thick layers of exfoliating skin.  He has had several amputations due to severe frostbite: he is missing 2 toes from his left foot, 1 toe from his right foot, and 4 fingers from his right hand.  Despite all of these physical quirks,  he is frequently smiling and joking.  A young man from the patient's household is accompanying him during this hospitalization, but displays a curious lack of knowledge about the patient's baseline level of functioning ("I don't know, I just got out of jail" is his standard answer to our inquiries).  On his second day of hospitalization, the patient's primary caretaker called to tell us that she can't take care of him anymore (not that she was taking particularly good care of him to begin with, given the maggots on his legs).
Patient (via Yup'ik interpreter): Was she drunk when she called?  Because she always talks like that when she's been drinking.

To be fair, the patient's lower extremity ulcers are healing quite nicely now, possibly because of the neat work of the maggots: they're quite adept at digesting rotting organic material.  The hospital social worker is filing an Adult Protective Services report for elder neglect, and she asked me to conduct a mental status exam to facilitate the patient's placement in a nursing home.

Here's my dilemma: the traditional Folstein MMSE is a 30-point questionnaire often used to screen for dementia.  Questions include asking the patient to spell "world" backwards, to subtract 7 from 100 and keep subtracting 7 serially from the resulting answer, and to name the year/month/date/weekday.  Are these questions appropriate for a patient who doesn't speak English and has limited exposure to formal education?  I looked at the Mini-Cog Assessment Instrument for Dementia which is supposedly valid regardless of culture and educational status, but one of the items asks the patient to draw the face of a clock, then draw in hands to set the time to "10 minutes past 11 o'clock".  Is this relevant to someone who lives in a remote village in rural southwestern Alaska and uses the position of the sun and the moon to tell time?

Patient (via Yup'ik interpreter): These questions are making my legs itch.

You & me both, baby...

Back in Bethel

If you're wondering what Bethel, Alaska looks like without all that ice and snow, look no further:  There is grass!  Trees with green leaves!  Daylight until 1 am!  And lots & lots of rain which produces copious amounts of mud.  I forgot my umbrella, but I did arrive equipped with an insanely cheery pair of child-size "fireman style" rubber boots:

I'm staying at one of the hospital-owned apartments next door to the jail (I will not lie--the barbed wire fence does give off penitentiary vibes).  So far, the prisoners have been extremely quiet and neighborly.  There is a super muddy trail leading from the apartments straight to the hospital that can be traversed in less than 5 minutes.  It's hard to believe that I can squeeze through the narrow gap between two barbed wire fences--wearing all my waterproof gear and my internal frame pack--without setting off several alarms and alerting the Alaska State Troopers.

Meanwhile, back on the inpatient wards, I feel like I'm swimming in jello,  and everything I do is soooo slow and cumbersome.  I have a large service of patients who have been here forever, many with tricky family dynamics that must be navigated carefully.  The RMT calls are as crazy as I remembered, and today's top prize goes to a call about a 79-yr-old woman who had chest pain, then dramatically collapsed in the doorway of the village clinic, then went into bradycardia with a pulse of 40 followed by a seizure after receiving one dose of nitroglycerin.  After being medevac'd to the ER, she was found to have a very low hemoglobin of 6!  Oh Bethel, how I've missed you...

How My Job Search Is Like An Episode of The Bachelorette

It really is, if you imagine each potential employer as one of the bachelors.  Also imagine the physician recruiter as Chris Harrison, the host of the show who guides the bachelorette through her deliberations before each rose ceremony when she has to decide which bachelors to keep and which ones to send home. I interviewed with 2 urgent care clinics and 2 primary care clinics, with the following impressions:
Bachelor/employer #1: practical, down-to-earth, confident
Bachelor/employer #2: organized, detail-oriented
Bachelor/employer #3: alarmingly charming
Bachelor/employer #4: arrived 10 minutes after I had already checked in for my interview.  Didn't really ask me any questions, just rambled on about random topics and how "nobody in this clinic ever works full-time [wink wink]".  I began to wonder if bachelor #4 had been imbibing alcoholic refreshments.

In the end, I went with bachelor/employer #1, an urgent care clinic with 12-hour shifts.  A 3-year contract was signed, just like in professional sports, with a start date in October.  I expect to see my face on a box of Wheaties any day now...

Disneyland for Procedure Junkies

A few weeks ago, I went to Charleston, SC for a refresher course on joint injections and management of fractures, sprains and dislocations.  In a strange twist of fate, the woman sitting next to me was one of the doctors at the family medicine clinic in Bethel! (and she reports they were still, in mid-April, buried under snow & ice).  We all loved the joint injection models (shoulder, wrist, knee, hip) with electronic needles that emitted a pleasant beep whenever we correctly entered the joint space.  Winning!  It was unadulterated fun spending hours fashioning custom splints and casts for the upper and lower extremities of our classmates.  We even got to put someone in a football uniform (complete with helmet and enormous shoulder pads) to practice c-spine stabilization & log rolling of sports injuries on the field.

Cooper River

Not a real squad car

Charleston is a gorgeous city on a peninsula flanked by the Ashley River and the Cooper River, filled with historic buildings dating from the pre-Civil War era.

Charleston is also home to The Citadel, MUSC (the most expensive medical school in the country--and no, their stethoscopes aren't made of gold.  I checked.) and Hyman's Seafood Deli where you can get the most amazing crabcakes.  So delicious, you never want to leave.  But leave I had to, because the tornadoes were a-comin'...

Best. Crabcake. Ever

Filing Taxes As An Independent Contractor vs Throwing Acid On My Eyeballs

They're both equally painful.  Why does the IRS make everything so horrifyingly complicated?  In order to complete the 1040, I have to fill out Schedule C (for profit or loss from business) and Schedule SE (to calculate self-employment tax), then start working on 1040-ES (for 2011 estimated tax) to figure out a quarterly payment schedule for taxes that don't get withheld from my locum tenens gigs while making random guesses regarding what my total income in 2011 might turn out to be [Dear IRS, Are you aware that I am not psychic].

Don't even get me started on what constitutes allowable deductions for business expenses!  I have read countless IRS publications & instruction booklets and wandered through confusing and ridiculously unhelpful worksheets & flow charts, and I still can't tell if my calculations are correct.  The instructions tell me to divide line 9 by line 15, then multiply by 0.0239, then spritz with aerosolized frankincense and bake the whole thing in a front-loading crucible gas kiln at cone 04 for 8 days while doing the hokey pokey.  Am I a minister, member of a religious order, or Christian Science practitioner?  Am I a farmer or fisherman?  Really?!  This information is somehow crucial to sorting out the jumble of paperwork?!  Hire a tax professional, you say?  Yes, I really should have done that months ago but you've probably deduced by now that I am the world champion procrastinator when it comes to paperwork involving taxes.  The idea of working the counter at McDonald's is starting to sound inexplicably attractive...

Spring Has Sprung

Having returned to Seattle (after admitting my last patient on night float: a 14-yr-old girl who overdosed on tylenol and then had to endure lectures from both me and the ER doc on Why Acetaminophen Is Not Your Friend), I am delighted to find that everything from daffodils to cherry blossoms is now in full bloom, even if there is still more drizzle than sunshine.  I am thankful to be walking on actual pavement instead of snow & ice, armed only with a light windbreaker.

My precocious 3-1/2 yr old nephew has advanced by leaps & bounds while I've been away, and he can now write most letters of the alphabet with minimal assistance.  He wants to learn words, so I've been constructing small sentences for him to trace over with color pencils:

RMT Gone Wild

Another night of nearly nonstop RMT calls, which can be neatly summed up like one of those Chinese restaurant menus where you choose options from each of two columns...

Column A                                              Column B
S/he was drinking       and               got hit on the head with a guitar
                                                        got shot with a BB pellet
S/he was on a snow                        got stabbed with a knife
machine/4-wheeler     and               fell down
                                                        started having seizures
S/he was playing                             got into a fight
with a BB gun            and                drank 3 bottles of R&R
                                                        got run over by a 4-wheeler

One man who was extremely intoxicated and combative got stabbed in the chest but would not allow the village health aide to apply pressure to the wound.  Under normal circumstances, I would have activated the medevac, but this patient was belligerent and uncooperative and stated he would refuse to fly to Bethel; so I had the health aide monitor him in clinic.  She called with frequent updates (vital signs, bleeding check), and each time, I could hear the patient yelling loudly in the background.  Finally, the health aide had the VPO (village police officer) cart the patient off to jail because he was out of control.  I figured if the patient was running around and throwing things in clinic, the likelihood of a pneumothorax, hemothorax or cardiac trauma from the stab wound was pretty low.

Cama-i

Cama-i means hello in Yup'ik.

The Cama-i Dance Festival occurs over a 3-day weekend each year in late March, drawing performance groups (showcasing mainly traditional Yup'ik and Inupiat story dances) from rural Alaska and other regions.

It is an exceptionally well-attended event accompanied by a Native crafts festival featuring intricate beadwork and fur accoutrements.  There was even the promise of Hmong lion dancers this year [which I did not see because it's really really hard to sit on bleachers in a crowded high school gymnasium for more than a few hours at a time...]

Night Float

Major highlights from the previous night:

19:05  RMT call from a village health aide regarding a 37-yr-old female who had been drinking, then blacked out and had an unwitnessed fall onto an unknown object that left a puncture wound at the crown of her head.  During the day, we would have just put the patient on a commercial flight to Bethel for further evaluation in the ER and a possible head CT, but at night the major mode of transportation is medevac which should only be activated when critical care is necessary.  Pt was as lucid as one can be while intoxicated, no alarming neurologic deficits, but the health aide called to report that the puncture wound was actively bleeding.  The photos she sent over telemed were a bit blurry and did not give any sense of the depth of the wound.  How to manage this by telephone?  I told her to put several layers of gauze on the wound, then wrap it as tightly as humanly possible with an ace bandage, then apply ice to the region of the wound.  20 minutes later she called to report that the bleeding had stopped and the patient was sobering up.  Disaster averted.

20:53  I admit a 16-yr-old boy with suicidal ideation whose parents were involved in a tragic murder-suicide just a few months ago; he was the one who discovered their bodies and had to break the news to his younger sisters.  Suicide has become such an alarmingly common problem in the Yukon-Kuskokwim Delta that several of the Iditarod competitors this year dedicated their race to suicide prevention.

21:30  A 16-yr-old primip in OB who had just given birth several hours ago after a 3-day induction for mild preeclampsia starts bleeding.  We give her 1000 mcg of misoprostol and the bleeding ceases.  Her post-delivery CBC shows a drop in hematocrit from 34 to 23.4.

22:44  I pick up several ER patients, one of which is a 13-month-old girl with a nasty-looking abscess on her R posterior thigh with a large area of surrounding cellulitis.  Her mother seems unconcerned about the infection, and I am worried about mother's ability to administer daily medication and manage dressing changes, so I decide to hospitalize the girl and start her on IV antibiotics.  After perusing her old chart, I discover that she has been hospitalized twice in the past 8 months for large MRSA abscesses with cellulitis,  and that her mother has been investigated by the Office of Children's Services for suspected neglect.

00:13  The OB nurse pages me because the 16-yr-old primip produced another large gush of bright red blood. I medicate her with fentanyl & versed, then manually extract a large 200 cc blood clot from her uterus and order an additional CBC for morning.

02:22  More RMT calls about infants in respiratory distress, both of whom end up getting medevac'd.

03:10  More ER patients, mostly with viral respiratory infections that are stable for discharge.  The ones who don't have family or friends in Bethel can stay in the hospital-owned hostel overnight and return in the afternoon for a recheck before flying home to their villages.

04:31  Several RMT calls about minor injuries from fisticuffs.  The health aides aren't trained to do laceration repair, so they mainly irrigate the wounds and apply butterfly bandages to hold the wound edges together.

06:17  A 21-yr-old primip is admitted to L&D in active labor and quickly progresses to complete dilation.  Instead of the usual stoic tolerance of labor, this primip yells, "That f*ing hurts!" every 10 seconds while pushing her baby out.  Thankfully, it only takes 4 pushes to deliver her vigorous baby boy.

Breaking & Entering

From the Delta Discovery, a local newspaper serving Bethel and the villages of southwestern Alaska:

"Burglar Caught On Video, Befriends Guard Dog
An intruder broke into the Westlake Hangar at the Bethel Airport during the early morning hours between 4:30 am and 5:15 am, causing extensive damage to a window and a steel door.  The thief stole 42 bottles of alcohol.  The vandal used a sledgehammer.  He also rifled through everything.  The thief left behind 3 hammers."

Balmy, then...KABOOM!

For the past few days, it has been downright balmy, with temperatures in the mid-30s, ice melting, puddles forming on the side of the road.  Last night brought the emergence of the Supermoon (the largest full moon since 1993!), as the moon arrived at its perigee, the point in its orbit closest to the earth.

All was well until the spring equinox today brought gale force winds and a snow storm.  All flights between Bethel and the outlying villages have been canceled due to weather; even the medevac has been grounded.  The RMT calls from the villages were pouring in nonstop:
-A 61-yr-old male with blood intermittently oozing out of his penis but no recent injury or trauma...the health aide estimated a half cup of blood had dribbled out within the past hour.  I spoke with the on-call urologist in Anchorage who suggested attempting gentle insertion of a foley catheter for tamponade until the planes can bring the patient in for further evaluation.  Apparently urethral injury is not a urologic emergency.
-A pregnant multip in active labor at 39 weeks who had missed her "Be in Bethel" date, baby delivered by the health aide who gave us a blow-by-blow account over the phone as it was happening.
-A 6-month-old baby in respiratory distress: tachypnea, hypoxia, tachycardia, fever of 100.7.  The health aide was treating the baby with oxygen, albuterol nebulizer,  and ceftriaxone IM and checking in with us every 2 hours while waiting for the weather to improve so medevac could resume flights.

As Aurelie has mentioned, if medevac is grounded, a Blackhawk helicopter can be summoned in life & death situations...and it's nerve-racking to be the one who determines what constitutes "life & death".

Meanwhile I was attempting a massive diuresis of my service before the next set of ward docs start tomorrow.  My two loony-bin suicidal adolescent patients (one pregnant, the other withdrawing from an alcohol binge) on Title 47 (involuntary psychiatric hold for danger to self, danger to others, or grave disability) were awaiting transfer to the psychiatric facility in Anchorage.  My intoxicated 49-yr-old female with fractured ribs and a tiny pneumothorax not apparent on chest x-ray, but seen on chest CT: when would it be safe for her to fly home to her village?  I checked with the on-call pulmonologist in Anchorage who estimated 5 days after complete resolution of the pneumothorax.  My patient can't get home without flying...unless she goes on a several-hours-long ride via snow machine over the bumpy frozen river, which would be quite painful with cracked ribs...

At the end of a very hectic day, I walked home from the hospital in the middle of a blizzard.  At least all the waterproof gear I got at REI has proven to be truly waterproof.

A Word About Permafrost

It's underground. It's composed of rocks, soil and frozen water.  It forms when the depth of winter freezing exceeds the depth of summer thawing.  If permafrost begins to melt, the ground above becomes waterlogged, soft, and prone to collapsing.  Hence the proliferation of boardwalks & ramps in Bethel.

To avoid melting the permafrost, the buildings in Bethel are built on stilts, and water & sewer pipes are installed above the ground.

Contact with the outside world?  You can't get cell phone reception here unless you use a phone card or have an account with the local wireless company, but there is decent internet access and satellite television.

Overheard on Labor & Delivery

Here, in the land of pregnant ladies (both primips and multips alike) who are mysteriously able to deliver most of their babies in just 3 pushes, one of the OB nurses was musing over a non-native delivery she had just seen in which the expectant mother (loaded up on pitocin, with FSE & IUPC in place) had to push for 90 minutes before her baby emerged.
Nurse: (somewhat puzzled) I heard that's normal...

I confirmed that yes, in the lower 48 states, many primips do end up pushing for up to 2 hours.  It really gives me pause about the medicalization of labor:  in medical school & residency, most of the deliveries I saw involved breaking down the bed, feet placed in stirrups for pushing; intrauterine pressure catheters to measure the force of contractions; fetal scalp electrodes to better capture the fetal heart tracing; and of course IV pitocin for augmentation/induction of labor.  Here in Bethel, the bed is often kept intact and instrumentation is kept to a minimum.  Shorter 2nd stage of labor, cuter babies...

Qayagaluku

The difficulty of working on the wards is that your attention is pulled into 3 different directions:
1. Hospitalized patients (both adult and pediatric): the most prevalent reasons for admission on my service currently are multilobar pneumonia, frighteningly large & out-of-control abscesses, and alcohol withdrawal.  There was a bit of drama today with a young lady brought in for suicidal ideation who turned out to have been diagnosed with TB one year ago and somehow successfully evaded treatment.  Now she's captured in a negative-pressure isolation chamber, moody and crying, while Public Health tries to get a court order for her to remain in isolation until adequate treatment has begun.
Alcohol withdrawal came in the form of a married couple, both prone to DTs, sharing a room and a 24-hour sitter.
Day 1: Rowdy and drunk
Day 2: Still drunk
Day 3: Sleepy and drunk
2. OB patients: I delivered my first Native Alaskan baby a few days ago, an adorable rosy-cheeked infant who popped out after just 3 pushes.   The L&D nurses here are refreshingly pleasant and extraordinarily helpful.  And they gave me a salad!  My first fresh veggies since arriving a week ago!  I feel like my hospital-issue lime green scrubs are mocking the lack of fresh fruit in my diet:

3. RMT: a.k.a. Radio Medical Traffic, a term from the old days when communication was via two-way radio.  In order to provide health care even in the most remote villages, each village has health aides who are on-call 24 hours.  The health aides are equipped with a rudimentary clinic and modern technology that enables them to transmit digital images of patients and fax clinical notes to doctors at the hospital for feedback.  I'm responsible for reviewing the notes & images from health aides, then calling them to discuss the patients.  If you don't call them soon enough, they will hunt you down and have you paged repeatedly. In my head, I've been lumping the cases into 3 different categories: Benign (OK to treat in the village), Scary (take a commercial flight to Bethel for further evaluation!), and Scarier (medevac NOW!).  Sometimes the health aides are frighteningly complacent.
Me: Is this 4-month-old baby really breathing 80 breaths per minute?
Health aide: (calmly) yes
Me:  AAAAEEEEEEEEAAGGGGGHH! (translation: give her oxygen & a nebulizer treatment while I activate the medevac!)

I Need Ice Cleats, Stat!

Once again, I find myself practicing medicine in a wintry climate, this time in the small community of Bethel which is located near the mouth of the Kuskokwim River in southwestern Alaska.  The Yukon-Kuskokwim Delta region is populated by 56 tribes in remote villages spread all the way to the west coast of Alaska adjacent to the Bering Sea.  Admissions to the local hospital are divided by village, with one group comprised of villages clustered along the Yukon River and the other group consisting of villages scattered along the Kuskokwim River.

The Yup'ik name for Bethel is Mamterillirmuit ("smokehouse people") in reference to its origin as a trading post with a fish smokehouse in the late 19th century.  Although Bethel can only be reached by air or by river, it has the highest number of taxicabs per capita in the entire country; paved roads constitute a very modest 10 miles within the town itself.  I love how the hospital supplies its locum tenens providers with cab vouchers that resemble Monopoly money:

Temperatures have been in the single digits, but really more like -15 degrees with the wind chill factor.  I'm making good use of my gore tex goose-down L.L. Bean parka and insulated Sorel boots.  For those of us who enjoy ambulation, there's a shortcut to the hospital that involves walking across a teetery boardwalk hovering over a large snow-covered marsh.

  

The roads are super porcelain icy, and the main challenge in getting to work (other than the chill of the tundra) is trying not to get run over by a snow machine (a popular form of transportation, given the exorbitant cost of importing a car by barge or cargo jet).  The approach of a snow machine is heralded by a loud high-pitched buzzing remniscent of a giant mechanical mosquito.

I was warned about the high cost of food [thanks, Aurelie!] but I was still bowled over during a trip to the grocery store that revealed 6 oz of slightly moldy blueberries selling for $9.59 and a wilted head of cabbage for $6.99.  Half of my luggage was an experiment in food transport: I made pasta sauce with ground turkey & spinach, packed frozen in quart-sized ziplock bags tucked into gallon-sized ziplock bags wrapped in larger plastic bags to protect against leaking.  I also packed black beans, salsa, wild rice, shredded mozarella, and rotini.  I froze a loaf of whole grain bread to make almond butter sandwiches with dried mangos & dried cherries.  So far, the food supply seems to be holding up, but it's reassuring to know that if I do run short, I can always head to the hospital cafeteria for elk meatloaf.

ATLS and a Casino Heist

What I did while visiting my friend Jules in Denver:
1. ATLS: We both signed up for Advanced Trauma Life Support, a grueling 2-day course taught by trauma surgeons bursting with testosterone.  One particularly manic instructor with rapid pressured speech entertained us with such comments as, "Big whoop!  No one ever died of an EJ laceration!" and "Oh, you did a thoracotomy?  What kind of suture did you use?  Silk?! [raising his eyebrow judgmentally]...mmm hmmm..."
2. Dinner at Table 6: The highlight was dessert--an amazing sweet potato cinammon roll with carmelized pecans and cream cheese sorbet

3. Casino Heist: A mystery-solving dinner held in a 3-story Victorian mansion, whereupon entering, we were approached by a very young person in sunglasses with a fedora and a camera

Me: A minor just took our photograph!
Jules: He's a sixth-grader!
We played several rounds of fake roulette and blackjack before retiring to the 3rd floor ballroom for dinner and guessing which of the eccentric characters had stolen "millions" from the casino.  I was rooting for our blackjack dealer, a mysterious woman in a mask and a black wig with an endearingly unidentifiable accent, but alas it was someone else...

Back in Seattle, Bottle of Gin Intact

When I unzipped my checked baggage upon arriving home, I found this official notice tucked inside:

Either they failed to detect my bottle of gin (given to me as a door prize at the clinic holiday party in December) wrapped inside my white coat which was wrapped inside one leg of my ski pants...or the TSA has given its seal of approval to juniper-derived spirits.  If any of my peeps from Swedish are reading this, we must have a gin & tonic party soon...

When They Say Potluck, They're Not Kidding

At my farewell potluck, there were no fewer than 4 slow cookers, 2 different kinds of chili, multiple casseroles and pasta salads, scalloped potatoes, a chocolate cake, and a strawberry rhubarb cobbler.  To be polite, I had to eat one of everything.  It was all perfectly delicious.  My nurse implored me to return in the summer, so she can give me a ride on Pearl, her prized Harley-Davidson motorcycle.  

Despite the crazy work hours, a teeny part of me will miss practicing full spectrum family medicine at the clinic, hospital and nursing home:

I will most definitely miss the H's and their cozy home in the mountains:

Dr & Mrs H then...

...and now

Qu'est-ce Que C'est?

A 51-year-old female asks me to remove an intriguing growth from her right inner thigh.  She calls it a skin tag.   I call it a violaceous 1.5 cm x 0.8 cm pedunculated mass that--I kid you not!--is shaped like a kidney.  There's no other way to describe what looks like a miniature kidney sprouting from her thigh...has she discovered the secret to growing diminutive replicas of vital organs?  I want to take it home and transplant it into a Barbie doll with end stage renal disease.  Sadly, pathology confirms it's just a humble capillary hemangioma.

A very young 24-year-old mother of four brings her 7-year-old son to clinic with great urgency.  "There are these lumps!" she tells me, getting very upset, "On his stomach!".  I am half expecting to see something crazy like dermatofibrosarcoma protuberans, but when she lifts up her son's shirt to reveal his abdomen, I see...  cellulite.

Pimp My Ride

Found in the forest while snowshoeing...

Police Blotter

For hours of endless entertainment, my nurse recommends reading the Police Blotter which is a verbatim account of all local police dispatch calls.  Check out these awesome gems:

B11-0068 13:53:30 Starr Rd  SUBJECT IS BURNING MODEL AIRPLANES AND BIRDHOUSES IN A BAR B Q, HIGHLY INTOXICATED

T11-0107  14:18:11 Western Ave  CHAINSAW TAKEN FROM SOMEWHERE IN TONASKET

W11-0013  08:35:14  Bigelow St  MAN SAYS WIFE IS THROWING BOOKS AT HIM

R11-0070  15:46:37  Golden St  STRAY CHIHUAHUA IN AREA.  UNABLE TO CATCH.

K11-0309  19:43:50  Engh Rd  INTOXICATED MALE WEARING A HAT AND DRIVING ELECTRIC CART, OFFENDING FEMALE CUSTOMERS

And last, but not least, my all-time favorite:
THE REPORTING PARTY'S PERSONAL PET GEESE HAVE GONE MISSING EVERY NIGHT THAT HER CAR ALARM GOES OFF.  HER DOGS ARE BARKING AND LOOKING TO THE EAST

Ever File An L&I Claim for Someone Kicked By A Cow?

A lovely lady was milking one of her cows on Sunday when the cow became startled and kicked her in the face.  That's right, my patient was sucker punched by her very own quadruped ruminant.  Filling out L&I forms for patients who get injured on the job is tremendously tedious, but it becomes ever so much more delightful when writing a narrative description of a cow assailant.  Anyone know if there is an official ICD-9 code for injuries sustained from being kicked by a cow?  The facial swelling has improved significantly, but my patient still has a bit of a black eye.  I decided to call it a "periorbital contusion" (ICD-9 code 921.1) and to be extra appreciative of the milk I'm having with my chocolate chip cookies.

Beyond Gingivitis

I never knew how much I appreciated dental hygiene until recently, when I saw a patient with several teeth that were visibly rotting, and a stupendously receded gum line on her lower jaw.  It looked as if her central incisors were held up almost solely by levitation.  "I think I have a tooth infection," she said in what I believe is the understatement of the year.  For some unknown reason, she adamantly refused to go to the dentist.  I visualized myself with a sturdy pair of Kelly clamps and a half gallon of novocaine, removing bad teeth like a vigilante in the name of Truth, Justice and Dentures.  I would not have been surprised to see a maggot crawling by her 2nd or 3rd molars.  Why do methamphetamine users always have the worst teeth?

Hooked On Antibiotics

I can't get over the amazing number of clinic patients who believe that antibiotics will cure all the evils of the world.  They come into clinic demanding antibiotics and if I don't give it to them, they'll make an appointment with another doctor who will.  I'm getting tired of trying to explain how a huge proportion of respiratory illnesses are caused by viruses, and that even if antibiotics are warranted, it's important to choose one that is targeted toward a specific type of bacteria.  This town is teeming with people who are hooked on antibiotics.  One lady even requested antibiotics for "fatigue".  So don't blame me, tiny town of Tonasket, if one of you falls prey to a super-resistant bacteria that was able to flourish due to handfuls of amoxicillin and azithromycin being thrown around here like confetti.

Now that I have succumbed to the respiratory virus that has been nipping at my nose & throat, I have even less of an inclination to prescribe antibiotics for most respiratory infections because I know that antibiotics would do absolutely nothing for my nasal congestion, cough and laryngitis.  I got sent home early from clinic Wednesday when I lost the very last remnant of my voice.  Try dictating hospital discharge summaries over the phone when your voice is an unpredictable mess of screeching, warbling, and honking...it ain't pretty.  When I returned to work on Friday, my voice had recovered to about 35%, so I was trying to speak as little as possible.
Ancient elderly male patient: You speak really good English, especially for someone from China
[note: I have never even been to China]
Me: [thinking, "Are you freakin' kidding me?!", but instead saying...] Thank you?