Night Float

6 p.m. My evening started off innocently enough. I am on “night float” this week. A position anywhere else in the world which would consist of putting out minor fires and tucking people in for the night. I the world of Rural Alaska Family Medicine, there is no such this as easy. Our first patient had been brought in by medivac from one of the local villages at 29 weeks into her pregnancy with relatively few concerns until a week’s worth of abdominal pain came to a head.

Now, before we discount the poor woman’s choice for waiting this long to come in, please understand that the flight across the wetlands and roadless miles that make up the Delta is not cheap. Also understand that we have a resilient breed out here in Western Alaska. I have seen a child brought in for wrist pain only to find out that he had broken his wrist nearly two weeks previously and was only coming in now for attention because they had been out at fish camp. (We had to actually sedate him and re-break his wrist in the ER, as the orthopedic surgeon in Anchorage wanted us to give it a try before we shipped him in.)


14 mg of morphine on the way in, and a heart rate of 160, twice that of a healthy person. This was one sick woman.


As she lay in one room, teetering on the brink of multi-organ failure and sepsis, our next patient had come in, a 41 year old G13 P11 (that means thirteen, yes, thirteen pregnancies and 11 living children) also in her 29th week of pregnancy, who hadn’t been feeling any pain, as a matter of fact, she hadn’t been feeling anything. No movements for several days and the village health aide couldn’t find any heart beat when she arrived. As she lay on the table I passed the ultrasound wand over her obviously pregnant belly. I found the head, limbs, abdomen, and not a single beat was heard. Per the professional sonographer, it was fetal hydrops, an unexplained death in utero. A plane had been activated from Anchorage to take our patient in for immediate surgery for what was likely an appendicitis. This woman also needed a ride to town.


It is now 8 p.m.

A quick note...

The events of the past few days have been exhausting. I have been working "night float" in our local hospital here, admitting acutely and chronically ill patients, monitoring children wiht rare viral infections, and delivering babies with complicated and potentially dangerous prenatal histories. Additionally, I have been trying to make the best of my short time on the Delta flying with the medivac crew during the day. Needless to say, I have had approximately 8 hours sleep in the past four days, and have a plethora (Hefe, do you know what a plethora is? Yes El Guapo. Tell me Hefe, what is a plethora.) of stories to tell. All in due time.

In the mean time, great thanks to Tunda Medicine Dreams and Blogborygmifor including me in their weekly Grand Rounds posting. Check them out for more medical stories and associated interests. To the couple hundred new visitors over the past couple of days, I hope you enjoy, and check back in the future.

A couple of funny things...

I'm a hairy guy. Literally, not figuratively. Mostly this entails my arms. They are wooly like the day is long in the Alaskan summer. Angora sheep send me hate letters. The only two places I don't grow hair effectively are on the top of my head and the tops of my feet.

Although the hairless fashions of the day have prevented my modelling aspirations, there are many benefits. This is not a complete list

1) Warmth. I don't get as cold in the long dark winters.
2) Protection from mosquitos. The difficulty of navigating the maze of my hair folicles is hardly worth the sweetness of my type A+ blood. (Oh yes, I am sweet, like sugar)
3) Women like to pet me. There is something comforting about a hairy guy, like that warm quilt your grandma made, with the velveteen lining.
4) Extra sensory powers. I know when you are trying to sneak up on me.

Finally...

5) Yupik children adore me. They have never seen anything like my hairy arms. They are fascinating. Yupiks are surprisingly quite hairless, at least in a body hair kind of way. The children look. They smile. They giggle, and they reach out to touch. I tell them it keeps me warm like a bear or a musk ox. They think I am funny. That makes my job easier.

Please note the Friends links are finally updated. My apologies to my wonderful friends who have kept their links current. If you have ever thought about writing a blog, check this page out first.

Pimp my ride - Hovercraft Edition

Transportation throughout the Delta has been an issue since villages began to settle within the last century. The Kuskokwim and Yukon Rivers, along with their tributaries behave like highways, filled with boats during the summer, and snow machines or trucks (yes Martha, they build an Ice Road on the Kuskokwim) during the winter. The road often extends to Aniak, nearly 100 miles away. This time of year, however, transporting large items is a little more difficult. Barges can only go so far up river, and daily boat service can be quite encumbering.

Solution??? Hovercraft. That’s right. The back pages of Popular Science and the prospects of building my own personal hovercraft from a few simple materials and a vacuum cleaner engine have arrived. The future is here on the Y-K Delta. They travel the river in summer and winter delivering the needs of the outlying villages.



Alaska Hovercraft (a subsidiary of Lyndon Transport, one of the big cargo companies up here) has a 40 ton capacity, British built, former Marine carrying hovercraft in operation supplying the villages of the Kuskokwim River. For a modest fee, you too can travel the river at rates greater than 30 knots (alledgedly it can reach 40-50 knots). Bonus, if you are an “elder” such as the two members of our party who will be code named “Mom” and “Dad”, you ride for free.

When the morning fog boiled off, we had a beautiful blue sky day and spent the afternoon visiting the villages of Kwethluk, Akiak, and Tuluksak. Unfortunately we didn’t have much time to walk around, as our stops entailed unloading such staples as chips, soda, Tang, ramen, and the US mail. The ride alone was worth the trip. As far as hovercraft being a practical means of transport…the future is now.

Part Deux

The syringe filled with blood. Evidence that the .22 cal bullet he had fired through his own chest had nicked his lung. I quickly finished numbing the incision site and the flight medic proceeded to place a chest tube. (I was disturbingly jealous that he did the procedure, but know that they need to keep their skills up as much as I do.) Our patient was surprisingly thick. One cut didn’t do the job. As the medic worked his way toward the chest wall he found his landmark (4th – 5th rib on the axilary line) and cut into the pleural cavity. With a wealth of experience behind me, I deftly stepped to the side (I was holding the patient down) and avoided the gush of blood that shot out of his chest. The chest tube was quickly worked into place and blood flowed readily into the reservoir attached past the 500ml mark. Lung sounds improved. Mildly. Oxygenation improved. Mildly. A call was made and our patient was going to head to Anchorage. Surgery was in his future.

We loaded him onto the trailer, behind our four wheeler. Two of us sat astride the rear wheels and two sat in the trailer with the patient for the short ride back to the airstrip. Our next stop was St. Mary’s, a village with an airstrip large enough to accommodate a small jet which would complete the transport to Anchorage. As our plane lifted off the runway, low on the horizon was the deepest blood-red moon I have ever seen, backed by the number of stars that only a location this remote and this dark could present (galaxies…I could see galaxies). The orb barely rose above the tundra, appearing as a warming fire in the distance on this cold night. Turning to look back the opposite direction, towards the village, I also noticed a thin blue vein dancing across the sky. My first sighting of the Northern Lights, this year. Fascinated, I watched the ever-so-slight dance as we headed south to St. Mary’s.

The story ends with a 3a.m. return, lack of sleep, and an appreciation for small caliber gun shot wounds. Sadly this is not the first time I have flown to pick up some one who managed to “wing” themselves with a rifle. Suicide and suicide attempts in the villages are far too common. Is this the result of western influence? The TV showing teenagers a lifestyle they can’t have? Simply (or not-so-simply) a substance abuse problem? A result of the lives that were spirited away to BIA schools, leaving their culture and family behind? Something that has always been present, but not acknowledged due to the lack of a written history and the color of oral tradition? I don’t know. Our patient is still alive. The family member who encouraged him to shoot himself, while they were both drinking heavily, has to live with his influence. I’m glad that our patient’s young son still has a father. That means a lot to me these days.

How do you keep good friends and loyal readers in suspense?

I'll tell you tomorrow. Sorry, it is too late to write tonight. I have just finished Life of Pi by Yann Martel. Fantastic book involving religion, a boy, a tiger, and a life raft. Read it now. More on the story of my flight to Kotlik and our hovercraft (yes, you heard it right...hovercraft) ride from last week hopefully tomorrow.

Me picking blueberries. Sweet, sweet blueberries.

Part One

with the sun riding low across the western edge of the Delta. The lighting was beautiful, but made it damn near impossible to see out my window. As we headed North, the flat marshy landscape of the Kuskokwim valley gave way to the hills (closest thing to mountains I have seen in weeks) and trees of the mid-delta range. We flew between 500 and 1000 feet, gliding along side the tops of these hills as we wove our way down small nameless valleys. With the sun setting, thousands of lakes and ponds below us appeared nearly black, without reflection or depth.
Kotlik is 143 air miles from Bethel. Our longest single flight from the center of the Y-K Delta. As we approached the village, the pilot circled around the end of the airstrip and cutting into the hazy atmosphere above the village pulled nearly 3 Gs around a turn which buzzed the clinic to let them know we had arrived. Everyone in town knew we had arrived.
On the ground, Kotlik was a much more hospitable village than many to which I had been. The mud was absent, as the entire town rested on pilings and boardwalks. A long narrow artery led through the center of the village with tendrils reaching out to each house and building. It was late, but nearly every child in the village was awake and playing on the boardwalk in some manner. We slowed on our four wheeler only to avoid flattening little pink bikes ridden by little girls. Upon arrival at the health clinic, out patient was curled up on a couch in the front room. Grumbling, he slowly moved to one of the exam tables in the back where we could better evaluate the extent of his poor judgement. A small hole, about the size of a pencil eraser about 3 finger breadths above his left nipple matched a mirrored copy just medial to his left scapula. Decreased breath sounds at the left base, and a slowly falling hematocrit reminded us that his lungs were filling with blood.. As I numbed the location for our chest tube, I pushed through the chest wall, drawing back on the syringe and revealed what we had anticipated.