Tuesday, February 24, 2009

Best in Snow

Sunday was the 5th annual Bethel dog show. The town seemed abuzz with some kind of hidden energy. Eric and I had journeyed into down so he could purchase groceries at A&C, one of the two grocery stores in town. We had wandered the isles for some time, evaluating the choices that had so much financial implications. I kept my distance from Eric as he took photos of the prices. At the end, he eyed the cache.

"Think we can do it, or should we call a cab?" he asked. The hospital had given us $5 cab vouchers. The cab companies were subsidized by the government, so any ride in town cost only $5 per person, no gratuity required. However, we were running low on vouchers, and were thus conserving our trips. The grocery store was a little over a mile away, so it seemed relatively manageable on this relatively calm day. We decided to walk. Eric filled his rucksack with the heaviest of goods and we split the rest. On the way back, we passed a man, possibly a YK employee) chipping away the ice on the boardwalk.

"Dog show's today," he said as we passed. I'd been hearing about it for some time. I was told it was quite the spectacle. On the way home, Eric stopped to take a few pictures of some graffiti on a dumpster.

Eric taking a few photos of the dumpster.

When we finally arrived back at the house, our arms were exhausted from carrying the goods and running short on time before the dog show. We needed to get there quickly, and so, shaking our heads from our lack of planning, we called a cab. Instead of using the cab vouchers to help us carry the groceries from the trip back, we'd use it to go just half the distance carrying nothing.

The dog show was entertaining. I was surprised to find the cultural center packed with people. I found a seat in the back row next to Mark, the LifeMed medic. Before long, there were no seats left--people began lining the walls. Dogs barked from backstage. There were numerous categories, including toys, working dogs, and sporting dogs. Also included were categories such as "Best Tail Wag," "Best Trick," "Best costume," "Most Independent," and "Most Obediant." Of the latter, there were no entries.

Bethel residents brought out their dogs, marched them around the room, and lined up. The panel of judges (who received much applause on their entry) stood alert and appeared studious with their clipboards. Typically there were five or six dogs in every category. Aside from two pure bred pitbulls, a black lab, and a pure bred huskey, the "Bethel breed" dominated the population, the star being a huskey dauchsund-mix. The audience clapped their hands enthusiastically for the winners, roared with laughter when dogs escaped their collars and found more interesting things to do than perform, and took plenty of pictures. The winners came away with tiny trophies, dog biscuits, and medals. Everyone--winners, losers, and audience members, left smiling, waving and hugging each other goodbye after the event. It was another example of a small community coming together to create an event that was simply pure fun.

Sunday, February 22, 2009

Pharmacist vs Wild

-- Yup'ik word, meaning "to be persistent when faced with difficulty."

I spent the morning seeing pediatric patients with Beverly Burden, who had graciously taken me under her wing for the morning. I enjoyed working with kids and found them easy to provide for, as long as I wasn't about to inject them with something. The YK region (about the size of the state of Oregon) sees a lot of skin infections, primarily MRSA, and thus I'd seen plenty of mupirocin and hydrocortisone topical agents being prescribed. I was reviewing a chart when Beverly ran in.

"LifeMed's getting ready to fly," she said. "They're taking off in half an hour--if you're not there, they will leave you." I thanked her and darted to the pharmacy for my coat. LifeMed was essentially the YK ambulance for outside of Bethel. Should an outlying village need help, LifeMed was ready to dispatch its paramedics and transport the patient back to the hospital if needed. I raced over to my coat, threw it on, and explained hurriedly to the pharmacists where I was going. Soon I found myself in a taxicab on the way to the airport. I was unsure where the medical hangar was and thought for sure the experienced Bethel cab driver would know. However, he had no idea. After finding every hangar except the medical hangar (including the National Guard hangar) we stopped to ask the cargo flight crew where the med hanger was. I was sure I was going to miss the flight, but after asking the cargo crew, they pointed to the big white building next door. I gave my cab driver two vouchers and ran across the ice to the medical hangar.
The EMTs were getting ready and ushered me through the door. We made our hurried introductions as we jumped on to a Cessna 280. There was Mark and Mariso, the EMTs, and Taka, the pilot. The plane was loaded with the usual emergency equipment, stretchers, hypothermia gear, etc.
"We can do basically anything in the field," Mariso explained to me. "We're given a great deal of liberty since we might be hours away." He showed me their pharmaceutic pack. It was filled with drugs from nearly every class. Since it might be hours (or days, if they were delayed by weather) before the patient would see the hospital, they were equipped to stabilize and begin managing nearly every medical emergency. I asked where we'd be going.

"Kotlik," he said. He handed me a copy of the flight plan. Kotlik was a small village on the Yukon River with thirty to fifty buildings, a small airstrip, and not much else, up in the very Northern corner of the area YK served. It was about 154 nautical miles from Bethel.

We took off and flew at approximately 4,200 ft, traveling at about 160 knots. The trip took about an hour. Underneath us, I watched the barren Alaskan tundra roll by. Not a tree, shrub, or moose speckled the perfectly snow-painted ground. Tiny frozen rivers weaved in an out, flowing to and from the small lakes. Presently we passed over sparse forests and I wondered when the last time, if ever, that a human had walked on the land beneath me. I was now further North than I had ever been before in my entire life.

View of some Tundra on the way to Kotlik.

Blinded on the way back to Bethel.

We arrived in Kotlik and loaded up a handmade dog sled with gear, climbed on, and rode into the village, powered not by canine mechanism, but by snow-machine. It pulled us over the small ridges and around corners fast enough to make the 18 degree temperature feel much more like -20. I braced down the equipment. "You'll have to tell your pharmacy buddies about this one," Mark said, riding on the back of the sled, where the musher would. "I bet they all wouldn't do this." We hit a large bump, sending myself and the gear a foot into the air. I landed hard back down on the wooden sled. I pictured some of my fellow students doing this and figured Mark was probably right.

We past several dozen small buildings, each supported above the permafrost on pillars just like in Bethel. But where the buildings in Bethel were relatively well maintained, there were several buildings in Kotlik in desperate need of repair. Aluminum siding was braced against the sides of many buildings, not unlike some of the village housing I'd seen while in Fiji. Snow covered everything. A husky gave us a few welcome barks from on top of a large stump. Several people were walking around, looking toward us as we passed by, our nylon parkas, brightly colored bags, and sense of urgency contrasting greatly with the environment around us.

On arrival, we stabilized the patient and began our return to the airport. The people of Kotlik were kind. The kids were listening to iPods. I would have liked to explore more, but we were obviously not there to sight-see. I jumped up in the co-pilots seat for the flight back. The sun penetrated the windshield easily. The sky was perfectly clear, making it easy to the ground. I wished I had my favorite sunglasses, since I spent the hour and a half-flight back squinting.

I imagined myself in a different situation--as the patient in a village who had to have the village call the EMS after an accident. I would wait for hours before they arrived. The weather, unlike today, wouldn't be the ideal, perfect visibility conditions, but one of the frequent torrential blizzards, which would delay the return to the hospital. The pilot, constantly having a plan B, or C, would turn the plane around to a safe place to land, but the EMTs would have only so many resources available to them. For some people, this is a very real situation.

Then why live out here? Why live in the middle of nowhere, without running water, away from help, where one must trap, attempt to farm, and fish to guarantee survival. The answer I obvious to the people who do this. They do it because that is who they are, and that is how it has been done. This kind of continuous survival has instilled a kind of genuineness that is so easily lost with convenience. It is something to learn from, and during my last bit of time here, I plan to soak it in as much as I can.

Wednesday, February 18, 2009

Fast Change

When the temperature drops so fast like that, it means someone has died or is dying on the tundra. Just today a man was reported missing from one of the villages. --Roxanne, Behavioral Health Clinic, Bethel, AK

Where yesterday was easily negative thirty without windchill (they're saying it was -50 with), today the temperature has again shot back upwards to near 30. I had heard it raining last night for the first time since my arrival in Bethel and awoke to find everything coated in 1/8" of dense ice. I half walked, half sailed my way to the hospital this morning, hearing the thin layer of ice on the snow shatter under my feet with every step. I didn't find the temperature change annoying--more amusing, since I'd never experienced a sixty-degree temperature change in fourteen hours.

The wind and rain didn't really come across well in this video, but I thought I'd experiment and post it anyway.

With Eric's persistence motivating me, I had called the internet provider up here to see if we were supposed to have service. They claimed we were, and sent someone out yesterday to repair it. It's not a fast connection, yet it is faster than at the hospital, so I'm hoping to be able to upload things easier. At any rate, I should at least have more opportunities to get online, which will make email, my PharmD project, and general communication much easier.

Tuesday, February 17, 2009

Will Wander for Experience

"When I was a kid, we were somewhat nomadic," she related. "We went to fish camp, we had a summer and a fall camp and a winter camp, and we traveled far. We also had a permanent home in Bethel. Respectfully, traditional people were taught to leave camp areas better than they found them. There is no evidence at all of my family ever being in those places, because my dad kept the camps up well. Life seemed very carefree and peaceful then."
-- Yup'ik Mary Stachelrodt in Lowry's Natives of the Far North

I recovered slowly, but more or less fully from the "Bethel Crud," and had been looking forward to my three day weekend. Saturday morning I woke and hopped in a cab to watch the Bethel Shotokan Karate Club practice.

I arrived in time to see a fairly large group of kids finishing up their practice, practicing Heian Shodan. The kids practice was before the adult practice. I was pleased to hear them counting in Japanese and watched as a few kids practiced with very focused expressions. Soon the practice concluded and the instructor came to greet me. He introduced himself as Ted Berry and talked a little about their practice. They were part of the International Shotokan Karate Federation, a branch of the JKA, which had split from the SKA, the organization to which I belonged, several years ago. I watched the adults (and older kids) practiced and although the practice was different from my own, it felt like home hearing the kata being announced, the cry of "hajime!", and the sound of over a dozen karateka kiai in the dojo space.

There were significant differences as well--the movements were very diliberate, almost as if each kata were being counted by the movement instead of the kata as a whole, they "popped," making their gi snap with each movement (though not as much as some JKA karateka I'd seen), and they waited for the instructor to announce before they began their attacks in kumite. I had seen these differences before in karateka coming to practice with our SKA group. I was invited to attend Monday's practice and did so. I enjoyed the kata practice. Ted came up to me and said "I notice you don't wait very long in between movements," as a general observation, which was undoubtedly correct, comparatively. I knew that sometimes I had the tendency to short-change movements for the benefit of continuous feeling throughout the kata and took the opportunity to attempt to make each technique correctly. It was a fun practice with kind people.

My new roommate, Eric, arrived on Sunday. A pharmacist currently living in Seattle, he had spent some time in Anchorage and signed up for a 2 month stint in Bethel at YKHC. He enjoyed photography, and within an hour of his arrival had removed his camera equipment and was educating me on "camera tossing" and "water world," two new methods he was interested in. Camera tossing is done at night, where a neon sign is the target of the shot, the shutter is opened for a second or so, and the camera is tossed in the air, so that the result is a swirls of color. That night, he practiced taking "water world shots," using a glass illuminated by a light in a dark room, taking pictures of the ripples and patterns the light made. He maintains a website of his photography as well. He seemed like a nice guy and I anticipated a pleasant two weeks with him.

Sunday night one of the pharmacists, Greg, picked me up and took me to his home to show me some of the processing that occurs after an animal is trapped. It's been a record year for Greg, trapping a total of 17 lynx, 2 wolves (with the help of his partner), plenty of fox, and a handful of mink. Compared to the lower 48, he explained, much of Alaska was virtually overrun with wildlife. He insists trapping has not had a negative effect on the population as a whole. Regardless, I was interested in the cultural learning opportunity ahead of me and proceeded to help him skin a lynx, which definitely goes down in the books as something I didn't think I'd be doing on my clinical rotations.

He and his family welcomed me to stay for dinner, where we had a Korean dish made with caribou. It was tasty. I drove Greg's Durango back to the "prison row" housing, which was somewhat daunting considering it was snowing a thick, wet snow, the roads were slick, I was in a vehicle I'd never driven before, in a town I'd never driven in, and was without any form of identification. But I made it back without incident, left the keys in the ignition for him to pick up the next morning, made sure the doors were unlocked and went in to go to sleep.

Monday the temperature dipped from the low 30's to the negative teens. A howling, 45mph wind had picked up during the night and had frozen Greg's doors shut, effectively locking his keys in the car. After some struggling, we managed to get it open using some boiling water along the seam of the door. Mandy showed up and we attempted to enter one of the respiratory therapist's house to get her birth certificate, which she'd left by accident before leaving to Anchorage. We were unsuccessful. Security here, it seems, is pretty tight.

This morning the temperature fell to -27 with 5mph winds. It will make for a good trip when I wander over to behavioral health to round with a nurse practitioner there.

Friday, February 13, 2009

When Providers Become Patients

"Everybody was healthy then. Gee, we'd come down from spring camp in the hills and we'd get to Akiak and we'd look at the people who stayed in Akiak and they'd look pale. I asked one of my uncles if he was sick all spring. 'Nope,' he said. All the rest of us were sunburned and weather-beaten--healthy."
--Carl Kawagley, Bethel, Alaska

Respiratory issues are not uncommon, particularly in cold areas. Frostbite doesn't just occur outside the body. When the temperature drops low enough and the conditions are right, the tiny alveoli in the lungs can freeze, leading to infection, COPD, and other respiratory issues. I'd seen a few cases of it since I had arrived in Bethel.

Of course, one of the potential problems with traveling to a far away place is first time exposure to new pathogens. This barrage of primarily cold virions leads to what has been called "The Bethel Crud." I was not surprised when I started showing minor cold symptoms several days after arriving, but I rapidly improved to a near base-line condition as the days progressed.

Until several days ago, when I had suddenly found myself feeling very sore, weak, and cold. I didn't have a thermometer available at the house I was staying in, but shivering in an environment that is room temperature is a sign the body is trying to increase its temperature more than normal. I bundled up and crawled in to bed, hoping the soreness would subside by morning, as I knew it would be a busy day.

I didn't have to wait until morning to wake up. At 02:12, I found myself tossing and turning, sore, and feeling very feverish. After a few minutes of struggling, I pushed the blankets off, crawled out of bed, and stood up--and nearly fell over. Bracing myself against the wall, I assessed what was going on. Difficulty forming thoughts. Not entirely unusual, but something seemed amiss. Sweating, yet freezing. That was definitely unusual. I hurt all over. Had I been in an accident? No. Did I just return from a hard practice or was I recently knocked unconscious during kumite? No. Definitely unusual. Head pounding. I rarely get headaches. Any new medicines? No. Sign and symptom identified: FEVER. Letting a fever run for a while isn't necessarily a bad idea in some cases, but since I was having obvious nervous system impairment, I decided it was time to halt the process my body had deemed necessary.

Leaving my primary diagnosis undiagnosed for the moment, I found my way to the cupboard and removed a bottle of tylenol that had been stashed there. I wondered which temporary clinician had brought and left it--had it been one of my fellow pharmacy students? I wasn't sure, but I took 1000mg and gulped a glass of cool water, sitting myself down on the couch. It was definitely difficult to think, uncomfortable to move (or sit still), and my head throbbed. I dipped my finger in the water glass and ran it around my neck, feeling the evaporation cool my body. I sat there for an hour, tried to read Pharmacy Times, found it impossible, and resulted to watching bad late night TV. An hour and fifteen minutes later the symptoms had diminished somewhat, but where not completely gone. Okay, I thought. Plan B time. I pushed myself up, turned the shower to cold, and hopped in. I alternated between warm and cold water until I felt the fever had broken, and got out of the shower. I toweled off, felt better but not great, and went back to bed.

The next morning I felt like my head was heavy but made it in to work. As the day progressed, I became more symptomatic--headache demanded I acquire some of my preceptor's tylenol.

"There's both acetaminophen and ibuprofen," she said, handing me a bottle. "It's all in the same one." I stared at the bottle. Tylenol and ibuprofen both in the same tablet? I was having trouble thinking straight again.

"What, together?" I asked. She looked up at me and shook her head. I popped open the bottle and clearly saw two different kinds of tablets, a pharmacy faux pas. "Oh. Together as in you put them both in the same bottle." She asked if I was going to make it and I assured her I would.

Later that day I decided to go home early and rest. I felt more rested the next day, but my symptoms had not improved. I increased my hand washing regimen to its highest alert status to ensure I wouldn't contaminate anyone while on rounds. My voice quickly degraded, until I was barely squeaking. I soon began a non-speaking role. At the end, a physician asked me why I hadn't gotten antibiotics and for the first time, I took the time to put all the pieces together:

Fever. Headache. Pressure on sinuses. Heaviness, especially when leaning forward. Phlegm, color: greenish. Post nasal drip.

Probable diagnosis: Bacterial sinusitis
Practical Treatment: Augmentin 875mg/125mg 1 PO Q12H x 10 days

I found myself creating a chart (with the help of the people up at reception) and soon picked up my prescription, where Steve, a pharmacist with a sense of humor, had thought it funny to place the "Antibiotics may decrease the effectiveness of oral contraceptives. Use an alternate form of contraception." sticker on the bottle.

Though my voice hasn't totally returned, I am finding myself feeling much better and plan to be tip-top on Tuesday. I'm reminded how easily it is for care providers to let themselves go untreated. It was interesting to see myself "in the system" at YK and to have a reminder to look at things from the patient perspective.

This weekend is the open market, which I am going to attend after watching a local karate club practice.

Monday, February 9, 2009

Alaska Has the Greatest Number of People Walking To Work

"When we hunted by kayaks we went in pairs, two boats together, but many boats going out. Sometimes we would catch five seals, put them in the kayaks and paddle back to camp with the kayak very low. Water almost over the deck. Slow paddling! After seal hunting and the drying of the herring, in the middle of the summer, we'd move back to the village. And then, get wood, driftwood for heat. All the time coming and going. I could paddle for many hours and not even get tired."
---Dick Lawrence, Toksook Bay elder, excerpt Always Getting Ready

My first weekend in Bethel was relaxing. The temperature dropped back down to it's normal twenty below-zero, calming the land like a giant atmospheric blanket. The one exception to this seemed to be my roommate, Erik, who was busy triple-checking his luggage. He would leave that afternoon.
Though the temperature might have dipped into it's normal range, the wind had picked up, sending great swirls of snow into the air, bending the shrubs outside and testing the aeronautical ability of the raven, a life form that seems to be able to subsist anywhere--the arctic tundra no exception. Erik looked nervously out the window, no doubt wondering whether or not an airplane could take off in the weather. I suggested the impossible notion our weather was due to Mt. Redoubts eruption, making him cringe. He had been keeping himself updated on the volcano's status for some time, but it had remained the same: possible eruption, time frame unknown, severity unknown. As the morning progressed he became more anxious. When one o'clock came, he had his bags ready to go, wheeling them out the door at almost the same instant I opened it for Mandy, who was taking him to the airport. He shook my hand, and with that, he left Bethel.
Or not quite. For apparently, when he arrived at the airport, the visibility was too bad for a Alaska-inexperienced pilot to try to land. The plane had turned around before it had arrived. He spent some time exploring his options instead of simply waiting for the next flight, even inquiring the possibility of chartering his own. Mandy had left the airport after waiting for him for some time. Erik never returned to the shack we had shared for the week. And so, based on that evidence, he eventually made his way out of Bethel, AK.
I spent the morning cleaning up the small house. Due to it's frequency of temporary tenants, very little had ever been done to ensure a hygienic environment. The material I removed from the bathroom could have made a biohazardous waste employee stagger in shock. After I had upgraded the building's status from "Fallout Zone: Do Not Enter" to "Rehabilitation Area: Proceed With Caution," I set about doing some projects for the day until the evening.
That evening I had planned to go with Beth and Alexis, both pharmacists, to see the Bethel Actor's Guild presentation of The Wizard of Oz, in which Mandy was assigned to be the accompanist and projected several of my other fellow health care workers in various roles in the story. For the $20 admission price, you might expect ushers, stadium seating, and the like, but the performance was held in the Cultural Center, on a staged pieced together with angled platforms and boasting padded folding chairs for the audience. Though by itself it wasn't a fantastic performance, there were a few excellent actors tossed in the mix, the largest value of it being the ability to see one of the recreational options available to the people who lived here. In the end, Toto growled at everyone, the wicked witch had a perfect laugh, and Dorothy delivered all her "oh!"s and "oh my!"s to a T, and was worth the $20.
That evening I made my way to another shack on "prison row" to hang out with some of the other health workers, listened to stories, and learned some interesting things about the town. The next day, I decided to walk into town and buy some more paper towels (I had ran out relatively early in the sanitation work the day before) and a few other necessities. I made my way down and passed raised building after raised building. Upon reaching my destination, I found several chunks of ice frozen to my eyelashes, eyebrows, and unshaven face, despite much of it being covered up.

Travel is an important part of life for the people here. Whether or not one lives in an outlying village or not, long distances are traveled both on foot and by vehicle. People so elderly most Americans would be surprised to see them standing are frequently walking miles to do basic tasks. It is a hunting/gathering/nomadic culture, and no one seems to complain. I do think, however, that the majority of people would never expect the kinds of conditions that exist here to be present in the US, much less North America. I found this to be highlighted, to my surprise, on CNN today: http://www.cnn.com/2009/US/02/09/rural.alaska.villages/index.html
It is, without a doubt, a completely different culture, and a valuable one to see. Greg, a pharmacist, stopped by not long ago and delivered the news I'd be traveling to one of the villages on Wednesday to investigate the mysterious disappearance of narcotics from a clinic there. We'll see what happens.

Friday, February 6, 2009

...And he began to feel some movements on the surface of his skin. When he looked, he was covered with fur. Continuing on, he thought to himself, "I was a human a while ago. I am so embarrassed, I should be living in the wilderness."
-- excerpt from Yup'ik story of the fox, told by Alma Keyes
The temperature can change quickly in Bethel. Not long ago it had been a comfortable -22 degrees. Overnight, the temperature had soared to a scorching +26 degrees. The snow, as it fell, had become wet and sticky, people began to walk around with jackets unzipped (or even without) and vehicles tended to leave a lengthy stopping distance between them and the next vehicle.
The small house my roommate and I share had abruptly won the battle against the cold outside; with the previously-set maxed-out thermostat pumping heat out endlessly the temperature inside rocketed towards 85 degrees, no longer suppressed by an external Arctic temperature. Prior to then, despite the thermostat's setting, the best heat we could muster was a comfortable 63 indoor temperature. However, it wasn't just our thermostat that suffered.
As a health care provider, I've often noticed unusual cases popping up when a sudden temperature change occurs. Whether this is to barometrics, actual temperature, or my own delusions, I'm not sure. Regardless, I'd been scheduled to follow Dr. Hartman, a resident physician, during the day. Each patient I saw seemed to present unusually to me. There was unexplained recurrent bilateral sinusitis, somatic patellar pain, and aneurysm induced nocturnal anxiety.
Beth, a pharmacist here, was kind enough to take Erik and I out for lunch. Bethel, it seems, offers a wide variety of foods. There are Greek, Japanese, Chinese, Italian, Mexican, and traditional American options in town. The only chain restaurant I've come in contact with is a lone Subway, tucked away on a side street. Sushi was our destination and we were not disappointed. Though I'm sure the fish had been frozen (as most things are here), it tasted relatively fresh and was prepared nicely. Beth then asked if we'd mind if we might stop by her house and take her dogs for a walk. I was eager to be reunited with the polar-bear-sized yellow lab I'd met at the superbowl party, so I didn't complain. We arrived at her house outside of town, where a 20ft high snow pile sat in her yard.
"I should have realized why everyone was parked on the road that the weather was going to be bad earlier this week," she said, pointing at the snow. She explained the plow had come by and blocked in her driveway, causing her to have to hire out the bulldozer to free her in time for her shift. The polar bear, Blitz, bolted towards us from the living room, in the process knocking everything off the coffee table with his massive tail, which was frantically waving side to side. He bounded out the door and into the snowy yard after Daisy, Beth's other dog, a terrier.
Soon it was time to leave and we readied ourselves for going back to work. "I hope I have my keys," she said as we walked back to the jeep. She searched through her purse. "You know what's funny? I don't." She turned and stared at her own house, the door firmly shut behind her. She expression was blank, as if she were watching a movie.
She soon called her husband, who worked nearby, who retrieved the keys for us. Afterwards he gave Erik and I a tour of his cleaning shed, where he cleaned and prepared all the animals he caught. His students were busy making caribou bratwurst. They boiled one up and provided me with a sample. Attempting to block out the scent of gamey flesh emanating from the unprocessed goods in the shed, I found it to be delicious.
I finished the day (and the week) counseling patients and updating this blog, which I had originally planned to have finished two hours ago. This weekend, the Bethel Actor's Guild is putting on The Wizard of Oz...I think I'll go.

Thursday, February 5, 2009

Going With The Flow

We the People, are not feeble.
Alazsxaq, Alyeska, Alaska is our home, the seas comb.
Hear her heart pounding loud and proud, over and under every cloud.
Creatures of the Great Land, high and low, go with the flow.

---- excerpt, Alaska the Wild, Maricia Skinna

The past two days I've been attending mandatory orientation for every YKHC employee, regardless of the length of time they are there. There have been some interesting presentations on culture, as well as general information about YKHC, which has been useful. Other sections, such as those on privacy, safety, etc., are not unimportant, but a little redundant for someone who has had training in those areas previously. However, it was nice spending time with some of the other new employees and getting to know them.

They come from everywhere--there are two optometry students from Quebec, nurses from Florida and Texas, and locals from Bethel--all here for either a short stint or a long term commitment to YKHC. All of those attending have a strong desire to help others--that much is clearly evident in their personalities and manner of speaking.

Last night I decided it was finally time to break the ice, so to speak (although literally as well), and buy some milk to drink. Many natives are lactose-intolerant. Cattle do not flourish well here this far North (though musk-ox, caribou, and reindeer do quite well), and this leads to the relatively high price for milk. My 1/2 gallon of 1% was $6.43. I could have sprung for the gallon--$9.75, but for whatever reason I was unsure I'd drink that much before it expired. There must have been some kind of subliminal fear of kidney stones. Regardless, the trip down to Swanson's (the grocery store) was easy. The store offers a wide variety of food and the taxi trip was easy. Good to know things are available if I need them--and am willing to pay.

Tuesday, February 3, 2009

Yukon Kuskokwim Regional Hospital

Yukon Kuskokwim Regional Hospital

As to my credentials, I do not hold a master's or a doctorate, but I am a Yup'ik Eskimo and I was born into a world which no longer exists.

-- Harold Napoleon, Yuuyaraq: The Way of the Human Being

My first full day in Bethel went well. I had slept soundly through the night and had gotten up with plenty of time to stretch, practice a few kata in my limited space (how fitting the kata of the month would be Tekki!) and got ready to shower. I consider myself relatively up-to-date with plumbing fixtures and had seen a good share of quirks here and there, but for whatever reason I found it completely impossible to turn the shower on.

The knob twisted, but would not pull out, nor push in. No other button, lever, or dial was in site; I even tried flipping an extra light switch. Later I heard my roommate Erik get up and go into the bathroom. Seconds later, I heard the shower turn on. What had I done wrong. Soon after, Erik described the proper technique. "The first shower I had here was barely a trickle and was either scorching hot or frozen cold," he said, resting my concerns that perhaps it was me that had the problem. Still, he had at least gotten some liquid water from the pipes. The secret, it seemed, was to stand in the shower, grasp the knob with one hand, brace your body with the opposite hand on the shower wall, place one foot on the wall near the shower fixtures--and pull as if your life depended on it. This proved successful and exactly three minutes and forty-one seconds later, I was clean.

We walked outside toward the hospital, our parkas, hats, gloves, under armor, boots, and thick socks composing a veritable army against the -17 weather that greeted us. There was very little wind, which was a good thing. When the temperature dips below -15, even a slight wind can cause frostbite in just a short span of time. Our walk was about 5-10 minutes long and took us down the row of provided housing (all up on stilts), past the prison (yes, the housing is just over the fence from the prison), through what was described to me as "the gap in the prison fence," across the parking lot, and into the hospital.

The YK Regional Hospital is small yet the main location for health care for the entire delta. I met Mandy, my preceptor, in the inpatient pharmacy, where she was busy mixing a bag of unasyn. I asked if I could help and she put me to work, only after assuring me that I "won't have to do a lot of technician things. This is not a slave labor rotation." After that we ran around the hospital checking things off of her morning to-do list. I was then given my first project, which surprisingly, wasn't pharmaceutical, but cultural. I was to do a short presentation on some aspect of Yup'ik culture. Inspired by the previous night, I chose snares and trapping.

I had a long conversation with Sara, who works here in the pharmacy about crafting. The culture here is largely sustenance based--very few people simply have a job (which aren't numerous themselves). Sara engraves bone and makes jewelry that is simply astounding. We had a long discussion on Yup'ik culture and she showed me tundra tea--a low-lying conifer that can be picked and used to make tea. "It grows all over," she said, "you don't have to go far." I hope to learn more about edible local flora.

The rest of the United States is very different from here. Time and change has not been kind to the native populations in America. Sara explained how crafting was losing ground. There is something important about becoming good at something and doing it well, over and over. The people here have an understanding of tradition, perfection, and dedicated practice. Their character reflects it as well. Even in the hospital, people are smiling, say hello, and nod their heads. They are patient, caring, and respectful. This, in turn, makes health care a good deal easier for both providers and patients.

Monday, February 2, 2009

A Beginning

A Beginning
The Northward Pharmacist
A woman was inside. She said to her, "The bear will catch you soon! You have to go! But don't go through the entrance, go here!" And she had the little girl open an exit which had been covered up by a wall-hanging.

Then she came out into another world.

--- Nunivak Eskimo story

Each adventure story has a beginning. At the time the beginning is recorded, the ending may have not yet occurred. This is the case with this story.

As a pharmacy student nearly finished with academic rotations, I have had the opportunity to practice pharmacy in many locations, both traditional and nontraditional. When signing up for rotations, I had told the coordinators that I wanted to "get my hands dirty" and experience pharmacy outside of the traditionally thought-of roles. After all, I'd spent hours in retail pharmacies, taking calls from physicians, standing at drive-through windows, and counting out pills and putting them in amber-colored vials. Doubtless, it was an important part of pharmacy practice, and absolutely essential. But I looked at my academic rotations as an opportunity to push my comfort zone, practice medicine in some non-traditional yet essential areas, and to learn more about the world around me.

Therefore when I noticed the entry "Under served: Indian Health Service, Bethel, AK." on the list of available sites for rotations, I was immediately interested. I'd always felt at home "up North," doubtless stemming from my summers in Upper Michigan with my grandmother and two brothers, where wilderness was king, the sky was alight with stars, and the nearest walmart was held at bay by at least the span of 120 miles.

I was lucky. Most of the sites I was interested in were drawn by lottery. I remember feeling a rush of adrenaline when I read "Under served: Indian Health Service, Bethel, AK" on my list of confirmed rotations.

Of course, at the time, I had very little idea of what the Indian Health Service was, what sort of work the rotation would entail, or even where Bethel was in Alaska. Alaska is the largest of the 50 states, filled with many different ecosystems ranging from rainforest (of the subarctic, not tropical variety) jagged mountain ranges to flat, low-lying deltas.

I soon found that the Indian Health Service was a branch of the US Department of Health and Human Services designed for health care for Native American populations. The IHS provided all types of health care, including pharmacy. Bethel turned out to be located in central Alaska in the Yukon delta, near the Kuskokwim river. Bethel serves as a major hub between many outlying small villages, yet can hardly be called a metropolis. No roads lead in to Bethel--the only way to get there is either by plane or boat. The area is flat, pot marked by thousands upon thousands of lakes.

Once the excitement of getting the rotation site I wanted had washed over, I glanced at the time period I'd be visiting the town of Bethel. I looked over at the "date" column, and read:

February 2-27, 2009.

And so, on January 31st, I boarded my flight to Phoenix, Arizona. When I arrived there, the pilot announced it was 74 degrees Fahrenheit. I changed planes, and, six hours later, arrived in Anchorage Alaska, in the middle of the night, where the pilot happily chortled that the temperature was ten degrees below zero.

I had another flight leaving for Bethel, but it wasn't until noon the next day. So I picked up my baggage (since I was told it would be locked away until 5pm if I didn't) and found a bench next to the world record-holding Kodiak bear, his poised stance preserved forever in a taxidermied state. I piled my luggage next to me and lay down. The bench wasn't exactly the same softness as my mattress at home. What they say is true, I thought. Everything IS harder in Alaska. I slept on and off until 8AM. I then did something I'd never done before. I checked my bags and--left the airport.

I'd been warned that groceries were expensive in Bethel. A gallon of milk, I was told, was upwards of 8 dollars. In a land that was very unkind to farmers, all dairy and produce was extremely expensive. Everything had to be shipped in by plane or boat. So I had decided to go shopping in Anchorage, pack up a box of groceries, and take it with me. I took a car to a grocery store near the airport. I marveled at the view along the way. Mountains reached upwards, practically disappearing from view they were so high. Tall, thin conifers stretched skyward as well, blanketed in snow. It was truly a beautiful city. I managed to muscle all of my groceries in a box, taped it shut as if there was a wolverine inside desperate to escape, and headed back to the airport, where I checked the box to go with the rest of my luggage.

I soon found myself on Alaska Airlines flight 43, a 737 jet on the way to Bethel. It seemed half of the passengers knew each other. I felt as if I was at a family reunion of a friend. The group was diverse, bubbling, and happy. I watched the mountainous terrain outside slowly turn to barren tundra, filled with lakes and rivers. A plume of steam rose from Mt. Redoubt along the way. Soon, the plane made its way down and I soon found myself stepping on the snow-covered ground of Bethel, Alaska.

I met with a human resource representative, Tony. He said he "wasn't really with human resources...more employed by the clinical rotations department," and had been working there for a month. He collected myself and two optometry students from Quebec. He asked if we needed anything at the store and after we assured him we didn't, he drove us to our lodgings.

I met my housemate Erik, another pharmacy student, from North Carolina. His rotations were five weeks long, he explained, and would be leaving at the end of the week. "Remind me to give you the number to the phone here," he said. Indeed, when I had checked my mobile phone, there was absolutely no signal, nor would there be, for the next four weeks.

"If Mt. Redoubt doesn't put an end to my departure plans," he said. Mt. Redoubt, a volcanic site near Anchorage, had been blowing steam lately, and seismologists in the area expected an impending eruption--which would not put us in any danger, but would certainly cause problems flying.

"Yeah, they wouldn't fly through that," my friend and roommate at home in Indianapolis had said before I left. He had gotten his private pilot's license over half a year ago. "The ash turns to ceramic in the engines and will drop you like a rock." Erik was obviously concerned about this. I thought about the last roommate I had named Eric and wondered if this guy would be anything like him.

Superbowl Sunday reaches everywhere, Bethel, Alaska, was not an exception. The Pittsburgh Steelers were going to be playing The Arizona Cardinals. Erik had been invited to a Superbowl party with some of the other pharmacists and invited me to go with him. I agreed, and soon found myself in Beth and Gary's home, talking to them, their three kids (Lars, Ashley, and Caroline) and Amy and (Kevin?), another pharmacy couple. I ate some food and had a good time getting to know some people who lived in Bethel. After the game, and a particularly good episode of The Office, Gary took Erik and I down to what Amy and Beth referred to as the "man-shed." Gary taught trapping as part of subsistence education. And apparently, he had just caught a wolf.

Sure enough, when we descended under the house, a half-frozen Cannis lupus, or timber wolf, was waiting for us in room full of hides, a veritable PETA nightmare. Wolves, he explained, have always maintained a healthy population, sometimes too healthy, in most parts of Alaska. How much more I would have enjoyed seeing it alive! We helped him lift it so he could suspend it from a beam. Soon after, I found myself outside, waiting to be driven back to the housing IHS had provided us. It was very cold, but beautiful. It was dead silent and the stars filled the sky, in sharp contrast to Indianapolis. I was truly in another world.