He Bit Me

It was a routine 2 year old Well Child Exam on a developmentally normal boy. I knew there was going to be a challenge in it because the nursing staff had to herd the child back into the exam room twice in the 10 minutes he and his mother had to wait there for me to finish up with the previous patient. Mom sat quietly in the room while Jacob ran up and down the hallway, opened exam room doors and stuck his head inside to see who was there, and generally entertained himself in any way he wanted. This behavior is not unusual in our clinic; the nurses are frequently apprehending disruptive children.

Once corralled in the exam room, Jacob amused himself by finding ways to make noise. The exam table’s hinged, sliding stirrup extensions produced a few decibels when slammed in and out, as did jumping on and off the retractable step at the base of the table. When I entered the room he was in the process of tearing the table paper off and making balls of it, which he threw at his mother. As soon as he saw me, he began crying (actually, “shrieking” would describe the noise a bit more accurately) and ran to hide behind the far end of the exam table.

I took a deep breath and sat down to talk to Mom. Jacob is 2 years, 10 months old, lives in an upriver village with both parents and his 1 year, 6 month old brother. Mom is in her early twenties, and about six months pregnant. She has no concerns about his health or development, and feels that he is a normal boy. Except, she notes, “he’s mischief!”

Jacob was up to date on his immunizations; the main reason he was in clinic was that he had to have a hemoglobin check to enter the village pre-school program. The health aides in his village refused to do it, so Mom had to bring him to Bethel. I should have paid a little more attention to that fact at the time.

By the time we finished the history portion of the visit, Jacob’s crying had decreased in volume, but had not stopped. He came out from behind the exam table when Mom called him, and stood next to her; but as soon as I tried to speak to him about doing his exam, he wailed and crawled under Mom’s chair. Mom’s only attempt to change any of this behavior was to say “Jacob, be nice.”

I grabbed his feet and pulled him out from under the chair, picked him up and set him on Mom’s lap, and told him firmly that we had to do his exam. I wasn’t mean or rough with him, simply direct and firm. He kicked and fought from Mom’s lap, elbowing her in the stomach once and kicking me in the shin before I trapped his flailing feet between my knees and Mom held his arms so he couldn’t punch. I talked to him all the while, telling him what I would do before I did it. His struggling never stopped and his crying was pure mad.



As I was placing the stethoscope on his chest, he threw himself forward from Mom’s lap and bit my arm. He bit me! The little brat actually bit me! I was astounded. In all my years in family practice, that had never happened before. As I looked at my forearm, a hematoma rapidly formed. There were slight abrasions where he had dragged his teeth as I jerked my arm away (saying “OW!” quite loudly), but his teeth didn’t break the skin.

Once my astonishment and disbelief passed, I was angry. How dare he! My instinct was to pick him up and spank his bottom for that behavior, but of course I didn’t/couldn’t/wouldn’t. Mom’s response was to say “Jacob, that’s not nice, say you’re sorry.”

Right.

She looked at me apologetically and said “He does that when he is mad.”

We managed to restrain him (carefully!) to complete the exam, which was normal except for his notable baby bottle tooth decay. When I asked Mom about it, she said that he still goes to bed with a bottle every night—usually milk, but sometimes Coke!

The hospital’s health educators and the Dental and Pediatric Clinics have been focusing educational efforts on the issue of baby bottle tooth decay and its prevention since before I first came to southwest Alaska in 1998. How could anyone still be doing this? I tried not to look aghast as I told her that this was the worst possible thing for his teeth, and the reason they were so rotten. She just shrugged helplessly and said “He won’t let us put him to bed without it.”

So who is in charge here? It is clearly not the parents. Jacob is a willful little bully who is not yet three years old; what will he be like at nine? At sixteen? And what do I tell his mother about changing his behavior when she is clearly impotent at managing him?

Yupik Eskimo culture generally subscribes to the School of Permissiveness when it comes to parenting. Children have very few restraints, and punishment often consists of threats (to restrict access to junk food or TV) which are not implemented or “time outs” which are not enforced. This mom’s helplessness in dealing with her son’s behavior is not uncommon.

On any given day, the hospital lobby/waiting area may have a half dozen 3-to-5-year-olds chasing each other around and entertaining themselves unmonitored by an adult or older child. An overhead page saying something like “there is a little boy going out the front door wearing blue pants and a red shirt. Somebody come and claim him, please” is heard almost daily.

My personal culture is in a head-to-head clash with Yupik culture over this issue. I grew up in the 1950s and 60s, and my parents subscribed to the School of Corporal Punishment. Acceptable behavior was very clearly outlined, and punishment for infractions was swift. It consisted of spanking, but only on the bottom, and only with a hand, never with a belt or switch as my parents had grown up with in the 1930s and 40s. In the 1960s, boys at my grammar school were still paddled by the principle for misbehaving.

I never had children, and so never had to deal directly with the issue of punishment. I don’t consider spanking to be a requirement of discipline, but I also don’t believe a smack on the bottom for misbehaving to be child abuse.

What I see in this region is a population heavily skewed toward young age, families who commonly have six to ten kids living in small houses with inadequate space, a fair amount of dysfunctionalism due to alcohol abuse, and lots of kids growing up with little behavioral restraint. Which is not to say that all, or even most of the kids are bullies, brats, or holy terrors. They aren’t. Many Yupik children are quiet, polite, well-behaved, respectful, charming, and totally delightful. The School of Permissiveness definitely has its successes.

But what do we do with the failures? What do I tell Jacob’s mom that will help her to keep him from being a totally out-of-control teenager who is capable of doing real harm to others?

On that day, I didn’t tell her much that I felt would make a difference. I strongly encouraged her to put him to bed without a bottle, expecting to spend the first few nights with him yelling about it.

“Don’t give in!” I told her.

I advised her that the biting behavior had to stop; he will cause serious infections by doing that. I referred him to Dental Clinic for his cariotic teeth, and sent them off to lab for his finger-stick hemoglobin test. I put a sticky-note on the lab form, saying “Warning—he bites!”


Photos: some of the delightful children of Pilot Station, Alaska

Alaska Reading

Reading has been one of my great joys and avid pastimes since childhood. My preference is for good, substantial fiction, books with something to chew on, think about, learn from. I love historical fiction, biography, some classics, and occasional science fiction or mysteries. Mostly I love good writing, and will read just about any genre, if the writing is good. I have a larger-than-average vocabulary, and love it when a writer sends me to the dictionary to look up a word I don’t know.

Some of the many writers who have enthralled me are Charles Dickens, Aldous Huxley, Colleen McCullough, Diana Gabaldon, Jean Auel, Marion Zimmer Bradley, Elizabeth George, Jack London, Patricia Cornwell, Ferol Sams, Margaret Atwood, Margaret George, Alice Walker, Mark Twain, Jane Austin, Maya Angelou, Margaret Mitchell, Barbara Kingsolver, Annie Proulx. And others which I can’t recall at this moment.
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Since I started blogging three months ago, my time spent with “dead tree” media has decreased significantly. But I still love reading books; there is a physical pleasure in holding a book, turning the pages, feeling the paper, and--yes--even smelling the ink, that a computer screen cannot replace. It is a sensual experience into which the engagement of the imagination is interwoven.

I love finding really good books, the kind that suck you right in, involve you totally in the story, and that you wish would not end. Since I have lived in Alaska, I especially enjoy finding good books about life in The Last Frontier.

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Two books I discovered recently I would like to share with you and recommend. Both are outstanding.
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Ordinary Wolves by Seth Kantner is a novel about a boy who grows to manhood deep in the bush in arctic Alaska in the 1970s.

From the cover notes:

In this novel about a boy growing up in the Alaskan wilderness, the reader is allowed no escape into the fuzzy myth of the Arctic, but instead is led down its true trails, feeling the pliers’ pinch of cold, tasting salmon shared with shivering sled dogs, hunkering in an igloo while blizzards moan overhead. With his siblings and father, Cutuk Hawcly lives a day’s sled-drive away from the nearest Inupiaq village, their link to the outside world. Reared entirely on the land in the presence of wolves, moose, and ravens, Cutuk’s imagination is shaped by his father Abe, the legendary hunter Enuk Wolfglove, and the faraway but nearing drone of an America he has never seen.

It is a very honest and unflinching portrayal of Alaska's social dynamic. Both funny and heart-rending, it is well worth reading.


And She Was by Cindy Dyson is set in Dutch Harbor, in the Aleutian Islands, in 1986. It is the story of a smart and brassy cocktail waitress named Brandy who follows a curly-haired fisherman with a cute butt to the barren pile of rocks at the end of the earth which calls itself “the birthplace of the winds”. Interwoven into Brandy’s story is 250 years of Aleutian history, told through the lives of Aleut women.

From the cover notes:

In a tense interplay between past and present, And She Was explores Aleut history, taboos, mummies, conquest, survival, and the seamy side of the 1980s in a fishing boomtown at the edge of the world. It leaps across time and culture to a lost woman, who more than anything needs to understand the gray shades between heroism and evil, between freedom and bondage, between this place and the rest of her life.


Both books are good reads, and have something special to offer. I highly recommend them.

GRAND ROUNDS is up

For some delightful, engaging, thought-provoking reading, check out this week's Grand Rounds, Vol 2, No. 44, at Medical Humanities blog. I am honored to have been included in the weekly compilation of the best of the medical blogosphere. The hosts have done a marvelous job of creating a garden in which to do your reading. Enjoy!

Breastfeeding

One of the many questions we ask at our hospital during the first prenatal visit is whether the mother intends to breastfeed her infant. The answer is usually some variation of “probably.” We strongly encourage moms to breastfeed, starting at that first prenatal visit and continuing throughout the pregnancy.

Regular encouragement by her health care provider(s) does seem to positively influence a woman’s decision to try breastfeeding her baby. But the encouragement of her own mother, her aunties and grandmothers is a stronger influence in whether she continues breastfeeding past the first few weeks. Extended family is a closely knit unit in the villages, often with multiple generations living under one roof. A new mom has many advisors.

Breastfeeding is strongly supported in Yupik Eskimo culture; many moms will breastfeed a child for two to five years, and some are nursing multiple children at one time. A woman came to clinic recently who was nursing a 4 year old, a 2 year old and a newborn. Many women are nursing an older child throughout their pregnancy, and only wean the older child when they have to come to Bethel for the last month of pregnancy. Cultural tradition is for a newborn to have exclusive right to breastfeeding; the belief is that the baby will not bond appropriately with the mother if the breast must be shared with older siblings. Some women lactate continuously for ten years or more, due to frequency of childbearing and extended patterns of breastfeeding.

Breastfeeding tends to inhibit ovulation, but many women do become pregnant while they are nursing. I have seen at least one patient who was nursing and already pregnant at her eight week postpartum visit. One reason for this may be the tendency of many moms to supplement breast milk with formula. The Women/Infants/Children (WIC) program supplies formula at no charge to the mother for her child’s first year of life, and most (if not all) women in our region qualify for the program. This easy availability of formula provides women a quick alternative if they have any problems with nursing. WIC does encourage nursing, and provides a free hand-operated breast pump to any mother who wants one. The WIC office here also has a grant-funded loaner program to supply electric pumps for short-term use. These machines retail for over $500, and work quickly, as they pump both breasts at once.

Southwest Alaska has one of the highest rates of initiation of breastfeeding in the entire U.S. It is rare to see a biological mom who is exclusively bottlefeeding, especially if she is more than 20 years old. Teen moms sometimes make little or no effort to breastfeed, but older moms almost always do. We have a fairly large rate of drop-off in breastfeeding when the baby is between six weeks and six months of age, but our breastfeeding rate at six months of age is still higher than most of the country. A small percentage nurse until four or five years of age. The oldest child I have seen still nursing was seven years old.

Instructions in breastfeeding are given to women who want or need them while they are admitted at the hospital for the delivery. We have one lactation consultant available; she is a family practice physician and nursing mom herself who had a strong personal interest in it and pursued certification. There is no La Leche League in Bethel or the YK Delta. Once a woman returns to her village, she has her own female relatives and the village health aides to help her. She rarely needs more.

Maternal complications from breastfeeding are most commonly cracked nipples, for which we give lanolin; and mastitis. The latter is a far more serious problem. Mastitis often develops quickly in Eskimo women and becomes severe. Deep abscesses are not uncommon, and occasionally the woman becomes febrile, bacteremic, even septic. We have very high rates of the dreaded MRSA, which is cultured from most of the abscesses we see. Cephalexin (Keflex) is essentially useless, our resistance rates to it are so high. Our most commonly used drug for abscesses is trimethoprim-sulfamethoxasole (Septra, Bactrim), but it is contraindicated in pregnancy and lactation, as is levofloxacin (Levaquin). We use ciprofloxacin (Cipro) much of the time. The deep and wide incisions needed for some of these breast abscesses can leave a woman with a very scarred breast.

Breastfeeding has been shown to reduce the rates of RSV, otitis media, and diabetes in babies who are breast fed. This is our strongest selling point to pregnant women. Our region has one of the highest rates--and greatest severity--of bronchiolitis in the world. Almost every home has a nebulizer, and almost every mom knows how to give a nebulized albuterol treatment and do effective percussion and postural drainage (P&PD)*. Yupik children have horrendous rates of acute and chronic otitis media. Draining ears are a daily staple in village clinics and in the hospital.

Overall, breastfeeding is easily accepted and widely supported in the Yupik Eskimo culture. On any given day, if you walk through the hospital waiting room, you may see a half dozen women nursing infants as they chat with family and friends around them. There is no hiding the baby under a blanket to do it, either. They are right there in the open, proud of their child, and their motherhood. It is the most natural thing in the world, and one of the most beautiful.

*Wikipedia had no entry to explain this. Many of our patients call it "pounding". The mom sits in a chair with one foot slightly elevated so that one knee is higher than the other. The child is placed face down on the lap with the butt on the higher knee and the chest on the lower knee (i.e., headed downhill). With her cupped hand, mom percusses ("pounds") the baby's back for several minutes. The vibration of this action helps shake loose the mucous plugs obstructing the baby's smaller airways and facilitates productive coughing to remove the mucus. P & PD following a nebulizer treatment enhances the effectiveness.

Puppies in the Dog Yard

Summer is the off-season for dog mushing, so I haven't blogged about it because there isn't much of interest to tell you about. The chores, of course, never stop. Dogs must be fed and watered twice a day, salmon soup cooked up every other day (4 whole fish cut in half with an axe, boiled in 10 gallons of water on a propane cooker in a kettle made from a 55-gal. drum cut in half), poop scooped once a day, weeds and grass kept whacked back to keep mosquitos down, bug dope applied to the dogs' faces twice a day in the bad spells, and pic kept burning much of the time to repel mosquitoes. Summer is pretty much all work and no play in the dog yard. Puppies in their house at 3 days old.



The one big exception is puppy time. Two of the females were bred this spring, Little Belle and Sunhouse. Little Belle's pups were born about two weeks ago, and they are beautiful. It is her first litter and she is being a great mom. She is roaming the dog yard freely now; she doesn't need to be on a chain, as she won't leave her pups, and the chain could hurt them. She had nine pups, but the runt didn't make it, so eight survived--four males and four females. I took this photo of Andrea holding five pups two days ago, at Day 9 of life; their eyes opened yesterday. If you click on this photo to get the larger version, you can see that average-size mosquito on her right hand.
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On Day 2, their dew claws are removed, standard practice for sled dog pups. It makes it a lot easier to put their booties on when the trail is icy. Otherwise, the pups are not handled at all the first week. Mom rarely leaves them, and doesn't go far. They grow quickly, and by the second week are almost twice their birth size. Mom stays out of the house a lot more, and the pups begin being handled frequently. It socializes them to human touch and smell, and is a very important part of their training.

My favorite, a little mostly black boy with classic sled dog markings.

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Now that their eyes are open, these little guys are stumbling around inside their house a lot more. Soon they will be tumbling out the door and will need some wooden blocks to be able to get back in. By the time they are 8 weeks old, they need to be corraled to keep them from wandering out of the yard, so they'll be put in the heat pen. By this time, personalities and dominance traits are on display, and they need a close eye; sibling rivalries are tough, and sometimes the litter will gang up on one member, and may actually kill that pup.

Belle is still a little anxious when her pups are handled.

Sometime between three and four months of age, the litter will be separated, and each pup given its own circle and house, and put on the chain. This causes several sleepless nights for the musher, as the pups whine and cry a lot at this transition. But it doesn't usually last long. They adapt well to the new circumstance. At five months old they start harness training and going for very short, easy runs with the team. It is amazing how easily it comes to them; they are born and bred (actually, that should be "bred and born" now, shouldn't it?) to pull the sled, and they take to it like the proverbial duck to water. Their excitement and joy is totally evident.

The other pregnant female, Sunhouse, is waddling about big as a barrel, and starting to get that anxious look in her eyes. Her pups should be coming any hour now. There is a restless energy in the dog yard as a female goes into labor. Dogs are running around their circles, jumping on and off their houses, sniffing the air a lot. Once the pups begin to deliver, there is lots of joyous barking, howling, and general excitement over the event. The pack's survival is being assurred, and they are very happy about it.

More photos to come.

Not missing from the planet...

...though people may begin to think so, I haven't posted in so long. Life just got in the way of blogging for the past few days. What can I say? I hope this doesn't mean I have to give up my Blogoholics Anonymous card! Yeah, I even missed the BA meeting at May's place yesterday. And I still don't know what pancit is, but it's gotta be yummy. I'm hoping it has shrimp in it.

So what could I possibly have been doing that would keep me from blogging? Well, working for one. It was a really heavy week at the hospital, and I came home from very long days looking something like a zombie. Sat in the chair and stared out the window. Barely managed to put dinner together for Dutch and me (he works even longer hours than I do, I can't complain). Very little energy left over for dogs.

The weekend came at last, and Henry came over for coffee on Saturday morning. He and Dutch and I spent several frustrating hours dealing with the flat tire on my boat trailer. Lug nuts were frozen; lubricant, blow torch, and impact wrench all failed. Finally, Dutch's massive muscles prevailed and he managed to get them off without breaking the studs, but it was too late to get the tire replaced (sidewall is rotted, it can't be repaired). Once the tire is replaced, the boat goes to the Bethel Boat Shop to get a new lower unit--only $2,000! Such a deal... This is what has kept the boat out of the water for the second summer in a row now. Grrrrr... Maybe by next weekend.

We decided to end the day with a steam bath at Henry's house, which was just lovely. The weather has been cool and cloudy with intermittent rain for several days now, and a steam felt great. Afterward, Dutch and I went home and grilled steaks for dinner--yeah, we eat beef when there is no moose or caribou in the freezer. And cuddled on the sofa watching a movie, Proof. We both like Anthony Hopkins, and found the movie intriguing (somewhere between interesting and odd). I thought it was time to go to bed, but the writing muse had other ideas. I was up until 2 am writing a post which is not yet finished that I will submit for Grand Rounds (and keep my fingers crossed) tomorrow.

After the late night slaving over a hot computer, I didn't feel the least bit guilty sleeping in till 9 am this morning. If Henry hadn't called to say "Let's go fishing!" we'd have probably slept later. Dutch was feeling a bit sore after his he-man display of strength yesterday, wrestling with the lug nuts, but he was up for it, so we said "Sure!" Henry said he only wanted two or three reds out of today's catch; we could have the rest for freezing, smoking, or giving away.

It was about noon by the time we got everything organized and gear loaded in the boat. The mosquitoes were really chomping on us at Henry's, so I pulled out the Deet and sprayed my cap and the back of my neck. Dutch winked at Henry and said "Guess I won't be kissing her there for a while!" Henry grinned back and said, "That's pure Alaska perfume! And Pic is pure Alaska incense." I realized with a start that when Henry had lit some Pic in the steambath last night, I really thought he had lit incense.

High tide was at 10 am, so by the time we launched it was going out strong. We were fishing on an ebb tide, which is not ideal, but we were only hoping for a hundred or so fish with a dozen of them reds. The rest could be chum or humpy, we didn't care. Henry now has about a thousand fish in the freezer, which would be enough for the sled dogs to get by with. The most the freezer will hold is about fifteen hundred.

The high winds from yesterday had settled down a lot overnight, but it was still pretty breezy, especially out on the river. The water was choppy, which causes a fair amount of spray from the bow. We were fully rigged out in hooded sweatshirts, fleece jackets, and Helly Hansens.

We went to one of our favorite spots alongside Missionary Island, a few miles upriver from Bethel. No other boats were out fishing. Henry drove the boat and Dutch and I crewed. We got the net into the water in a perfect "C" shape and settled back to drift. The coffee was hot, and we enjoyed visiting. As much as we see each other, we never run out of things to talk about.

Henry thought we were catching a few fish, but nothing spectacular. The floats were not bobbing much, and the net was not jumping around with fish slapping the surface of the water making tangles. When the wind is blowing as much as it was today, it can be hard to judge how much the net is pulling on the boat, which is another indication of how many fish are in it. Henry said "We may have to do a few drifts, just to get our hundred."


After a half hour, he decided we should pull the net. When the weather is calm, we cut the motor and let the boat drift while we pull the net in; but in windy weather the boat can run over the net, causing tangles and problems, so one person has to maneuver the boat while the other two pick the net. With me on the float line and Dutch on the lead line, we began hauling the net in. We were immediately in Fish City. There were about 20 fish in a net tangle right at the end of the net. Henry yelled at us from the back of the boat, "Round haul! Just get it in! NOW!!!"

Dutch and I were pulling net as fast as we could. Every pull brought a dozen fish in the boat. Henry was yelling, "Faster! Faster! Get it in!" We were pulling, groaning, sweating, pulling, grunting, pulling as fast as we could. My arms were burning, my thighs were aching, my fingers stung from grabbing the net. It was fearsome. The boat has low sides, but lifting 60 or 70 pounds of fish with each arm load, while pulling a 300 foot long net loaded with hundreds more fish towards you is exhausting. And I had the lighter upper half of the net. Dutch had the lead line, which had lots more fish. When I thought I couldn't possibly lift another fish, we still had 20 feet of net to pull in. My arm muscles were fasciculating, they were so exhausted. Sweat was running in my eyes. I was knee deep in squirming, flopping fish. The boat was listing to starboard from the weight of the fish. Another pull...lift the fish over the side...pull again...lift the fish in...one more pull...is there any end to this net? Henry was calling from the back, "Come on, you're doing great! Don't quit now, you're almost there!"

Finally the last arm load of fish and net came over the side and we were done. Dutch and I stood looking at each other over a huge mound of salmon with chests heaving and eyes round in exhausted disbelief at what we had just accomplished. It was all I could do not to fall over on top of the fish.

We headed over to a protected spot on the side of the river and tied the boat off to an overhanging tree. Picking the net actually went fairly quickly; it only took us about an hour. Most of the fish were small, as the run is nearly over; many of them could be pulled through the net, which is quicker and easier, instead of having to back them out of it. We ended up with two full totes of chum with a few humpies, 12 reds, 2 small kings, and even an early silver. We had all five species in one drift! In all it was close to 200 fish. Henry said, "We were planning on recreational fishing today, but we got combat fishing instead." I couldn't agree more.

We got the boat home and hung all those fish in the freezer. Dutch and I took most of the reds home in a cooler which is now sitting on our back deck ready for a few hours of filleting. I just couldn't do it tonight. They are well iced and will be fine for two or three days. I did fillet one nice red, which Dutch grilled for our dinner, and it was very tasty. So now it is Sunday night and I am nearly mashed flat with exhaustion. Every muscle in my body aches, despite ibuprofen and a hot shower. As my dad always says, "It's hard work having this much fun!"

So... that's why I haven't posted for a few days. I sort of hope you missed me, but I also hope you didn't worry. Life just got in the way. The things I write about take time to do, and I wouldn't have it any other way. Livin' large in Alaska...

Midnight Sunset

...moments ago...

...the days are already getting shorter...

Asthma versus The Beaver

Oscar was 28 years old, thin and muscular, with the look of the outdoors in his eyes. He was not from one of my villages, and I had never seen him as a patient before. His appointment was for “cough and runny nose x 2 days.” His chart was as thin as he was, which told me he had not been seen in the hospital very often. When I asked him why he had come to clinic that day, he said “it’s just a cold. I’m coughing a lot at night, and I wondered if I could get some cough syrup.”

We discussed his symptoms and their duration, and I noticed that his breathing was unlabored and his speech regular. His vital signs were normal, except that the oxygen saturation seemed a little low (96%) for a person of his age and apparent level of fitness. He denied any chronic meds, but when I asked him if he were taking any meds for his cold, he said “I have a puffer if I really need it.” I saw in his chart that he had been given an albuterol inhaler about a year earlier.

“When did you last use it?” I asked.

“About two weeks ago,” he said.

I asked whether he had ever been given a second inhaler or other medicines to help his breathing, but he said no. He denied a history of asthma, had never been told he had reactive airway disease. He did admit that he often didn’t sleep well, and woke up tired in the morning.

His physical exam was unremarkable except for the runny nose and the persistent expiratory wheezes in all lung fields. His best effort on a peak flow meter was 85% of predicted for his age and height. His chest x-ray was normal.

He admitted when I asked him that he could hear himself wheezing. “So why haven’t you been using your inhaler?” I wondered.

“Well, I’m still breathing good, even I’m wheezing, and I don’t want to get hooked on it,” was his reply. “I’ll use it if my breathing is really bum.”

“Oscar,” I said, “what you have is asthma. You need to have two inhalers, an inhaled steroid that you use all the time, and albuterol that you use whenever you are coughing and wheezing.”

“It works like this. Asthma causes the lining of your airways to be inflamed, you know, like red and warm and extra-sensitive. That makes the little muscles encircling the airways want to squeeze up, so instead of breathing through a nice big garden hose, you have to breathe through a tiny little straw. It is hard work and it makes you cough and wheeze. If you use the albuterol inhaler, it will help the squeezing to relax and let you breathe better. But it won’t take away the inflammation, so as soon as the albuterol wears off, your lungs will squeeze back up again. You need a second type of puffer, an inhaled steroid, to take away the inflammation so you don’t squeeze back up. The albuterol is your rescue medicine; when your breathing is bum, it will help you right now. The inhaled steroid is your maintenance medicine; it will work to keep your lungs cooled down so they don’t want to squeeze up, and your breathing will stay good.”

He was mostly getting it, but not quite. I could feel an analogy coming on.

Think of it this way. Your house is next to a stream, and you get your water from that stream. Up stream there lives a beaver. He is working night and day, chewing through saplings and dragging them across the stream to build a dam. When he does that, you don’t get enough water at your house. You can spend all your time with a saw, cutting through the saplings he has piled up, and you can keep the water flowing well enough to get what you need. Or you can get rid of the beaver.

“Ah,” he said. “I get it.” He smiled sideways at me. “I’ve got a beaver in my lungs.”

Perfect Fishing

Hooray! Photo success on Blogger!

Hard to see the net in this photo; the red dot on the left is actually a 2-ft diameter round float at the far end of the net, which stretches in a "C" shape back to the bow of the boat.


Friday was one of those amazing days that you just can’t plan for. The weather in southwest Alaska is fickle and changes rapidly. One day it is 75 degrees, sunny and beautiful, the next day it is 40 degrees, windy and raining. “Weather permitting” is a well-worn phrase around here, and nearly as applicable in summer as in winter. For many people here, fishing is not so much a pleasure as a requirement; salmon is the basis of survival, and getting it is time-limited. When the fish are running, you have to be out there, in all but the very worst weather. So you take the extra gear along and hope you won’t need it.

Friday it was time to go fishing again. The catch from the fourth of July was almost frozen solid in Henry’s big freezer, and the reds and kings that Betty and Andrea had cut and dried were in the smokehouse. Joan and I were ready to start getting our fish. We both want reds; Joan has her own smokehouse, and will dry and smoke them in the traditional manner. I don’t have a smokehouse, so I fillet and freeze my salmon in ziplock bags of water. The reds are well preserved this way, and Dutch and I will eat great-tasting salmon all winter long.

High tide was in the late afternoon, so Henry and Joan and I went out just before noon. The skies were overcast, but it wasn’t windy, which is nearly ideal. When the sun is shining brightly, the fish can see the net and swim around it; and low wind makes it much easier to handle the boat and the net. A little breeze is nice to keep the mosquitoes off, and that was just what we had.

Our goal was not to catch too many fish. The fourth of July catch was just TOO big. That many fish (over 400) is one heck of a lot of work. We were shooting for maybe a hundred fish, but more importantly, a better red-to-chum ratio. Henry’s freezer had room to hang one tote of chum, about 75 fish. The last two trips had yielded about 10% reds and kings and 90% chum; we were hoping to get 25% reds on this trip.

.Picking fish from the net.

About five miles upriver from Bethel, Henry pulled in to a different spot than we usually fish. There was not another boat in sight (one way to tell if a spot is any good) but Henry had a good feeling about the place, so we put the net out and waited.

The tide was coming in strongly, so the river’s current did not move us at all, we just sat in one spot. That is usually a hopeful sign; salmon tend to migrate upriver in “pulses” with the tide. Swimming is easier, and it conserves their strength.

.Red salmon (also known as sockeye). My personal favorite for eating fresh or for freezing. Dries well also, though not as oily as king.

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.Chum salmon (also known as dog). The red bruised-looking water marks will increase the longer the fish spends in fresh water. By the time they reach their spawning grounds, they are red all over. Great dog food.

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A float bobbed here and there, so we knew we were catching fish, but they weren’t crashing the net. We ate the picnic lunch I brought, and had a half hour to drink coffee and enjoy the river.

It was so peaceful and quiet; just water lapping the sides of the boat, a few birds singing here and there. Breeze keeping the mosquitoes off. Sun in and out behind some clouds, just warm enough.

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.King salmon (also called chinook). Really small ones like this are often referred to as "jacks". Normal size for this guy is about 4 times this big.

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When we started to pull the net in, the results were immediately exciting. The first three fish were reds! There were plenty of chums also, and a few humpies (also dog food up here, but sold in the lower 48 as canned “pink” salmon). We did a second drift of about the same length with similar results.

.Humpback, or humpy, named for the hump in front of his dorsal fin. Meat is not very red, tends to be mushy, and has a mild watery flavor.

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By the time we finished the second drift, the tide was turning and starting to ebb. We had one full tote of chums and humpies for the dogs, and 36 reds and 4 small kings for Joan and me. There were even three fat whitefish for Henry, who was thrilled. He loves whitefish even better than salmon, and we don't often catch them in the summer. We got exactly what we wanted, and at a far more relaxed and enjoyable pace of fishing.

.A tote full of chums and a half tote of reds and jacks. Just right.

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The sun was out in full now, and the sky had only a few clouds. Once the work is done, when the weather is nice we love to pull over to the side of the river, take off the heavy gear, and just relax. Talk. Drink coffee. Maybe take a nap, or even go swimming if it is really hot. We’d been talking about birds earlier, so Henry and I both wanted to visit the cliff swallow colony at The Bluff, a big dirt cliff not far from Bethel. There are hundreds of holes in the face of the cliff, made by nesting swallows.

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We pulled over to the edge of the river just at the foot of The Bluff and cut the motor. We didn’t need to throw the anchor out, as the river still wasn’t moving much yet. A few birds came and went from the nesting holes. We weren’t talking much, just lying in the bottom of the boat watching the sky. Joan asked with eyes closed and a smile on her face, “don’t you just hate living here?” And Henry responded, “ummmmm, yeah. Requires so much sacrifice.”

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In a few minutes there were more birds flying in and out of the holes; and then more…and more…and more. The sky was alive with hundreds of wheeling, swooping, diving, loudly chirping swallows. Swallows are incredibly acrobatic flyers. It was an amazing sight. The agitation level was becoming intense, and we were clearly the source, so we cranked up the motor and cruised off. Of course it put me in mind of Hitchcock’s movie The Birds.

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Back at Henry’s, we quickly hung the single tote of chum in the freezer. The reds and kings went into coolers for Joan and me to take home. I picked out the prettiest red in my batch to cook on the grill for Dutch’s birthday dinner last night (Happy Birthday, my love!). It was perfect—just like the day in which it was caught.

Henry, ever the voracious reader, provided the quote of the day adapted from a book he is currently reading, A Sense of the World by Jason Roberts: Life on the river quickens the stagnant blood and enlivens the nerves. Um, yeah. Definitely.

Is She Coming Back?

About two months ago, shortly after I started blogging, one of my favorite bloggers decided to throw in the blograg. Written by an OB/gyn in New York City, The Blog That Ate Manhattan (TBTAM) was a fun-to-read blog on medicine and food. While doing some blog-housekeeping, she inadvertantly managed to delete her entire blog! (Whoa--scarey!) When I stopped in for my regular visit, I found only her short post saying that this untoward event had occurred, and she was taking it as a sign from the celestial portion of the blogosphere that it was time for her to quit. All of her archives were gone; there was nothing left of her entire (extensive) blog except this one short post.

Some recent discussion on the blog of Doctor Anonymous about Blogaholism and the addictive nature of blogging reminded me of one of my favorite posts from TBTAM called I Love My Blog. I regretted that it was no longer available, as I was sure that Dr. A and his commenters would enjoy it, and I really wanted to read it again--now that I have been blogging long enough to appreciate her words. I did not get around to deleting TBTAM from my Bloglines, and was surprized a few days ago to see that TBTAM had a new post! I was hopeful that after a few weeks off, she decided to come back (we can't really quit, can we?). The "new" post wasn't actually new, it was the last post before the big "Oops!"; but suddenly all her archives were available again. I re-read I Love My Blog with delight. She hits a few nails right on the head.

In case this reappearance is due to a freak opening of a black hole in the blogosphere where TBTAM may again disappear to, I will reproduce I Love My Blog here, so that it will survive any such future disaster.


I Love my Blog

It’s true. I love my blog. No, you don’t get it. Yeah, I love blogging, and love reading and sharing blogs, having a blog, blah, blah. But what I mean is – I love my blog. Really love it.

Oh, all right, I’ll just say it. I am in love with my own blog. As in the I can’t wait to see you, you’re the last thing I want to see before I go to bed and the first thing I want to see when I wake up kind of love. The I can’t get enough of you love. The what did I ever do before I met you kind of love.

And the worst thing is, I can’t stop looking at my blog. Any excuse I can make –“I wonder if there are any comments?" "Did I spell that right?" "Oops – didn’t realize it was still loaded in my browser." Yeah, right. Just another excuse to look at your own blog. Read that last brilliant post just one more time. Stare in astonishment at this thing you have created. This wonderful, marvelous, one-of-a kind expression of everything you are. But not the way a parent might stare at their child sleeping like an angel in the crib. No. That would be normal.

More like Narcissus staring into the pool at his own reflection all goddamned day long. IN LOVE WITH HIMSELF. Pitiful, isn’t it?

And don’t get me started talking about my relationship with statcounter. How many hits today? Any hits since I last looked 3 minutes ago? It’s like asking everyone you know to stand around the pool and stare with you, then looking up every 2 seconds to see how many are still standing there.

Well, it has to end. And soon. I’m starting to ignore my kids and husband. Letting work pile up on my desk. At this point, I’ll be here till 8 pm tonight getting caught up. My kids won’t get a proper dinner and I’ll be an even worse mother than I already am.

It’s sick, I tell you. Sick.

Look, I gotta' go. But don’t tell this to anyone, ok? And don't worry. I’ll be all right. I just had to get it off my chest.

posted by TBTAM at Friday, January 06, 2006

6 Comments:
mzn said...
I used to love mine too, just like you describe. It *was* sick and I suspected that my loved ones worried about it without fully letting on. I am doing better now. Right now the blog and I are more friends than lovers. I enjoy the blog and it's a good thing to have around, but the mad passion lasted only for a couple of months. Sometimes a few days pass between posts and I don't feel that painful longing I might have during the more intense phase.I do still check the statcounter way more than I should, though.
January 06, 2006

BigMamaDoc said...
You are right to love your blog. I love your blog, too. :)
January 13, 2006

Difficult Patient said...
Oh well--there are worse things . . .
January 13, 2006

shrinkette said...
Love the Narcissus analogy. And love your blog!
January 13, 2006

Yasso said...
U know,u awakened my feelings towards my blog.I always wondered why do i log in thousands of times a day to check my posts, people's comments, whether my posts r written correctly, no mistakes, ofcourse u know all these sorts of things (although i just created my blog recently and it doesn't have this much of topics)

Anywayzz, u have the full right to fall in love wit ur blog coz i really like it so much. I'm never bored reading it.
January 14, 2006

Kim said...
My Site Counter. What can I say? And let us not forget the TTLB Ecosystem. I am a Maurading Marsupial again!
January 17, 2006


So there it is... I miss you, TBTAM! And I still hope you'll decide to come back.

Tagged

I got "tagged" by Doctor Anonymous to list my "fours"; here are my answers:

4 jobs I have had:
steak house waitress
massage therapist
medical transcriptionist
autopsy assistant

4 movies I would watch over and over:
The Wizard of Oz
GWTW (that's Gone with the Wind, for you non-Southerners)
Monty Python and the Search for the Holy Grail
The Shawshank Redemption

4 places I've lived:
Alabama (born there)
Germany
California
Washington State

4 TV shows I love to watch:
Bones
House
Numbers
24

4 places I've gone on vacation:
Aruba
Costa Rica
Big Sky, Montana (winter skiing)
The Alaska Highway (not a single place, but 2000 miles of gorgeous road trip)

4 places I'd like to go on vacation (not in the original, my own addition):
Hawaii
Ireland
Greece
The Big Ride (6 week bicycle trip from Seattle to Washington, D.C.)

4 web sites I visit daily:
Bloglines (my daily blogrun has 32 stops, so I'll leave it at this)

4 people I tag (how do you know who has been tagged already?):
Peg Spenser at PegSpot
Doc Shazam at Mr. Hassle's Long Underpants
scan man at scan man's notes
Dr. Hebert at Dr. Hebert's Medical Gumbo
Jordan at FineArtDoctor
(one extra in case one has already been "it")

Now I'm home free, it's your turn!

Fishin' on the 4th of July

Henry called last night and said "Are you guys up for going fishing tomorrow?" Dutch and I haven't been out on the river since break-up, so of course the answer was a resounding "YES!" The morning low tide on the river was at 8:30, and Henry wanted to fish when we'd be likely to have the river to ourselves; most people prefer to sleep in and fish the late tide. He said to be at his house at 8, ready to go. Joan was coming too, so there would be four of us.


When we go fishing, it is not with a rod and reel. We are doing Eskimo-style subsistence fishing, with a drift net. No fishing license is required, but only Alaska residents may do it. Until you have lived here for a year, you can go along in the boat, but you can't touch the net or the fish.

The day started out in a pea-soup fog. (This photo is from a previous year's trip; it was way too foggy to get a good photo of the net this morning.) Dutch and I were up at 6:30 to get our gear packed. Helly Hansen's bibs and jacket, knee-high rubber boots, PFD (Coast Guard approved personal flotation device, aka "life jacket"), hooded sweatshirt, fleece vest, mosquito shirt, fish-picking gloves, picnic lunch, thermos of coffee, bottle of water. We loaded it in the truck, put the big dog on his outside chain, and got to Henry's right on time. The 300 foot long fish net was already in the boat, so we added our gear and four large fish totes (which hold about 75 fish each) with ice in the bottoms, and headed for the small boat harbor. It was 8 am and the town was completely quiet under the blanket of fog. Visibility was just about nil.

Out on the river it was cold and damp as we motored slowly, trying to keep our bearings. Henry was watching the depth finder, as the river can go from very deep to very shallow with no visible change on the surface. Getting stuck on a sand bar happens quite frequently, especially at low tide. Joan, Dutch and I were peering into the gloom, trying to see the shoreline and any floating logs we might run into. The job is complicated by the fact that the incoming tide overcomes the river's sea-ward current, and the water stands still for a while. It was slow going; fortunately there was no other traffic to run into on the river at all. We definitely had it all to ourselves.

Thanks to Henry's intimate knowledge of the river, we only misplaced ourselves once in the dense fog before getting to our favorite fishing spot a few miles upriver of Bethel. The depth-finder showed plenty of fish swimming under the boat, and as soon as we started feeding the net into the water, fish were hitting. The float line was jumping and bobbing like hailstones raining on pavement.

Floats are spaced about a foot apart on the top line, and the net hangs from it to a depth of 20 feet. The net is held vertical in the water by the weighted lead line at the bottom. If the depth of the river is less than 20 feet where you are fishing, then the lead line bounces along the river bottom as the net and boat drift downriver. Nets are either 300 feet long ("full shackle") or 150 feet long ("half shackle"). The size of the net's webbing will determine the size of the fish you catch. We are going after red salmon, not kings, so we are using a net with smaller (five-and-a-quarter) webbing. Three hundred feet is a lot of net; it makes a big pile in the boat.

We had only drifted for about 15 minutes when Henry said, "Let's pull it and start picking." The drift is the fun, lazy part of the trip; time to drink coffee and enjoy the peace and quiet of the river. If the fish are not hitting hard, a single drift may last an hour. The way the float line was bouncing, we knew we were catching fast, so we couldn't leave the net in for long. It is possible to sink your boat by catching too many fish. The 400 fish Henry caught last week with Joan and Michael had pushed the boat's limit. They had to "round haul" the net--just pull it in the boat as fast as possible, and pick the fish out afterward. It took the three of them two hours to pick the net after they got it in the boat. It is exhausting work to deal with that quantity of fish. We were hoping for about half that amount.

A great photo of picking the net would go right here if STUPID Blogger would let me load it; but no...

Fish swim into the net and get caught by their gills. They thrash and twist, trying to free themselves, and often make big tangles, especially if a cluster of fish hits in one spot. Every armload of net we pulled in had three or four fish in it, and a few had eight or ten. We picked the fish out as we went, tossing them into the totes; it took the four of us an hour to pick the net clean after 15 minutes of fishing. We ended up with about 200 chums (dog food) and 25 reds and kings (people food). Another nice photo here... The run is almost over for reds and kings, so we won't get too many more of them. The chum run will continue through most of July, and silvers will start running in August.

We had over a ton of fish in the boat as we headed back to Bethel, so it was a good thing that the tide had come in, giving us deeper water, and the fog had lifted, giving us better visibility. The sun still wasn't out, but at least we could see where we were going. And it was a little warmer. Thank goodness, because by then we were out of coffee.



Back at the small boat harbor, it was a bit tricky to get the boat loaded on the trailer and pulled up the ramp. A ton is one heck of a lot of fish. Henry's old F-150 was pretty maxed out, but managed to do it. While he and Dutch were loading, I snapped this photo (yeah, here too) of the "Kid's Don't Float" board near the ramp. Bethel has a lender program of kid-sized PFDs that anyone can borrow any time. It is on the honor system; you take one if you need it and return it when you come back. It is really a great program. Regulations require kids under 18 to wear a PFD at all times when on a boat; adults have to each have one in the boat but don't have to actually be wearing it.

Once we got the fish back to Henry's, the next step was to hang it in the freezer. He can back the boat up right next to the 10 x 20 foot walk-in freezer and lay a 4 x 12" gangplank from the gunnel to the door. We then fill a washtub with about 25 fish, slide it down the gangplank, and form a fish-passing line from the tub to the person at the back of the freezer who is hanging one fish at a time on big nails that line the top of the walls. About 100 fish can hang at one time. It will take them two days to freeze solid, then they will be taken down and stacked like cord wood in a big bin on the floor. The second half of today's catch will wait on ice until the first half is frozen. Henry's goal for each fishing season is about 1000 fish; that will feed the dog yard for a year, when supplemented with meat and kibble.

The reds and kings from today's catch went straight to the cutting table where Henry's wife Betty and niece Andrea were waiting. They filleted the salmon and set aside a red and a king to have for dinner; the rest were cut into blankets and strips, brined and hung to dry. In two or three days they will go into the smokehouse.

Once the fish were hung, Dutch and I went home to see to our own dogs and clean up a little. Shortly after noon, the sun came out and we had our first real taste of summer--70 degrees! (Big change from the 45 degrees we started the day with.) Bethel's 4th of July festival was happening at the park just down the street from our house, so we wandered down for a bit of Bethel-flavored culture, but didn't stay long. Dutch took a nap and I did a little blogging, and then we went back to Henry and Betty's. Henry had gotten the steam bath ready, but decided at the last minute not to join us, so Dutch and I had it all to ourselves (yummy!).

After the steam, Henry cooked salmon over the fire. He distains charcoal; he builds a fire in the fire ring in front of his house, waits for it to burn down to coals, and then cooks the fish over them. And a lovely shot here with the fat running and the fire smoking... He uses mostly cottonwood, which gives it a great flavor. Andrea stayed for dinner, and her husband Trevor joined us too. It was a nice, relaxed evening after a day of hard working fun.

Happy 4th of July, everyone! I hope you enjoyed it as much as we did.

Photo Addendum To The Moving Wall

Who knows what magical combination of rattle shaking, circle dancing and creative cursing of Blogger finally worked. After umpteen attempts, here is the photo of The Moving Wall that should have gone in the prior post. Maybe the message is: don't save the important stuff for last. Fickle Blogger may decide to say "no!" long before you are ready.

The Moving Wall Comes to Bethel

Bethel is proudly hosting The Moving Wall for the next five days. For those of you unfamiliar with it, The Moving Wall is a traveling half-sized replica of the Vietnam War Memorial in Washington, D.C. It was created in 1984, as a means of sharing the incredibly moving experience of the Memorial with people throughout our nation who may never travel to the nation's capital to see this amazing monument to the men and women who died in the Vietnam War.

Bringing The Wall to Bethel was particularly challenging, since it had to come by air freight. A hardworking group of Bethel residents began the planning for this event months ago; the VFW and the American Legion were instrumental in bringing it about. The Wall only arrived this morning, hours before the opening ceremonies.

Despite cold, cloudy weather, a good-sized crowd came out for the opening ceremonies, which were very nice. A color guard from the Bethel JROTC presented the American flag and the Alaska state flag, and the veteran's groups raised the POW/MIA flag and a flag honoring Those Who Serve.

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The national anthem and America The Beautiful were sung a capella by two young women, and the Alaska state song was sung in Yupik by a group of young Eskimo women in traditional dress. The chilliness of the day made me wish I had on fur mukluks like theirs!

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There was an invocation by the Catholic priest, a proclamation read by Bethel's mayor, and several local dignitaries who spoke of the contributions made by Alaskans in World War II, the Korean War, the Vietnam War, the Gulf War, and the war in Iraq.

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Bethel's veterans were recognized by service and asked to stand for applause. Dutch was among these, as a retired Captain of the US Coast Guard (that's an O6, for you military-savvy types). He was asked to stand a second time as a department head for Bethel city government who was a member of the committee to bring The Moving Wall to Bethel. I was very proud of him!

The main guest speaker for the event was former governor and Vietnam veteran Tony Knowles. He spoke of the incredible impact of the war on the American psyche, the difficulty of returning service people to a country who opposed the war they had fought, and the anguish of families who lost children to the war with no sense that the country valued that sacrifice. He spoke of the Memorial as the avenue of healing for a generation torn apart by that war.

PHOTO OF THE MOVING WALL

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SEE POST ABOVE

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I have visited the Memorial in Washington, D.C., and it is an incredible experience. It is powerful, and deeply touching, though I did not personally know anyone who fought in Viet Nam. The Memorial is something every American should visit if they have the opportunity; for those who can't get to our nation's capital, The Moving Wall is a good second best. It does not have the devastating impact of the original, but nothing could. It comes close enough. When it comes to your community, make an effort to go and see it. It really is important. The healing of our nation over this war continues thirty years after it ended, and will for many years to come. We are each one a part of that.

The Villages of Southwest Alaska

A gray, cold, windy Saturday and I think perhaps it would be a good time for a geography lesson. Most maps of Alaska show only a few of the villages of the southwest quarter of the state. I've mentioned several of them in previous posts, and I thought you might like to see where they are. I love maps anyway; my dad taught me how to read one when I was pretty young, and I've always enjoyed pouring over them.

When I first came to Bethel in 1998, I was fascinated by the village names. Some of them are quite lyrical and fun to pronounce; kwig-a-LING-guk sounds like a bird call to me. AK-i-ak sounds like laughter. And e-MUNG-UK sounds like throat clearing. Yupik is a very gutteral language, with many sounds deep in the throat, so it makes sense.

The entire region between the Yukon River and the Kuskokwim River is referred to as the Y-K Delta. There are 58 villages in this region, home to about 20,000 people. The great majority are Yupik Eskimo. The smallest villages--Nunam Iqua, Oscarville, Pitka's Point, Lime Village, Stony River--have less than 50 people. The largest village, Hooper Bay, has about 1200 people. Most villages are in the mid-range, with populations of 400 to 600.

Each village has a health clinic staffed by community health aides with very limited services available. Health aides can draw blood to send in to the hospital for processing; the only lab tests they can do in the clinic are urine pregnancy tests, rapid strep tests, dip stick test of clean catch urine, and finger-stick glucose. There is no imaging (x-rays) available, and only a limited formulary of medications which health aides can dispense on a provider's order.

There is an intermediate level of care available in the Delta which I have not previously discussed. The hospital operates four larger Sub-Regional Clinics in the villages of Aniak, St. Mary's, Emmonak, and Toksook Bay, with a fifth planned for Hooper Bay in the next few years. These clinics are staffed by two mid-level providers (physician assistant or nurse practitioner), in addition to community health aides. They have x-ray machines capable of doing chests and extremities; these are initially read by the PA or NP, and then transmitted electronically to Bethel for reading by a radiologist. They have small labs capable of doing automated blood tests (ISTAT chemistries, CBCs). And they have a larger pharmacy than village clinics, with more medications available; health aides can only dispense this expanded formulary when the PA or NP is in the clinic. The goal is to also have a full time dentist in each Sub-Regional Clinic (SRC), though that hasn't happened yet. Each SRC does include a fully equipped dental operatory. The Physical Therapy Dept. at the hospital sends one of our four physical therapists on field trips regularly to the SRCs, which helps provide service to patients who cannot travel easily. It is generally easier and cheaper for patients to travel to the closest SRC than to come to Bethel.

When I first came to Bethel, there was only one SRC, at Aniak. The other three have been built in the last few years. There has been discussion in the past of having physicians at the SRCs and mid-levels at all the village clinics. I expect that will eventually happen, and I hope it does. At this point, staffing is such a challenge for us that it is not even a goal that is in sight. The SRCs have not been consistently fully staffed with PAs and NPs in the last two years; and the hospital has never had a full, permanent medical staff in my eight years of experience here. It is hard to find medical and nursing staff that want to come here, and even harder to find ones that want to stay longer than two years. The life here certainly doesn't suit everyone. I feel incredibly lucky to have found my way here, because it does suit me. If there are any hardy and intrepid souls out there who think it might suit you too, let me know. We are always looking for a few good folks who are ready for the adventure of their lives up here at the edge of the planet.