Saturday, December 22, 2007

At your service...

After a bit of a sleep-in, then a trip to the hospital to round on our inpatients, and a stop at the Frobisher Inn for a coffee at the Caribrew Cafe*, Aaron and I headed to Northmart to do some grocery shopping. We had almost filled the grocery cart, and we were browsing the section of the store that sells fox and rabbit furs, when I heard a loud "beep-beep-beep".

My first thought was, "Oh no, Aaron will to have to go on a Medevac and he'll get stuck up in Igloolik for Christmas." Then I realized it was my pager going off (I'm not on call today, but was wearing my pager anyway). I looked at the very familiar number on the screen, and walked about 5 feet over to the pharmacy counter.

I showed the pharmacist my pager and asked, "Were you calling?" He looked at me like I was a crazy person, and then I said, "Oh, hi I'm Dr. H." I must talk to these guys about 5 times a day on the phone, but I've only met a few of the people who work at the two pharmacies in town.

He looked very surprised and said, "Well, I have to ask about a clarification on a prescription." We looked at the script in question together, and quickly resolved the issue. Aaron was standing behind me with the grocery cart, and said, "The doctors are providing some excellent service in returning pages these days!"

I think I may have set a new world-record in "timely return of a page". Yet another benefit of practicing rural medicine!



*the highlight of sitting around drinking coffee at the Frob today was seeing Polar Man! I guess even super-heroes need some caffeine. It's been a while since I've seen Iqaluit's resident do-gooder. I think he might have been walking through town with the Christmas Parade a couple of weeks ago...other than that, the last time I saw him was at the museum last March when I was up visiting Aaron. All I remember about that encounter was having a very surreal conversation with a guy dressed in a white sweatsuit and a full-face ski mask, who was snacking on bannock. Who knows when our paths will cross again, Polar Man?

Sunday, December 16, 2007

All dressed up with some place to go!

Earlier this month we had a chance to go to a charity ball put on each year here in Iqaluit by First Air. For those who've never travelled in northern Canada it may come as a surprise that there are literally dozens of airlines you've probably never heard of shuttling people between the south and the north, as well as between northern communities. As one Inuit elder told me 'The Inuit people are still nomadic, these days we just use airplanes instead of dog-teams.'. His comment was partly in jest, but travel by air is a normal way of life here in the Arctic, and the business of the small airports up here reflects that.

As one of the biggest of the northern airlines First Air has a few major initiatives to give back to the communities it serves. The First Air ball is one of those initiatives. The money it generates goes to a number of important local charities (including the Women's Shelter which is an excellent organization and very underfunded). It's a big dinner and dance, where everyone dresses to the nines, and each table has a local celebrity (from the premier on down) to provide stimulating conversation. Like any good small town event it's held at the arena (well....at what used to be an arena before the floor somehow malfunctioned and made ice-making impossible). There was a great band, flown up from Montreal (I guess when you are the airline you can fly up who you want) who played hits from the '80's til the wee hours.

It was a fun night to cut loose and forget the worries and stresses that go along with medical practice. I can now also say with some certainty that although Nunavut has a small population, I will back our premier in a dance-off against any other province's premier, any day of the year....

Here's a pic from the event...

Monday, December 10, 2007

Northern Images


Colours on the ground. Photograph by Dr. H, Apex Nunavut, Fall 2007

Saturday, December 8, 2007

A White Christmas

One certainty when you live in the arctic is the promise of a white Christmas. We've had snow on the ground for almost 2 months now, and winter has a firm grip on Iqaluit. So far it's been a lovely winter here with temperatures warmer than usual, averaging -10C to -15C. It's nice weather to walk around in, though the warm temperatures have brought a little more snow than usual, and the ice on the bay is still not thick enough for safe travel. I understand from watching the CBC news that Southern Canada has been suffering through a dreadfully cold December and is looking at a colder than average winter (incidentally the temperatures there have also been in the -10 to -15 range).

The hospital is decorated for the holidays and we put up a small tree at home to bring some holiday cheer. Since we're way above the tree-line it's a fake tree with fiber-optic lights (it's sort of like a cross between a pine tree and a discoteque). Regardless, it brightens up the house and feels Christmas-sy. We have a lovely seal-skin angel to top it all off.


The small town Santa Claus parade is an event familiar to anyone who grew up in a non-urban environment. Everyone in the town is either in the parade or watching the parade, and the parade itself is mostly composed of any truck in town that has flashing lights. The Iqaluit Santa Clause parade started just outside our house at the Arctic Winter Games Complex, and we had a great view from our back porch. I'm happy to report that Santa did make an appearance, after all it's only a 25 minute reindeer flight from his place...

Saturday, December 1, 2007

Appropriate Apprehension

There is no more sickening feeling then looking down the blade of a laryngoscope and not seeing the airway, repositioning, attempting secondary maneuvers, and still nothing. Except perhaps the sight of the just delivered head of a baby suck back against the perineum in a severe shoulder dystocia. Or maybe a newborn baby, flat and blue and not responding to artificial ventilation. It makes the pit of your stomach drop. The feeling is sickening. These are cases that cause prudent people apprehension to even consider. In the seconds before repositioning the laryngoscope works and the airway slides into view, before the baby's shoulder disimpacts and delivers, or as another baby gasps it's way to a 5 minute APGAR of 9; these are the moments where the specter of that sickening feeling sits on your shoulder and waits to slide it's hand onto the back of your neck.

Medicine here in the north is a proposition that calls for interdependence between doctors, nurses, ambulance crews, flight paramedics, and interpreters. To practice you need to be able to trust that the other people in the team know what they're doing and will make good decisions. Although confidence can be a marker of an experienced person, in some situations it can also be a red flag. As a Family Medicine resident, one of my teachers told me that every grey hair he had was from a delivery (he was an experienced doctor with over 30 years of obstetrical experience, and a head full of steel grey hair, and always walked into a delivery with a deep breath preparing for trouble). If the specter of apprehension doesn't visit you as you walk into the case room to do a delivery, you simply haven't done enough deliveries to know better.

I once took a phone call from a very nervous nurse in a remote community who was taking care of a child who had stopped breathing. I talked her through bag masking the child, putting in an oral airway and an orogastric tube, and ensuring she had a good seal with the face mask. She was well trained and did fine, but even as the situation moved from chaos to control she worried: 'This might end badly'. Indeed. Appropriate apprehension. I arranged for a medevac, and felt that the pediatrician should go along to intubate the child. The flight medic disagreed: 'I can intubate kids, no problem', he told me, 'I've done it lots of times. You don't need to send a pediatrician' The temptation was to take his confidence at face value, to feel relieved that an experienced manipulator of the pediatric airway was on the case, and flying to the rescue, but instead the pit of my stomach dropped. I know people who intubate kids (Dr. H. among them), and it seems that the more children's airways a person looks in, the more cautious they become. Things can go wrong, and there is a marked difference between being able to handle the situation as long as it goes well, and being able to handle the situation.

Perhaps one of the most dangerous things that can happen to a young doctor (or nurse, medic, etc.) is to have everything go right early in their career. It blurs the line between the confident and the cavalier. Complications breed apprehension, but also strategies for coping with future complications. In an isolated place, where things can go wrong quickly, and help is limited, confidence can be misplaced and sometimes apprehension is simply a marker of good experience.

Monday, November 26, 2007

Sunday, November 25, 2007

Northern Images


Old Whaling Station, Pangnirtung Nunavut, November 2007

Monday, November 19, 2007

Am I really that fat?

I was seeing a very nice lady in follow-up of her hypertension the other day, and I'd just finished checking her blood pressure and heart rate. We had left the exam room and walked back into the adjoining office; we both sat down and we were chatting while I finished up my SOAP note on her chart. I don't remember what we were talking about, but out of nowhere (or so it seemed to me) she asked, "So, are you pregnant?"

For the record, I am 100%, without a doubt, definitely NOT pregnant.

It would be one thing if this was the first time I've been asked this, but this was the third time in the last few years. I vividly remember the other two times, as follows:

The first time someone asked me if I was pregnant was in med school. I was on call for pediatrics, and the resident I was working with that night asked me, "When are you due?" I sputtered a bit and said, "Excuse me?" She turned a ripe shade of pink and tried to take it back, but the damage was done. However, it all worked out to my advantage in the end, when she was too embarrassed to phone me to do any admissions that night. (It's also quite possible that, given the slim numbers of pediatric patients in the hospital where I trained, there were no admissions; I prefer to believe it played out my way.)

The second time I was asked was a rather sad moment. I was doing peds anesthesia and went to the ICU with my staff to get our little patient. This poor kid had some respiratory compromise as a result of a congenital syndrome, and his mom was sitting alone the corner of the room, looking distraught. I asked her if everything was alright. She looked at me and said, "I just found out that I'm pregnant again and I don't know what to do. I'm at the hospital all the time and I don't have much help." She stared at me for a moment and asked, "Are you pregnant too?" I made some lame joke about eating too much dessert, but I felt really bad for her. Here she was, in the PICU, watching her one sick kid get wheeled off to the OR, worrying about how she could possibly look after another one. Makes a pudgy tummy seem like less of a big deal.

I've always said it's best not to ask a woman if she is pregnant unless you are fully gloved and gowned and she is pushing. But let me revise that. Do not ask. Period. Except perhaps in the following circumstances:
-You are seeing her for abdominal pain and need to rule out an ectopic
-You are prescribing her medications
-You are sending her for an xray
-She is wearing one of the following shirts and obviously wants you to comment on it:




(you can buy all these, AND even more offensive ones, at cafepress.com)

All that being said, yes people, I am starting to get the hint. I need to go to the gym, do some crunches, and stop eating all that chocolate. Got it.

Sunday, November 18, 2007

The restless sleep of TB in the arctic

A man walks into emerg. on a quiet Wednesday evening. His wife is with him and prods him towards the registration desk, he is reluctant. His face does not betray his age, but tells me he has spent much of his time working on the land. He moves with subtle economy and purpose. I notice that he is wearing beautiful kamiks, and wonder if his wife made these for him. The receptionist hands him a mask and he sits in the waiting room. A cough shakes through his chest and out his mouth, and his wife watches him with worry. Outside the snow is blowing hard, it's a bad night to make the walk to the hospital.

What brings you in tonight?
He is coughing blood, she says.
For how long?
Maybe 2 months.
Are you losing weight?
Some.
Sweats?
ii (ee)

He is wearing many layers of clothes, protection from the elements and from the gaunt figure that speaks volumes about his degree of weight loss. His chest has lots of coarse sounds except in the left upper lobe, where I hear no sounds at all. He coughs frothy red sputum into a cup as another cough rattles from within.

I think I know what the x-ray will show, what the sputum will reveal under the gaze of the microscope. It is treatable, curable even. He will be able to go hunting again. I think you have TB, I tell him, puvallunaqtuq. His face does not betray him, but his hand tightens over his wife's. There are many layers of meaning here.

Tuberculosis has been present in humans for thousands of years, it is ancient, evolved, and subtle. It stalks it's human prey like wolves on the edge of a caribou herd, preferring the old, the young, and the sick, but also taking what opportunity pushes into it's path. Unlike flamboyant young illnesses that kill at rates so rapid they at times limit their own spread TB is patient. It infects young healthy victims and when no opportunity exists it simply walls itself in, to lay latent, asleep, biding it's time and waiting for any subtle slip of the immune system, any opportunity to awake, to divide, and to spread. A TB death can be dramatic, as the infection erodes into the large blood vessels of the chest. More often however the process is slow, the resources of the victim consumed by the infection until the are exhausted, wasted and consumed by the disease (hence the name Consumption).

For most of history there have been no effective cure for TB, and it has been endemic to much of the world. Much of treatment has revolved around long term hospitalizations in sanatorium with programs designed to build the patients health and immune system, coaxing the Mycobacterium tuberculosis back into latency. In spite of sanatorium TB killed the young, the old, the famous and the infamous. In 1943 the antibiotic streptomycin was discovered and a new era of TB treatment, an era in which cure was possible, began.

In the 1950's and '60's Tuberculosis was endemic in the Inuit population. Like wolves circling the caribou it struck mainly at the edges, the old, the young and the sick. In the times of famine it broadened it's reach, and in many who seemed unaffected it lay quiet, biding it's time. The government of Canada instituted a program of screening and treatment for Inuit. The Canadian Coast Guard Vessel C.D. Howe cruised the arctic coastline bringing aboard those it encountered for chest x-rays. In practice those identified with TB were not allowed to leave the ship (for fear they would escape rather than submit to treatment), not allowed to say goodbye to families, and not allowed to undertake the difficult task of making arrangements for the families they were leaving behind. Gathered and transported to the south for hospitalization and treatment.

In spite of the often good intentions of hospitals to provide country food and a positive environment for patients the experience was often anything but. Many patients died in the south, and neither their bodies nor word of their deaths returned home. Treatment could take years, and among those who survived many lost their language, or drifted into new lives in the south. For those who returned home they sometimes found that their families, who didn't know if they were even alive, had moved on, spouses remarried, children grown. Like their language, skills necessary for living a difficult nomadic lifestyle had atrophied, unused for years.

I know what his chest x-ray will look like, I can imagine the cavity I will see in the left upper lobe. His face does not betray his emotions, but the tight grip on his wife's hand does. He is old enough that some of his own elders disappeared on the C.D. Howe, and some of his immediate family may have died, consumed by the disease. Canadians often think of Tuberculosis as a disease of elsewhere, confined to distant and remote regions of the globe. In Nunavut TB plods onwards at a rate an order of magnitude above the rest of Canada. In overcrowded houses there will be many family members who will need to be treated for latent TB infection. His own treatment will involve 14 days isolated in hospital and a further 12 months of treatment. It will involve the testing of all his contacts and and family, treating those with latent infection. He will recover, he will hunt again.

There are many layers of meaning here, the personal, the historical, and in the deepest layer there is an old and softly spoken story about a small bacterium that is as old and as evolved as human-kind. A story about a bacterium that has more patience than we will ever imagine, and that for unclear reasons has chosen this corner of the arctic as a place to rest, until conditions in the herd at large once again favor it's spread.


The patient presented in this story is fictional, but the flavor of the story is accurate. TB continues to be a significant issue here in Nunavut.

Tuesday, November 13, 2007

Reviews

The Walrus is one of my favorite magazines. It's sort of a cross between Harpers and The New Yorker, but from a unique and Canadian perspective. It's always informative and topical, and the sort of magazine that leads to interesting conversations with strangers in coffee shops.

This months issue of The Walrus has a special arctic focus. There are articles on the history of the arctic and the future of the arctic as well as current topical discussion. To Live and Die in Wales, Alaska is a sad and gripping article that describes some of the ways that Inuit communities have struggled and become disconnected over time (due both to tragic circumstance and outside interference) and the consequences this has had. The article focuses on the life and death of a young man, who in another time and place would probably have been a leader in his community.

The Walrus is always a fantastic read, and this issue gives a sometimes wonderful, sometimes painful look into arctic life. I'd recommend the issue to anyone interested in learning more about the arctic. It's November's issue so may still be available at news-stands, and should be in many local libraries. Happy reading!

Monday, November 12, 2007

Jamaica, yea mon

We're back home in Iqaluit after a 2 week holiday that included a stop in Toronto to see family and some R&R in Jamaica. We had a great time snorkelling, swimming in the ocean and lounging around the pool. Dr. H. kept us well sunscreened so there weren't any burns. The trip was fun and relaxing and we are returning to Iqaluit re-energized.

In our absence the new hospital here in Iqaluit has been opened and is now up and running! It should be fun to work in a totally new building, and we will try to get some pictures up of our nice new workplace.

Here are some pictures we took in Jamaica....ahhh, I almost feel the ocean breeze.

The main arcade at our resort.


Some flowers around the resort.




This fellow was part of the entertainment crew one night and entertained with some fire breathing!


A couple of pictures of us enjoying our vacation.




In other news I am going to modify the format of the blog a bit to try to increase my posting frequency. Thoughtful posts can take time to produce and when work gets very busy the blog seems to get pushed to the back burner. I'm going to try also including some shorter posts with article links, book reviews or interesting facts pertaining to arctic life or health care, in between longer posts. We'll see how it goes, and feedback is always appreciated!

Saturday, October 27, 2007

Time to replenish our Vitamin D

Sand. Sun. Tempatures above -10 C. Ahh. Today we leave for a 10 day change of pace in Jamaica. It will be the first time we've been out of the north since our arrival July 15. We'll stop in Toronto for a couple of days to visit family on our way to our beach adventure. It will be interesting to be back in the bustle of the city (Dr. H. tells me she will be going on a shopping spree at Yorkdale). The current temp. in Toronto is 16 C, and that will be the warmest weather we've been in since our arrival here in Iqaluit. So good-bye parkas, good-bye sealskin mitts. We're off to stock up on Vitamin D for the long winter months ahead.

Wednesday, October 24, 2007

The hive at night...

During the daylight hours hospitals hum along like giant bee colonies. Workers everywhere, task oriented, some bring things in, some bring things out, some cleaning, some building, some fixing things. It hums, loudly, a never ending drone of activity punctuated by occasional bursts of what seems to the untrained eye like moments of utter chaos, and to the participants like an intricate dance. The biggest hospitals never sleep, the buzz goes on and on, in shifts, in perpetuity. The hive that is the hospital drains a little energy out of each worker to keep as it's own. It can be exhausting.

In smaller hospitals (like the hospital here in Iqaluit) the buzz quiets at night. All the excess movement stops, and all that are left are the nurses, a doctor, and a few sick people. Coughs, colds and such rarely make the trek out to the hospital emergency room in the middle of the night (especially when the weather is fierce), and the people left coming in are generally there for good reason. Alcohol brings them in, lacerations, fractures, and alcohol overdose. Pain brings them in, chest pain, renal colic. Breathing problems bring them in, heart failure, asthma, pneumonia. Fear brings them in, babies with fevers, relatives of dying patients who are afraid.

The hospital I trained at was right on a lake and had a spectacular view from the main tower. On a summer evening a chance to appreciate the view of sunset over the water from the top floor was a wonderful stolen moment. Here in Iqaluit I like to step outside at night in the quiet moments, shivering in the cold, to watch the dance of the aurora.

At night there is sometimes time for moments of laughter, or moments of sadness with time to appreciate it's meaning. Nighttime produces snacks in hospitals, baked goods that magically have no calories during the darkest hours. The patients left can be sick but it is easier to focus on them without the surrounding buzz. The bees are mostly sleeping and the hive is quiet. It's my favorite time to be in the hospital.

Thursday, October 18, 2007

Why low risk obstetrics isn't...

In Canada obstetrical care is divided up between OB/GYNs, Family Docs and Midwives. The exact nature of the mix depends mainly on the region of the country and local practices. In some larger centres only OB/GYNs do deliveries regardless of risk level, while in some smaller settings there is nary an OB/GYN to be found. In general a smaller percentage of family doctors are practicing obstetrics than in the past. In part this is due to difficulties with always being on call, difficulties earning a reasonable living as a family doctor, and increased risk of facing lawsuits coupled with higher malpractice premiums. People have strong feelings about obstetrics, and who should be doing what.

Obstetrics is one of my favorite parts of family medicine. In general it's one of the happiest parts of my job, and one of the few times I see totally healthy young families as they go through a happy experience (most of medicine being focused on ill people rather then well). That being said, the stakes are high in obstetrics. With 2 young and healthy patients (mom and baby) the expectation is that nothing will go wrong...a very different expectation then when caring for the very ill. When it comes to obstetrics my only agenda is safety. Most of the time labour is a natural process that proceeds smoothly and needs no intervention. In a minority of births intervention is required and quick and efficient actions can prevent bad outcomes for both Mom's and babies. As a Family Doctor I prefer obstetrics of the low risk variety, cases where bad things sometimes happen, but aren't expected to.

Here in the north obstetrics is made trickier by the issues of distance. Women from communities all over the island come down to Iqaluit at 36 weeks to wait to give birth. It can be a difficult experience for women who may have to be distant from their families for as long as a month while waiting to deliver. Obstetrical practice here on Baffin Island is fairly busy for a small hospital and there are between 400 and 450 births a year here (busy by the standards of small hospitals in Canada). We have about 5 Family Doctors who practice obstetrics, and a general surgeon who can do C-sections when required. In the arctic we are distant from help (evacuating a patient to a tertiary care centre typically takes 12 hours if the weather is good, and a plane is available for transport), and we try to limit those births to ones where problems aren't expected. In a perfect world that means that pregnancies that are at high risk for complications are sent on to a higher level of care early on, in order to avoid complications. As a general rule we try to limit deliveries to women who are relatively uncomplicated, at least 35 weeks along, and who have neither major maternal medical issues, nor known fetal abnormalities.

Because the obstetrical population is young and healthy, and because as a group of doctors we discuss each and every patient prior to delivery and identify patients at higher risk needing a higher level of care our complication rate is low (and our section rate is around 7%). Like any hospital with a fair number of deliveries we see complications of labour and delivery that can't be avoided; abruptions, post partum hemorrhages, prolonged rupture of membranes, pre-eclampsia and eclampsia (lots and lots of pre-eclampsia). But the remoteness, and the distances also lead to some situations that might not happen in the rest of Canada, where transfer to higher level of care is more easily available, and some of these situations are certainly higher risk than I enjoy as a Family Doctor.

One of the trickiest situations in obstetrics here in the north is the obstetrical medevac. It usually begins with a phone call in the middle of the night. Half asleep I answer the phone to hear I am needed for a medevac to Igloolik, or Resolute Bay or one of the other remote communities of Baffin Island. The usually story is a young, otherwise well woman in premature labour. It's a difficult situation, as usually I am flying to a health centre 3-4 hours remote from our hospital here in Iqaluit, and minimally equipped, to possibly deliver a high risk premature baby. Once I'm there I'm at least 3 hours travel time back to my hospital here in Iqaluit and a further 12 hours until the patient could be transferred on to a tertiary care setting.

I like to arrive prepared so I call the nursing station and ask for specifics. How far along in the pregnancy is she? Are the dates certain? Is there a history of prematurity or complications in previous pregnancies? Does the mother have any known health problems? Has a fetal fibronectin been done? What is the cervix like? Usually I instruct the nurse to begin an attempt at tocolysis (stopping labour with meds.....which is of course it's own discussion about effectiveness), ask for a dose of Betamethasone to be given if the dates are even close to 32 weeks, and head to the hospital to pick up supplies. Supplies take a small amount of time to gather, and time is of the essence, but it pays to go prepared for everything because once there there is no more back up, and no extra equipment.

Here are the extras I like to bring in addition to the usual gear and meds on the medevac plane:

2 units of O- blood
Blood tubing for infusion
5 pairs of size 7.5 sterile gloves
5 packs of 3-0 Vicryl suture
An OBS tray
An umbilical line kit
A number of various size angiocaths (makeshift chest tubes for babies)
A large bottle of Ketamine (a good choice for a required but nerve wracking sedation for a manual placenta removal outside of the hospital)
A difficult airway kit (for when the above goes awry)
4 vials of Hemabate (There are 2 on the medevac plane and 2 at the nursing station, the maximum dose for severe post partum hemmorhage is 8 vials)
Some misoprostol
Some nifedipine
Some indomethacin
Some surfactant
Extra Oxytocin
Some Narcan
Baby sized endotracheal tubes
A syringe pump
An infant ventilator
An incubator

The medevac plane is a KingAir 200, a fast, reliable duel prop plane with a good record in the arctic. The plane is without facilities, and a bathroom trip is the mandatory last thing to do before taking off. The plane drones, pure white noise, it's entrancing. I sit back for the 3 hour flight. Sometimes I joke around with the paramedic I'm flying with, but more often I sit back and run scenarios in my head. What will I do if the baby comes out flat? I run the the NRP algorithm in my mind. What if I have to intubate the baby or put in a UVC? I go over it in my head. What about a big hemorrhage? Same drill. What if both Mom and baby are sick at the same time? I go over how I will instruct the various people available for help. The plane lands, sometimes in the day, sometimes at night, sometimes through a hole in the clouds only the pilots could see. On gravel runways, on snow covered runways, through crosswinds, as soon as we touch down I call the nursing station for an update on the sat phone. Has the baby been born, has the labour stopped, has the cervix changed.

The second worst place the deliver a premature baby is in a remote nursing station. The worst is in an airplane. If there is any chance of getting the patient back to the hospital before a baby is born, time is of the utmost essence. The phone call to the nursing station determines if we travel light (no stretcher, vents or incubators because unloading the plane takes significant time), or travel with all of our gear. We drive to the nursing station, and I assess the patient and determine if we can safely make it back to the hospital, or if we will deliver the baby at the nursing station. The assessment involves a quick review of records and history (especially for previous precipitous deliveries), a review of contraction pattern or absence there-of, assessment of the cervix, the fetal heart pattern and of a fetal fibronectin test if available. If we fly back I usually make sure the patient is well loaded with tocolytics, usually nifedipine (because there are to be NO babies born on planes), and we move back to the plane as fast as possible. If it is safe to fly back to Iqaluit, I like to be back at the airport before the plane is refuelled, a turn around time of about 20 minutes. Once on the plane we monitor the patient and hope (because there are to be NO babies born on planes).

Sometimes medevac flights are lovely. Sometimes the pilots will turn off the cabin lights and the running lights as we fly through a field of northern lights. There is an adage here in northern medicine that 'we do the best we can with what's available'. It would be lovely if there were high risk obstetricians in every community, or even within easy reach. It would be nice if there were tertiary care hospitals here in the arctic. It's easy to look from the outside and see or say that we're falling short. The reality though is that it's unlikely those things will ever be here, so those of us who are here do the best we can with what we have. And we hope for the best. Usually it turns out well, though it sometimes feels riskier than I had bargained for as a family doc doing obstetrics. I'm pretty sure that every flight adds a few grey hairs to my head.

Saturday, October 13, 2007

Lighting up the night


The northern lights are one of the perks of living at high lattitudes. They are difficult to capture on film, and although I've been trying this is my best shot to date. I took this picture the other night from just outside our backdoor. We've had a few good aurora nights recently and I've been trying to get a few shots of them whenever possible.
The above shot was taken from a tripod on my Canon G7 powershot with the f-stop set to 2.8 and a 15 second exposure time. The camera does some automatic noise cleaning and outputs the picture as a jpg.
If anyone has any hints for captuing the aurora on film, please share!

Friday, October 12, 2007

Only in Iqaluit...

Here are two emails I got at work this week, word for word.

Number 1
"Northwestel continues to correct the problem of calls inadvertently reaching numbers other than the one dialed in Iqaluit. In order to complete the work, NWTel needs a 60 minute outage to the Iqaluit phone system beginning this evening at 18:00 EST, Thursday Oct 11, 2007.

We apologize for any inconvenience this may cause."

Number 2
"Please be advised that Nakashuk School, in Iqaluit, will be closing due to an unusual odor and parents should go pick up their kids.

Thank you."

I love that we live in a place where you can dial a specific number and end up with a totally random stranger on the phone, and that you can get out of school early on a Friday because it smells funny.

Sunday, September 30, 2007

Hall Beach

Warning: Some of the following images are not suitable for young children, people with sensitive stomachs, and any members of PETA. Consider yourself warned.



A few weeks back I visited Hall Beach to do a community MD visit. Each of the settlements around Baffin Island and the nearby mainland are covered by a specified physician in Iqaluit. The doctor covering that community takes calls from the nurses about more complicated patients, and would ideally visit to see patients and review charts about every 3-6 weeks (depending on the size of the community). Unfortunately, current physician staffing levels haven't allowed these visits to happen as often as they should. Luckily, I got to fly north of the arctic circle to visit Hall Beach and see the patients there. I had a great time, and I'm looking forward to going back again in the future.

Hall Beach is a community located on the Melville Peninsula, across the water from Baffin Island. It was founded in 1957, and was named for Charles Francis Hall, an American explorer. Hall Beach is not too far from Igloolik (Iglulik), another community on the peninsula. The actually "beach" is very rocky, and the topography is very flat, unlike many of the spots on Baffin, but I thought it had a beauty all its own. It's probably the smallest and most isolated place I've been so far; about 600-700 people live there, and pretty much the whole town knows each other. So it was pretty obvious I was a stranger...However, everyone would say hello on the street, and the kids would come up to me and ask me my name. I found the people there very nice.

Here are some of the highlights of my trip:

Arriving at the airport




I love the obligatory picture of the Queen (circa 1970) hanging on the wall.


The health centre



The lovely health centre staff



Some adorable sled dog puppies




While they appear adorable and cuddly now, once they're grown, it's best to stay far away from the sled dogs, which are usually kept chained up and away from the houses. These dogs are NOT pets. They are working dogs. You do not pet them and give them doggy kisses. They might eat you. Just kidding. Or maybe not.


The town

Community centre




The mall (ie: Northern)




The co-op



You may notice that there are no signs on the two (count 'em TWO) stores in town. I guess the scrawled spray paint job counts as the sign. Then again, in a place this small, do you really need a sign?




Churches





The hotel (pretty swanky! great food)



A crazy looking vehicle


Can't remember what this is called, but I guess they used to use these to go out on the land and look at polar bears or something.


The dump on the beach


I walked out along the beach and found...the dump. Where the heck did that old yellow school bus come from?


The spoils of the hunt!

Cariboo skulls





Cariboo skins



A seal skin being stretched out



Ummm...walrus?


My new friend, who was heading down to the beach to chop the tusks off this walrus. It's not often you can make friends with a guy walking down the street with an axe and a severed walrus head. However, you can tell he's a good guy, because he is obviously a Leafs' fan.


We apologize for the lack of recent posts...we've been pretty busy and the internet connection is so slow that uploading these pictures took forever. Fear not, we have some other posts in the works, so check back soon.

Saturday, September 22, 2007

The little differences make things interesting...

Inspired by a post about a taxi strike from my cousin Liana's website I thought I'd add a post about the way the taxi system here in northern Canada works. Now taxi's are an interesting topic in many places. In Toronto and Vancouver many of the taxi drivers are well educated imigrants to Canada. I've met doctors from India, engineers from Iran, and professors from Lybia all making a living behind the wheel. One of the tragadies of the Canadian immigration system is that with one hand it welcomes highly educated newcomers to Canada, while the other hand blocks them from working in the professions in which they are educated. Meaningful routes towards having their professional qualifications assessed, updated and recognized here in Canada being very limited.

Here in Iqaluit the cabs drivers mainly hail from Quebec. Many are French Canadians by heritage, while others are immigrants first to Quebec, and later further north in search of opportunities. They are an interesting, and cosmopolitian bunch. They'll point out the sights along the way, tell you which dogs are causing problems, and generally give you the gossip of the town.

Cabs in the south are bright and shiny. Many cities have bylaws that mandate cabs be no more than a couple of years old. They are also mini fortresses on wheels, the front and back seats divided by bullet proof glass, a camera trained on the back seat, a meter glowing with red numbers letting you know how far you've travelled and what you owe and a GPS screen to guide the driver. There are rules about when the cab must run the AC and what music they can have playing.

By contrast a cab in Iqaluit can seemingly be any vehicle as long as it has a sign on top from one of the local companies. The vehicle can also be of any age, and since the cabs are often run around the clock some of the vehicles have their share of wear and tear. There are no dividers, no meters, and only a CB that tells the driver where the next call waits for them. A ride anywhere in town (or to the adjecent town of Apex) costs $6 per person no matter how long or short the journey. The cab may stop to pick up others along the way, and may make detours that seem random, but bring them by high pick-up areas hoping for an extra fare on the way to your final destination.

Up until a few years ago cabs were the main means of transportation in Iqaluit. There were few personal vehicles and taking cabs was a part of everyday life. Over the past few years there has been a dramatic influx of vehicles of all types. Cars, trucks, SUVs classic cars, even Hummers. Iqaluit has them all. I've heard than on average ther are 300 more cars shipped up every year, a substantial number for a place this size. The influx has been hard on the cabs who have seen business go from a hustle to keep up, to a hustle to survive. One of the really important functions the cabs still serve is transportation for many of the medical folks here in Iqaluit. Since it is very expensive to ship and keep a car here in Iqaluit many of the people who come here to work at the hospital choose to take cabs instead.

In small, isolated places everyone has to look out for everyone else in order to survive. In that spirit the cabs of Iqaluit offer emergency transportation to the doctors of the town. When a doctor is called in to the hospital to deal with an emergency, the nearest cab will drop whatever else it is doing in order to provide quick transportation. When I phone in to the dispatch and say 'It's Dr. J., I have to get to the hospital quickly!', a cab arrives at my front door quickly. 'How fast?' the driver asks. I say either 'Pretty fast.' or 'Really fast.' depending on the nature of the emergency. When I say really fast that's exactly how the cabs go, like NASCARs, racing down the road, drifting around the corners, making every effort to get me to the hospital on time.

I wonder how often cabbies down south are responsible for getting a doctor to the hospital in time to catch a baby, or treat someone who's seriously ill? Probably not often, but here in Iqaluit it's just another part of regular business...

Friday, September 7, 2007

Odds and Ends

Winter has Arrived!
Well, not exactly but the first snow of the year fell yesterday (Sept. 6). It was wet and it melted as soon as it hit the ground and it only lasted for about 30 minutes, but it was definetely snow. Welcome to the arctic. Perhaps it will be an early start to winter, although recent history argues against it. For each of the last 2 years the bay has taken much longer than usual to freeze over. This has real ramifications for the people who live here because the ice is a major route of travel between nearby communities during winter and the floe edge (where the ice meets open ocean) is well populated with seals which are a major food source for some people. An early winter (or even an on time winter) wouldn't be entirely unwelcome.
In the picture below you can see the snow capping the hills in the distance.


Take out in Iqaluit
In Vancouver Dr. H and I spent many a Friday night curled up on the couch watching a movie and eating a dinner of take-out Thai food. Iqaluit is lacking in Thai resturants so tonight I tried my hand at opening my own Thai Away Home. I cooked phad thai, spring rolls and wonton soup. Dr. H gave it an enthusiastic thumbs up. Here's a picture of the finished product.


And speaking of food in the north...
The food selection here in Iqaluit is actually quite good (in spite of my previous lament about the lack of Tim Horton's). There are several grocery stores here in town, the two largest being Arctic Ventures and Northmart. Both actually have a fair selection of interesting foods, and overall the selection is probably better than in most small towns in Ontario. The produce here in Iqaluit is usually pretty fresh as it gets flown up on a regular basis. (I'll admit to recently purchasing a bunch of grapes from Chile....each with a sizable carbon footprint I'd imagine). The Northmart is a fascinating place, it's a large grocery store with a clothing section, a sporting goods section, furniture, a pharmacy, furs, and (my favorite part) a middle isle that in winter has a long row of skidoos and in summer ATVs.

When I was a resident I spent a couple of months working in Moose Factory, a small Cree town on the southern tip of James Bay connected to the south by a rail like to Timmins. The food at the Moose Factory Northern store was decent, but even more expensive than here in Iqaluit. Like many northern hospitals the doctors in Moose Factory travelled out to the smaller communities in the area to provide medical clinics. When sent out to a community we would be issued a food box containing what the hospital judged to be an adequate amount of food for the trip (food in the smaller communities was very expensive and sometimes the stores wouldn't have much in stock). The food box usually contained some spagetti, ground beef, tea, sugar, a couple of pork chops, a couple of loose carrots and onion, a banana, bread, eggs, and a litre of milk (and often a few other odds and ends). On one slow spring day in Moose all the doctors got together for an Iron Chef style cook off and pot-luck dinner. It was amazing what people came up with (I made a banana bread pudding), and great fun. Being in places where you have to make your own fun sometimes brings out the best in people...

Monday, September 3, 2007

The Fall of Summer

Labour Day

Today is the first Monday in September, historically a day set aside to honor workers, unions and the people who keep the economy of Canada moving. For many people in Canada Labour Day has many other meanings. It is summers last hurrah, the last weekend at the cottage, the weekend to close the cottage or the pool for the season, it's the first night to get lunches ready for kids heading off to school, or maybe the weekend to drive older children off to their dorms for the coming months of college or university. It's the weekend that the first red and yellow leaves start appearing on the maples in Ontario. For many Canadians it's a Monday to sit around with friends and enjoy some classic Canadian CFL football (that's 3 down's, wild passing, and very high scores for any American's reading) along with some fine Canadian beer.

For me the Labour Day weekend is the first time in every year where the air smells like fall, when (no matter how old I get) I feel like I'll be going back to kindergarten, high school, university and med school tomorrow, and when the oilthigh (the fight song of Queen's University) will run through my head at least once.

Happy long weekend!
Photo credit: October Gold by Franklin Carmichael



The worlds shortest forest
The close cropped tundra here in the arctic is a forest of sorts. It has a wide variety of plants, mushrooms and lichens, and it's growth is slow and ponderous, inching it's way across otherwise barren landscape. Here are a few pictures of this minature world up close.