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.