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!