Friday, October 3, 2008

Updates...

As most of you will have noticed I have stopped writing on this blog for the time being. Dr. H and I are back in Southern Canada, she having returned to further anaesthesia residency, and me to emergency room work in the Vancouver area. As I had mentioned previously it is difficult to know what to write about, city life doesn't lend itself nearly as well to story telling.

I am considering starting another blog with a focus on discussion of medical issues from a systems standpoint...less exciting to read, but interesting to write. I will post a link here if I do decide to start that blog.

As for the overall experience of living in northern Canada, it is difficult to encapsulate, but it was exhilarating, challenging, and perspective shifting. Adjusting to southern life is at times a challenge. The pros and cons of southern living were, I think, summed up nicely by an Inuit elder named Etuangat, who lived his life in the Pangnirtung area of Baffin Island and in 1995 travelled to Ottawa for the first time to receive the Order of Canada for his life long dedication to the health of the Inuit people. He was asked for his opinion on trees after seeing them for the first time and responded "One tree by itself is very nice, but when they're all crowded together they block the view." Wise words indeed...

Wednesday, August 6, 2008

City Rehab

I've now been back in Vancouver for a couple of weeks. It's definitely an adjustment. Everyone is in a hurry, all the time. You can buy anything at any time and choice is limitless. Since I've been back I've been working as a hospitalist in a small hospital in the lower mainland. It's been fun so far but it's all a little more anonymous than the north.
At the end of August I'll make a short trip back to Iqaluit, I'm looking forward to it, the end of the summer in the north is beautiful, the tundra is in flower, mosquito season is at an end and the days are bright but cool. Perfect for hiking or fishing!
In the mean while I'll lay low here in Vancouver. It's difficult to know what to blog about, life in the city has so many options, but in some ways seems difficult to understand. Really, why the rush?? Why the big deal??? Oh well, I'll re-acclimate eventually! (Or maybe my ongoing trips north will make me an endlessly strange person to city folk?)

In the mean time, here is a picture of a DC-3 taking off over Grise Fiord. The DC-3 is one of the planes that opened up the northern frontier in Canada. This particular plane was built in 1943, and is still serving in arctic duty. Just down the beach from the settlement of Grise Fiord there is a flat (slightly) grassy area with old fuel cans with holes in the tops lining the sides....the old runway, fully equipped for dark season landings....I wonder if there's an old runway on Jericho Beach??

Friday, July 11, 2008

Beginnings Ends and In-Betweens

The house is packed, the excess stuff given away and I fly out of Iqaluit tomorrow afternoon. It's been a wonderful year here and I've learned many things. I definetely have mixed feelings about leaving. I'll be happy to see Vancouver again and most of all to see Dr. H. (who has been out for a month already), but I'll miss the work here and the small town atmosphere and most of all the people. Being a small town doctor is an old fashioned idea but it is a nice occupation. The fact that you see your patients at the grocery store, at the movies and basically everywhere is, mainly, a nice thing. People seem to get a kick out of seeing their doctor doing non-doctor things (yes we have to go grocery shopping too, and no I didn't buy only healthy food!) I'll be coming back to Iqaluit (and Pangnirtung) regularly over the next year but it will be different to not live here.

There is lots to learn here, medical and otherwise and I think Iqaluit is a great place for young docs to work to enhance their skills. Here are a few important things I learned this year....

1) Everything is not a big deal.
2) Things don't always need to be on time.
3) More choice is not always a good thing.
4) You don't need much stuff to be happy.

(I also learned that people from down south talk way too fast, and that Inuit elders are as tough as anyone I have ever met, and many more lessons along the way.)

When Dr. H. and I first talked about moving north for a year we had mixed feelings about it. In the end our decision came down to this; 'When we look back do we want this to be the year we did something, or the year we did nothing?'. We took a chance and moved north, to both good and bad experiences but most of all to new experiences and ones that enriched us. Hopefully we take some of that wisdom with us into the rest of our lives, wherever that may lead....

Tuesday, July 1, 2008

Way way up

Last week I had a chance to visit Canada's most northernly community Grise Fiord. There are 2 other inhabited locations north of Grise (Alert and Eureka) but both of these are manned stations rather than communities. Although it has a difficult past, Inuit people from Pond Inlet and Inukjuak were resettled there by the Canadian government with far less than full disclosure of the difficult conditions in the high arctic, today Grise Fiord is a true community where people grow up, go to school and call home.
I was there for only a couple of days to provide a visiting doctor clinic but the people made me feel very welcome. I got to go on some nice drives along the shore line, and we had a nice barbecue after work one day while I was there. This time of year the sun is high in the sky 24 hours a day, in the high arctic this isn't summer but Light Season. The Inuktitut name for Grise Fiord is Aujuittuq meaning place that never melts. In spite of the name it was 14 C and sunny the entire time I was there.
I've been up in the Eastern Arctic for long enough now that I just accept the landscape as a normal part of life, and sometimes forget how dramatic and unique it can be. The landscape in Grise is impossible to ignore though and reminded me of that. Here are some pictures from the top of the world.

A view up a fiord on Ellesmere Island. (Taken through the window of the twin otter.)


Looking up the valley above Grise Fiord airport.


A glacier moving towards the shoreline.


A barbecue with the health centre staff, that's me and Tommy who is the health centre's interpreter, driver, handyman, and everything else to keep the health centre going.


A view of the sea ice from the air.


The twin otter lands at the airport. The landing approach is a flight directly towards a cliff, then hang a hard left, fly along the cliff and land on the short dirt strip.


A view of the town and surrounding mountains at take off.

Wednesday, June 25, 2008

How you know you've been in the arctic too long...

Now that I'm back in Vancouver, I'm trying to get used to several things:

1) living in a big city
2) trees
3) driving on the highway
4) Tim Hortons and many, many different kinds of takeout

Number 4 is certainly the easiest of these, and the most enjoyable.

However, tonight as I was going to put the hose back in the garage, I stepped outside and did a double take...it was really dark out, and it was only 10:30 pm! Where were my endless hours of daylight? How could this be?

I guess I'm not quite settled back out west (and south!) yet. I'm looking forward to starting residency again next week, although I admit I'm a bit nervous. Once you're out in practice, it's easy to get out of "study mode", and now I have to get myself back into it. I tried to do some reading on volatile anesthetics this morning, and I think if it weren't for my large coffee with milk from Timmy's, it's possible my brain might have exploded. It doesn't help that I have an anesthesia exam coming up in less than two weeks (a three hour exam! on a saturday! in the summer! this is a form of sanctioned cruelty I say!)


Although I'm quite enjoying the view outside on these beautiful summer days, I miss those little flowers on the tundra more than I thought I would...

Monday, June 23, 2008

You call that 'up north'

This afternoon I am flying up to Resolute Bay and from there on to Griese Fiord to hold clinics for a couple of days. As northern as Iqaluit is, it's a metropolis compared to these remote places. I'll be there for a week and hopefully have some material to post about when I return.
The recently released book The Long Exile is an account of how people came to inhabit these unlikely places. It's a worthwhile read and a piece of Canadian history that most canadians know nothing about.
See you when I get back!

Sunday, June 8, 2008

Real life, or something like that

We're safely back from our vacation. We travelled all around New Zealand over the past few weeks, and saw some amazing things. I've never in my life spent so long on a plane!! We won't likely have a chance to travel anywhere so far or for so long for quite some time so we really enjoyed our trip.
We're back in Iqaluit now, Dr. H for only a couple of weeks before she resumes her residency in Vancouver, and me for about 6 more weeks. It's still spring here, and like most springs it feels full of possibilities. I'm a little unsure what the next part of my own career will bring and am weighing a number of opportunities. For the next 12 months I will likely return north, here to Iqaluit, on a regular basis, but beyond that it's all up in the air. Iqaluit is a different sort of place than anywhere else in Canada, and it takes a little while to feel at home here. It seems like just as we started to feel like we're home it's almost time to leave...

Wednesday, May 28, 2008

Some posts need few words....


That's a 20 pound red snapper that I caught at while we were staying at the Chillout Taiwawe Retreat. The Chillout is just about the most perfect place on earth, and Des Corgan is an amazing host. Anyone who comes to New Zealand should enquire about staying there for a couple of nights!!

Friday, May 23, 2008

More Snapshots

We're currently on the west coast of New Zealand's South Island, in a small town called Fox Glacier. Most glaciers in the world (and most ice cover in general) is shrinking at an alarmingly fast rate and it is possible that during our lifetime there will be only a few glaciers left on the planet. In our usual part of the world (the eastern arctic) the Ward Hunt Ice Shelf has been rapidly disintegrating. The Fox Glacier is one of the few glaciers on Earth that is currently growing in size (due to very particular local weather patterns). Dr. H and I had a chance to hike high on the glacier and explore some of the beautiful ice caves. It was an amazing experience, but unfortunately one that may not be possible even 20 years from now.

Dr. H and I on the glacier.


The view from inside an ice cave on the Fox Glacier.

Tuesday, May 20, 2008

Through the looking glass...


Things are a little different in the southern hemisphere, and occasionally take a little getting used to. Driving on the left side of the road took a few days to adjust to (without any mishaps thankfully). It turns out most of what I do when I drive is automatic and I had to re-think much of what I usually do to hold a car on (my usual) wrong side of the road.
The seasons are also flipped here so we are enjoying a beautiful autumn (my favorite season). The trees here are beautiful and seem to only get better around each corner as we drive around this beautiful country. (More pictures when we get home and have an easier internet connection)

Monday, May 12, 2008

Snapshots

Here are a few pictures from our trip so far.

Dr. H and I getting ready to go into a cave.


A view of the Blue Lake in Rotorua as we hike around it.


Some of the many breeds of sheep here in New Zealand during a 'sheep show' put on for tourists.

Saturday, May 10, 2008

A quick post


We're traveling in New Zealand right now. It's an amazing country and the people here are very friendly. The internet access however is not great so this will only be a short post.
We arrived in Auckland last week and are currently in Rotorua, which is basically a town built in a geothermal field so there are geysers and mineral bathes around. A couple of days ago we went to something called a glow-worm cave. It was amazing! There were thousands of glow-worms on the ceiling that gave enough light to see everyone in the cave. The cave had a river in it so we floated around on a raft in there for about 45 minutes. AMAZING!
The tour was run by a small company called Spellbound and I would definitely recommend it to anyone who gets a chance to visit this country.
More posts next time I can connect to the net!

Sunday, May 4, 2008

OBS up here

I was sitting at the nursing station one night while on obstetrics call chatting with the nurses and generally distracting them from their work. We were talking about the differences between obstetrics in the south, and in the north and having quite a laugh. Leanne, one of the best OBS nurses I know, was talking about visiting a friend in an L&D suite in a southern Canadian city; 'She was just laying in bed, there were tubes and wires everywhere. She was on a monitor, the baby was on a monitor, and I thought the $%*# must be hitting the fan!'. It turned out her friend was having a normal term delivery, but in a different style than we are used to here in Nunavut. We all had a chuckle and agreed that going back to working obstetrics in a southern environment would be difficult at best.

I've written previously about the type of obstetrics we do here in Iqaluit. It's low to medium risk, with careful export of known high risk patients to southern tertiary care centres. In practice that means managing labour and delivery of patients 35+ weeks, including patients with PIH/pre-eclampsia, VBACs, previas, and other higher risk situations. It also means managing the unavoidable complications of obstetrical practice; cord prolapse, abruptions, eclamptic seziures, hemmorhages, thick mec, flat babies, etc. At times it means managing high risk cases in consultation by phone with obstetricians in the south, in particular premature labour and it means medevacs of preterm labour from remote communities. Because of our remote location women from even more remote communities come down to Iqaluit at 36 weeks for 'confinement' until they deliver. This is often the most emotionally difficult part of obs up here, as they are often seperated from family and kids at home while they wait to deliver.

There are 6 docs who practice OBS. It's a nice group and we all have a similar philosophy. We have about 400 deliveries a year in our hospital, and we have good outcomes. Our C-section rate is 5%, and we do about 1 or 2 epidurals a year in total (there is no epidural on demand service). For uncomplicated labour the strategy is low-tech and dependent on the wishes of the labouring woman. Want to labour at home for a while? No problem. Want to stay in the hospital? No problem. Want to eat? The toaster is over there. Want to walk around? By all means. Want pain control? You're welcome to any or all of the options we have available. Monitoring is by intermittent auscultation unless there is a compelling reason for something more invasive.

There are probably lots of reasons why obstetrics is different here than it is in the south. There are cultural and historical reasons. The reason that is most striking however has to do with what patients expect around labour. Labour and delivery in the south (at least in the media) is often framed as an 'experience', in the same way that climbing a mountain or bungee jumping is an experience. It also seems (at least from what I read on various blogs/comments and forums) that there is at least some population of people who believe that doctors are willfully trying to take away from their labour experience.

When I talk with women about L&D at their prenatal appointments, I often ask what they expect will happen. Usually the person says something along the lines of 'I think it will probably hurt'. What do you think about that, I ask? They laugh and say, 'Well it's not optional'. Most people seem to view labour and delivery as a natural process, and my role (and the hospitals role) to intervene when required for the sake of safety. It's pleasant, it's happy, sometimes one women in early labour is in the room next door coaching another women who is pushing. People are walking around (yes, and going for a smoke), laughing, talking and feilding various relatives and visitors who are stopping by to see how things are going. It's a different world than down south. My role is a little more on the sidelines, there to spot and deal with any problems that may arise. Usually there are none, and all I need to do is hand a nice baby to a new Mom, whose first question is almost always 'So I can fly home tomorrow?'.

Friday, May 2, 2008

Scenes to remember...

We're heading out on vacation today after a long and very busy April here in Iqaluit. Keep checking back for posts, we have our MacBook with us, and will hopefully see some sights to inspire us over the next month.
Here is a picture of the surf I took in Tofino. I have it set on my desk top at work, and in hectic moments I like to look at it and imagine the sound, smell and feel of standing beside the surf....
Enjoy.

Saturday, April 26, 2008

It feels just like a vacation...

Since living here in Iqaluit I've taken up squash. Yes, I know, it's a strange sport to take up in the arctic but it's fun and a great workout. Imagine doing a few hundred lunges and a few dozen wind sprints and you have the game pretty much down. The worse you are the harder you work on the squash court (I, for instance, work my butt off). It's been a fun way to meet people and get out during the cold winter months when going outside is sometimes not terribly appealing.

When physician supply here in the arctic is lean (and it often is) it's left to the long term docs to pick up the slack. The emerg. needs to be covered, obstetrics needs to be covered, anesthesia needs to be covered, and when there aren't enough docs around that coverage can be tough to find. For the last few months we've been pretty understaffed and that has meant a lot of 7 day work weeks and lots of on call. A couple of months at that pace really eat into the rest of your life and for me squash games got put on hold. This month has been better staffed and we've even had a couple of weekends off! I've been back on the squash court a few times, though any skill I had has definitely atrophied.

Since I started playing again about 5 people have come up to me and asked how my vacation was. Vacation? What vacation? They react in disbelief when I tell them I have just been working every day for a couple of months, assuming I had been out of town since I hadn't been playing. It can be a tiring schedule up here sometimes, but luckily the work is usually enjoyable even when it's too busy. At the end of this week we're taking a real vacation. A bit of R&R should recharge the batteries, though I doubt it will do much for my squash game....

Thursday, April 10, 2008

Charts

Lets be honest, the paper medical chart is on the way out, and probably for good reason. Electronic charts have the capability of moving the chart from being mainly an archive of information to being a tool for communication and error prevention. Electronic medical records are slowly but surely supplanting paper charts. Here in Canada many provinces are offering incentives for physicians to adopt new technology, and physicians are slowly integrating electronic records into their practices. In the north the eventual disappearance of paper charts will mean better communications between nurses in remote stations, physicians in hospitals and specialists in the south. It will improve care planning, meds prescribing, and hopefully patient care.

Even though I see the benefits of electronic charts I remain attached to the paper versions. Here in the north many charts stretch over an entire lifetime. In the back of many charts I'll find thin typewriter paper from the 1950's and 60's with interesting notes from the past. Medical charting of yore was very different than the notes of today. Recently I stumbled across a note that read 'Hospitalized for bacterial meningitis. Fully recovered.' That was it, the full hospital admission, and discharge summary in one simple line. It probably wouldn't be considered particularly adequate these days.

Paper charts can be part of a tale of the ups and downs of a life well lived. One of the great thrills I get here in northern practice is to see a single volume chart on a 60ish year old patient. In the back there is a birth note on thin and fragile typewriter paper, lists of childhood immunizations, notes about hospitalizations for serious illnesses that still add weight to the conversation, delivery notes about the patients own children, office notes about the stress of raising teenagers, chronic diseases, aging. Then I look up from the chart, a story of a lifetime, and see the smiling face of a patient. Oolakoot!! (goodmorning!).

Sunday, April 6, 2008

Pics from Pangnirtung

Usually I am the only doctor providing support to the nursing station in Pangnirtung. It can be a big job, the population there is now 1350, which would be a pretty normal size for an urban family practice. Here in the north a community that size is cared for mainly by a nursing station, and with a doctor a phone call away for support. I visit the community about every 6 weeks for a 3 to 5 day visit where I see patients in clinic, do small procedures, review charts and make care plans for complex patients. I don't really get any other devoted time for community care, and manage phone calls, emails, x-rays, lab reports, prescription renewals and more of the side of my desk while I'm working in emerg. catching babies, or whatever duties I'm assigned to here at the hospital on any given day. Over the past couple of months we've been fairly short staffed (again) here at the hospital and a pretty substantial list of patients to be seen had built up in Pangnirtung. Luckily this month they were able to send up both Dr. H. and I to see almost all of the waiting patients.

We spent the week in Pang. and in addition to a few days of medical clinics managed to walk around town, out on the ice and generally enjoy the beautiful spring weather that has finally arrived (that's about a balmy -10C for those who've never been here). Here are a few pictures from the trip.

A family heads out to enjoy the spring day.


The Pangnirtung pass...


Dr. H and I with the pass in the background.


Sunset.


This is one of the old houses the govt. built to house Inuit families as they moved in off the land. It's now uninhabited, but you can imagine a large family living in that small cabin. It would have been a very different life. The housing sitation here remains grim, and though the houses are usually a little bigger than this now, they are still very overcrowded in many cases.

Sunday, March 30, 2008

Odds and ends on a Sunday afternoon

Music in Iqaluit

Last night was an important musical night for Iqaluit. Nathan Rogers, son of Canadian icon Stan Rogers, played a great concert in the gym at the middle school. He did a great job, playing folk music, doing some eastern throat singing, doing a great mix of his type of throat singing, some local throat singing and beat-box. He finished the show with a version of Northwest Passage partly translated into Inuktitut. It was a great event and the proceeds went towards Alianait! the annual arts festival here in Iqaluit.



Just the stats
Every month or so I take a look at the website stats on google analytics. The site is averaging something like a hundred unique visitors a day. It's interesting to see where these visitors come from. The majority come from links on blogs listed on the sidebar, but a significant number come from other sites, some I'd never visited before. Here's a list of some of the blogs that have sent readers to this blog in the past month, there's some good Sunday reading in there!

A journey beyond the logical mind
Paramed: A paramedics plight
Adventures in good medicine
Future Doc
Temporarily assigned to planet earth
Northern Chirp
Tales from the arctic
X-ray rocks
Nunavut Newbies
Doctors girlfriend
Reflections in the snow
Nunavut nonsense
Not a wanna be, but a gonna be
Kent of the north
Anatomy on the beach
JB on the rocks
Just below 63
Wait time and delayed care
Townie bastard
Jen of Nunavut


Searching for something
In the same vein, it's fun to see what google searches pull up this blog. Most common are searches for the blog name but Adventures in Medicine has also been hit from google searches for "caribou tuburculosis", "anesthesiology scrub hats", and "I've never done that before".


Random facts
I usually read magazines from back to front, strange I know, and the above list is arranged from least referrals to most referrals, don't ask me why...

Friday, March 28, 2008

Northern Reading


While here in the arctic I have been trying to read as much northern literature as possible. Specifically I have been trying to read literature that is either written or transcribed from Inuit elders. Inuit have a strong oral history and the style of writing (and speaking) reflects this. One of the best books I've read is called Saqiyuq. It's a book about the life histories of 3 successive generations of Inuit women and chronicles the radical changes that have happened here in the eastern arctic over the last 60 years from a very personal perspective. It's definitely worth reading and I'd recomend it to anyone interested in the north.
In the following passage from the book Apphia Awa, the eldest of the three women, discusses the birth of her son Simon. Apphia's portion of the book is transcribed from taped interviews with her, and her stories are structured in an oral, rather than written fashion. The story she tells about the birth of her son Simon paints a picture of what t was like to live through difficult times and give birth without much help at hand.

WE WERE STARVING, AND THAT IS HOW I GAVE BIRTH TO SIMON
Being fearful of what is going to happen takes away your courage. It keeps you from being strong and doing things that you have to do to survive. As Inuit we went through hard times. I also understand that Qallunaat go through hard times ... but being Inuit, we lived very stressful and hard lives.
There was one time when we were really hungry. We had no light and absolutely nothing to eat. We were living in a sod house. We were up in Upirngivik. Sod houses are usually cozy and warm, but in this sod-house the ceiling was frosted over, and some of the pieces of wood that held it together were missing. We were really hungry and thirsty and cold and we had no fat to light our qulliit with. We had no light and no heat. This lasted all of March. In April when the young seals came, that is when we finally got some food. At that time in March, before the seals, I was pregnant with Simon. We were really hungry and we had nothing to eat. We were getting ready to move from our camp at Upirngivik, to move to where we could find food. The men were out hunting for seals to feed the dogs. We wanted to feed the dogs first so they would be stronger for the trip. This was in 1953. I was just 22.
We were starving, and that is how I gave birth to Simon. It was really, really, really cold, and Simon, he was a big baby! And of course we were living in the sod-house, so there were no doctors. When he cam out I thought, "What do I do? What should I do?" A woman who has been dead for man years now, David Mablick's mother, Aaluluuq, she was the person taking care of me while I gave birth. My husband and my mother-in-law were both out hunting, and Aaluluuq lived next door. It was cold, it was so cold! She took her own baby off her back and put my newborn baby, the one I had just given birth to, she put him inside her amautik. I tried to clean myself, I tried to clean p the placenta. It froze, and there was this umbilical cord hanging out of me still, and I was getting scared. I thought it was going to be like that forever. I became scared, having that thing hanging from me, I thought I was going to be like that all the time.
When my mother-in-law cam home, she told me not to worry. She said, "No, don't worry. When the cord dies it will come out." I was supposed to keep my pelvis warm, to keep the cord from freezing. It was so cold! The next day I began to have cramps. I felt like I was giving birth again, and the placenta came out. That was March 10th, and that is how it happened.

From: Saqiyuq: Stories from the lives of three Inuit women. Written by Nancy Wachowich, Apphia Agalakti Awa, Rhoda Kaukjak Katsak and Sandra Pikujak Katsak. 1999. McGill-Queen's University Press

Wednesday, March 19, 2008

DNE (Do not evacuate)

He sits in the waiting room with a portable oxygen tank in front of him, laughing with the friends he happens to have met today at the health centre, and telling stories to the children between their games of tag. He knows everyone in the health centre, he knows how they are related and where they came from, where their parents hunted and when they finally moved off of the land and into town. There is a wheel chair ramp to the health centre, but he came up the stairs, paused on each one for as long as he needed before moving along. I watched him come up the stairs, grasping the rail firmly, pursed lip breathing. Many people walked by him on the stairs. Everyone stopped to say hello, to shake hands, no one insisted to help him in his walk. I ask if he can come into the office to talk. He smiles, takes off his oxygen and walks along with me. I try to bring the portable tank and he laughs and shoo's me off, "interpreter" he says, and I hustle to find one.

In the office I ask what brings him into the health centre today.
He pauses, thinks about it, and answers in Inuktitut to the interpreter for some time. The interpreter relays the message: 'He wants you to know he is a strong man, he does not complain, but since you are asking he is feeling weaker than he should. He says he would like to go out hunting if that is possible. He says sometimes his breathing is hard, and when it is bad his wife is scared."
Do the medicines help?
'Not as much as before."
I ask him what he thinks the problem is.
Through the interpreter he tells me it is old age, his body is not young anymore, he wants to go hunting but his body does not listen. Before I can respond he asks me in english "Did white people cure old age yet?" and then laughs with both his eyes and his voice.

My own agenda for the visit is to discuss his wishes around extent of treatment and end of life care. The patient in front of me has end stage COPD and it seems an important thing to clarify. In hospitals this is framed as a DNR discussion, but here it is much more. It is a discussion about values, beliefs, and a cultural divide that at times seems as vast as the arctic itself. The current group of Inuit elders are the last Inuit people who were mainly born and grew up living on the land (that is; living a traditional nomadic lifestyle centered around hunting and survival). They are pragmatists, and when asked if they wish any particular medical intervention the usual response is 'yes, if that is what you think needs to be done'. When I first arrived in the north I had a few DNR discussions in the usual southern style, and they didn't go too well. Like they had talked about in medical school I asked the patients if their heart were to stop would they like us to try to restart it, even though the chance of success was small given their particular condition. They would look at me quizzically and through the interpreter say 'Of course he wants that, if he would die or live he wants to live. Now he wants to not talk about that anymore!'. It took me a few go-rounds to catch onto the fact that I was having the wrong conversation.

It is incorrect to think that because the Inuit people were nomadic that there was no attachment to place. Most groups travelled specific routes, returning to specific areas regularly. Place also meant (and still means) people, and small groups would meet at these specific places of intersection. Today Inuit elders are often much attached to the place they live, and often more importantly to the people there. In their own community they have a history, they are not a sick or frail elderly person, but strong hunter who is now getting old. They have a reference point other than their current physical health that is known to all those around them. It is no wonder that they might wish to remain here.

I get ready to have the conversation and frame it in the way that seems most relevant to the patient sitting in front of me. If you were to get very sick would you ever wish to go to Ottawa for treatment?
The answer is fast. 'He has already thought about this. He has been to Ottawa before and has no wish to go back.'
He understands that this means that we would not be able to do things like put in a breathing tube or do CPR because patients who survive that always have to go to Ottawa?
'He understands.'
Would he be willing to go to Iqaluit if he were sick, even if that would mean there was a chance he would die there?
This time the conversation between patient and interpreter is longer. Iqaluit is closer and more familiar but still not home.
'He would be willing to go for appointments if he could have oxygen on the plane, but he would not wish to go if there was a chance he would die there.'
That would mean he wouldn't go on the medevac plane?
'That's right, he doesn't want to be medevac'd. If he dies he wants to die here.'
Does he want treatment of his illnesses here in the community?
Again the answer is fast. 'He wants anything that will help as long as he can stay here.'

I tinker with his meds, maybe optimize them a bit, hopefully reduce some of the terrifying night-time dyspnea that is bothering him. I summarize our visit and make a DNE notation on the front of the chart. Do Not Evacuate. It is more complicated than DNR, but more meaningful too.

Through the interpreter he tells me he saw me fishing last summer and wonders if I caught anything. I tell him I didn't. He laughs, pats my shoulder and tells me to find him next summer and he will show me the right way to get a fish. He says thank you for my time and slowly walks back to his seat in the waiting room. It is still empty for him even though the room is very busy. He greets the people who have arrived while he has been in the office, puts his oxygen back on and rests for a while before walking home.

The patient presented in this account is fictional in the sense that the story is not about one single individual. It is true in the sense that it is an encounter and experience I have had dozens of times, with dozens of Inuit elders. They are pragmatic and realistic. They rarely believe themselves to be immortal, as the majority of people in North America seem to. They are reserved, but have a subtle humorous streak, and can laugh with their eyes. They are people who have been culturally transplanted, not by geography but by history and circumstance, and have keen insight into what is important to them. Usually what's important is what's close to home.

Saturday, March 15, 2008

The deal with seal...

Today was the International Day of Protest Against the Canadian Seal Hunt. Today was also the “Celebrating the Seal” event here in Iqaluit.

From what I gather, the protesters of the commercial seal hunt are against the practice of killing infant seals, and take issue with inhumane killing practices and wastage of seal parts. In my (limited) experience, these things do not happen in Nunavut. The seal hunt is not only an important part of the culture here, it is also a means to provide food and clothing for the Inuit people. Every single part of the seal is used. Seals are not “clubbed” and “skinned alive”, with parts left to rot on the ice. The skin is carefully removed and used to make very warm (and beautiful) clothing that is worn for many, many years. The seal oil is used to light the kulliq, the traditional lamp that was used inside igloos. Certainly, this is less essential than it used to be given the current availability of electricity in most houses in Nunavut, but the kulliq is still used in ceremonies, as it was today at the Arctic Winter Games arena. The seal meat is considered a delicious food, and as I witnessed today, the ENTIRE seal is eaten.



Just how it’s eaten is a bit different than a southerner would expect…bite sized pieces of frozen seal are cut using an ulu (traditional women’s knife) and are eaten raw.



Dr. J. and I joined in the “Celebrating the Seal” event and thoroughly enjoyed ourselves. The event was free and well attended. It was really nice to participate in a community outing. It was great to see people greeting each other and enjoying the sealskin clothing fashion show, listening to the kindergarten class singing a song and reenacting a seal hunt, and watching the throat-singers perform. People feasted on seal, caribou and bannock. By the time we left, the entire seal that was layed out on the floor of the arena had been eaten. It was also nice to see some of my patients (especially the ones with bad CHF and COPD) out and about, participating in community life. It reminds you that your patients aren’t just people who show up at clinic…they’re individuals with friends, interests, and important roles in the community.



They were also giving out bumper stickers with a picture of a hunter shooting seals that said “Eat seal, wear seal” in both English and Syllabics. I told Dr. J. he should put it on his car when we get back to Vancouver. He said that he would get the windows punched in with a bumper sticker like that in B.C. (probably true). It does bother me that some people, who have never lived in a place cold enough to need seal skin mitts and who have never met Inuit people who actually depend on hunting to have food to eat, feel entitled to protest against all seal hunting. I’d prefer to believe that the people who are protesting today are instead taking issue with cruelty to animals and with the practice of wasting animal parts for commercial gain. All I know is that you won’t see me holding a sign outside a government building. I was too busy enjoying a nice community event and thanking my lucky stars I didn’t get paged to go to the hospital!

Friday, March 14, 2008

Life in Black and White

When people think of the arctic they often picture a vast expanse of white snow-coloured ground against blue sky. Very occasionally this is true, but usually the colours in the arctic don't obey the normal rules. In the early morning the world can appear as though viewed through a blue lens. Everything tinted a light, bright blue, and every other colour suppressed. Sometimes the sky is purple, or red. In summer the ground can be a mix of every imaginable colour of rocks and plants.
Sometimes camera shots capture the wild colours, but more often not. Sometimes the strange lighting can make getting a shot difficult, and sometimes the colours are so overwhelming the make the subject of any shot nearly irrelevant.
The most dramatic pictures I've seen from the arctic are from early explorers, devoid of colour (as in black and white) but full of light. Last week I was in Pangnirtung, and tried to capture a shot that showed the power of the sea ice pushing up the fjord and towards the pass. In many of my shots the colours predominate. Brilliant blues, the reds of the rock face, the stark white of the snow. Of all the shots I took I think the one below best represents what I was trying to capture, in black and white.

Tuesday, March 11, 2008

You are what you eat

The traditional food sources in the eastern arctic are collectively referred to as country foods. Here in the eastern arctic many people still eat country foods at least some of the time. The traditional Inuit diet was based on food items that were locally available. Although contact with traders has been ongoing since the 1500's it has been sporadic, and not reliable for everyday needs like food until very recently.

Traditional foods include caribou, arctic char, seal, whale, arctic hare, tarmigen, polar bear, shellfish, berries and seaweed. The diet is meat rich, but most of the meats are high in good fats, low in bad fats and since overall food was scarce this meat rich diet was not traditionally a problem in terms of overall caloric intake.

As is the case for First Nations populations around the world the typical 'western diet' hasn't improved health at all for Inuit people. The more western food available, the more diabetes and obesity are seen. It is a familiar story in the Arctic, across Canada, in Hawaii and the Polynesian islands, and in Australia and New Zealand.

Grocery store food is expensive here in the arctic, probably about 3X the average cost down south. On average a cart full of regular everyday groceries probably rings through the cash register at about $350, a pretty hefty price tag. Often the cheapest items are also the worst in terms of health. To purchase a diet rich in fruits, veggies, and complex carbs would be considerably more expensive than the above quoted number (fresh fruits and veggies in particular are priced out of reach in many northern communities). Country food is not free either, and in fact has some pretty high cost items attached to it. In order to hunt one must be healthy, have access to a rifle and a boat in summer, snow machine in winter, and have time available to go out hunting.

Below is a copy of the Nunavut food guide. It's actually one of the nicest food guides I've ever seen, and blends country food and store food in a realistic way. It's great to talk about in theory, but in reality very few people here can afford to follow the guide. The cost of buying healthy food, or procuring healthy food from the land is an unreachable goal for many people, and that means there is little alternative to a diet rich in carbs and bad fats.




I also have a copy ofthe guide in Inuktitut syllabics, if anyone reading wishes a copy in translation, please let me know and I can make it available.

Friday, March 7, 2008

Check it out...

My friend Susan has recently started her own blog. She and I worked together in inner city Vancouver. She's a great family doc with expertise in HIV and is now spending part of her time working in Africa.
She's also very well read, and while we worked together she never failed to come up with a great book recommendation for me! It turns out her own writing is also excellent. Check out her blog Susan in Lesotho, it's a great read....

Unfortunately Susan's blog has been taken offline for the moment because the agency she is working through does not allow blogging. I look forward to reading about her adventures when she returns!
Another former co-worker from my days in Vancouver is also writing an excellent blog these days. Check out Fresh MD, it's a good read!

Wednesday, March 5, 2008

The Snack


My first visit to Iqaluit was in January of 2007. One cold morning I walked into the hospital and noticed smoke rising up over top of the 8-story (that's Iqaluit's version of a high rise for casual readers). When I got to the hospital the people seemed in a panic. Had something important caught on fire? You bet, the Snack had burned down. It was a tragedy.
The Snack is an Iqaluit landmark and has greased the arteries of visitors and residents alike for years. Interestingly this wasn't the first time the Snack had burned, as a suspicious fire had claimed a previous edition of the restaurant in the mid-1990's. After last years fire some people were lost, they didn't know where to eat. Business in the hospital cafeteria (which is the finest hospital cafeteria in Canada, by the way) went through the roof.
I'm pleased to say that for the last couple of months the Snack is back!! Once again the 4AM poutine needs of everyone in Iqaluit can be satiated. LDL is up, HDL is down, but people are happy....

Sunday, March 2, 2008

Pathogen Party in my Pharynx (or why I'm very bad at being sick)

So I finally, FINALLY, had a full two consecutive days off work (no call, no emerg, no second call, nada). It was nice except I spent most of it moaning about my strep pharyngitis.



Most GP's use the strep score to estimate risk of a sore throat being due to a streptococcal infection. You get a point each for: temperature > 38 degrees celsius, absence of a cough, swollen and tender anterior cervical lymph nodes, tonsillar exudate or swelling, and for being between the ages of 3 and 14 years. You get zero points for being between 15 and 44 years old. You get minus 1 point for being 45 years or older.

My score is 3, given that I haven't really had a documented fever. The recommendation is to treat with antibiotics if the score is 4 or more, and to treat a score of 2 or 3 only if there is a positive Rapid Antigen Test or positive swab culture. But look at that exudate on my tonsils, will ya?

That exudate, coupled with my hot potato voice, and my inability to swallow without feeling like I'm trying to Houdini a couple of razor blades leads me to believe that I do indeed have a strep throat. Time (and my properly collected pharyngeal swab) will tell. However, antibiotics it is for me. It should be noted that antibiotics for strep throat are used not only to speed resolution of symptoms, but to limit the period of transmissibility and to prevent post-streptococcal infection complications (like rheumatic fever).

I feel like I can usually tell just by looking at the pharynx whether I'm dealing with a true strep throat vs. a viral URTI with a sore throat. However, I do usually do a swab, and I can say that I've been fooled more than a couple of times (nasty looking throats that are culture negative, or vice versa). So I'll be interested to see what my swab actually grows.

The other thing I've discovered this weekend is that I'm a very, very pathetic sick person. My difficulty with swallowing my own saliva, and the GI distress from my antibiotic did nothing to make me a more pleasant individual to be around (sorry Dr. J!) However, I think it's not a bad thing for physicians to get a little sick themselves on occasion, as I feel it makes us more compassionate towards our patients. It's not fun to feel unwell, whether it's a small thing like a sore throat, or something more severe like abdominal pain or bad shortness of breath. I hope I'll remember how I'm feeling right now the next time I'm on emerg and seeing my 14th "sore throat x 3/7" in a row.

Tuesday, February 26, 2008

I've never done that before...

One of the keys to northern medicine is the ability to improvise. That means that sometimes patients ask you to figure things out that aren't in the usual physician job description. One day you might need to figure out how to use a volt meter to see if the batteries from an electric wheelchair are malfunctioning in the cold. Another day you might have to whip up a splint out of various materials around a nursing station. It's a fun part of the job, and makes you think outside of the box.
There aren't many doctors working in the arctic, but there are even fewer vets, and occasionally northern docs get asked to provide some sort of treatment to animals. Technically physicians should not treat animals, it's well outside the scope of what we are trained for, but in the absence of trained help sometimes people do what they can. There are certainly northern docs who've stitched up dogs, given infected cats antibiotics, and more. It's not ideal, but it's doing the best we can with what we have (and it is mostly in the interest of being humane rather than cavalier).
Below is an old sign from a nursing station that gives some basic medical advice for ill 4 legged friends. I'm not sure if this list ever got called into use, but it's presence in the nursing station speaks well to the spectrum of care that the health care providers in the north are asked to take on....

Saturday, February 23, 2008

Long time no blog

Wow, it's been a while since I've posted anything on the blog. Luckily Dr. J is diligent with his updates and has taken some great pictures lately.

It's hard to believe that we've been back in Iqaluit for two weeks, because some days it feels like we never even had a vacation. The number and the acuity of patients has increased by a ridiculous amount, particularly the pediatric cases. If you're a doctor looking for more pediatrics experience, look no further than Iqaluit in the winter! Weirdly enough, there has been very little RSV here so far...I may be eating those words within the next few weeks, though.

I have been on for anesthesia recently, and I feel like this was a good week. We had quite a variety of cases, including a couple of more challenging ones (for me) and I felt they went well. I'm still on call for a few more days yet, so I hope I haven't jinxed myself by saying that... Now I'll be expecting a call for a stat section at 2 AM someday soon...

It's getting light outside way earlier in the day these past few weeks, which makes it easier to get up and go to the hospital in the morning. I can't wait until it's a bit warmer so that we can go do some cross country skiing.

Here's a couple of Iqaluit pictures that I took this winter (the first one happens to have a sun dog!)



Friday, February 22, 2008

See you on the dark side of the moon

The recent lunar eclipse was spectacular. It was a cold clear night here in Iqaluit, perfect for viewing.
Here is a picture of the moon at full eclipse...

Wednesday, February 20, 2008

You don't have to know about this...

Every Family Medicine resident is familiar with the phrase, it occurs during a discussion about the acid base status of a complex patient, the settings on a ventilator in the ICU, or during a procedure in the emerg. "Don't worry, you don't have to know about this in Family Medicine." The temptation, of course, is to turn off your ears when you hear those words. The subject matter is complex, and apparently non-relevant. Sounds like a great opportunity to do a little mental wandering...but trust me, it's not. If you're a Family Medicine resident and you hear those words, resist the temptation, and listen to the discussion, not for the sake of being a keen learner, but to help yourself down the road when the lessons learned from that discussion may well come in handy.

From the point of view of the Specialist the phrase isn't meant to be derogatory towards future Family Docs. In big cities, where medical schools are located and where every manner of specialist and test is readily available it is probably inconceivable to Specialists in teaching hospitals that any Family Doc would need to know the nuances of whatever they are speaking about. In Canada some Family Doctors will spend their whole careers working in office based practices in cities, but just as many will spend at least part of their career working in a rural or remote area where a broader set of skills is called for.

So a heads up for any future Family Docs who read the blog. If you plan on spending some of your life outside of a city (and I'd encourage you to, it's a great experience), soak up all you can while you're a resident. Listen in on the stuff you supposedly don't need to know, ask the respiratory therapist how to boot up and work the ventilator, because in the end it will pay off. When you need to know something it's amazing how those conversations can pop back into your head and help you out in a sticky situation.

Wednesday, February 13, 2008

Not your average beach

While we were back in Vancouver Dr. H and I had a chance to drive across Vancouver Island and spend a couple of days in Tofino. Here are a couple of pictures from the beach there. The scenery is amazing, and the waves are huge. It feels like the end of the earth, and we would definitely recommend it as a great place in Canada to visit.
We are now back in Iqaluit and enjoying cold, but sunny weather. Minus 40 really isn't that bad as long as there's no wind!

Thursday, February 7, 2008

You know you're on call too much when...

So Dr. H and I have been back in BC for the past week and a half to visit. We decided to escape to Tofino for a couple of days to recharge the batteries and are staying is a nice hotel here. It's beautiful here. The waves are huge and crash against the shore with ridiculous force, the forests are still green, the air smells like trees.

Last night, at about 4 AM our hotel room was filled with a horrible beeping sound...beep beep beep...almost like a pager. By beep number 3 both of us were awake and out of bed. A quick check of our room revealed we were not on fire, and we were dressed, grabbed our day packs and were out the door immediately. In the lobby they told us there was some smoke in one of the rooms and we'd have to wait in another building until the fire department figured it all out.

What was interesting to us was the bleary eyed folks dressed in pajamas and bath robes who straggled into the lobby behind us. It turns out that being on call is good preparation for fire alarms. It also turns out that any beeping noise can wake both Dr. H and I from a deep sleep and have us dressed out the door and ready for whatever in about 2 minutes. Clearly all those on call nights are to thank/blame...

In the end there was no fire, the cause of the smoke was undetermined. Ahh well, we'll be ready for call when we get home to Iqaluit anyways!

Friday, February 1, 2008

Sorry we don't have that!

I've mentioned previously that one of the nice things about rural practice is that when you're in a jam you can 'phone a friend'. Sometimes it's a local friend, someone with specific experience that might be useful in a certain situation. In Iqaluit we have a General Surgeon for surgical consultations and GP-anesthetists for patients who need intubation or if we need assistance with critical care (that would be Dr. H). For all other consultations we make a phone call, usually to Ottawa.

Specialists in Ottawa tend to be helpful (or at least try hard to be helpful), but sometimes they aren't exactly sure where I'm coming from. 'You're phoning from where?' 'There's a hospital way up there?' For doctors accustomed to working in large tertiary care settings it can be hard to imagine that we're trying to practice medicine in such a remote environment. Sometimes their most well intentioned suggestions are simply impossible because we lack the medications or equipment to do what they suggest....

Milranone for a cardiac patient? Sorry, don't have that.
Add dobutamine to the mix for a shocky patient? Uh-uh.
Fomipazole for that guy who drank anti-freeze? Sorry, I have him on an ethanol infusion, we don't have fomipazole (although I have been agitating relentlessly for fomipazole for about 6 months now).
Dialysis? Haha.
CT-scans? Oh, my, no.
Okay, well maybe put in an arterial line and monitor the patients pressure until he can be sent out? No no no, we don't have a transducer, sorry about that.
How about a quick ECHO? Oh please.
Well, I guess just put the patient on your med-evac jet and send him down to the Ottawa ICU then? Well, we actually have to get a med-evac jet to come from Montreal then fly back down to Ottawa, shouldn't take more than 12 hours as long as the weather cooperates!

Sometimes it's a bit frustrating. Sometimes it raises the blood pressure of everyone taking care of the patient. Usually we just do what we can and hold on tight until the med-evac jet finally arrives. We do our best with what we have, though I think sometimes the specialists in the big hospitals in Ottawa must think it's all a little behind the times...

Thursday, January 24, 2008

Clean Water

Clean water is an important and increasingly scarce resource. In Canada our fresh water resources are not only our play-grounds, but all too often have also been our dump sites. Here's a sign from the Pangnirtung Airport that illustrates the situation pretty well. Litter in the water supply equals sick kids. Can't get much simpler than that...

Thursday, January 17, 2008

Time to hit the Beach!

I was back up in Hall Beach this week, doing a community visit. I think this visit was the best of my 3 trips there so far. The clinic ran really smoothly and I got to see quite a few patients in follow-up. The size of the community certainly helps: with only 600 people, there's a good chance I've seen the more complex patients previously. Not only that, I've probably seen several of their relatives as well. If I had some actual free time and giant piece of paper, I could perhaps plot out a chart, and never have to ask anyone for their family history again...


The only downside to this visit was my stay at the hotel. Now let me say that I was very excited to be staying at the hotel this time around (it was full the last time I was there). Mostly I like not having to cook dinner after clinic, because the hotel provides meals for an extra fee.

For those of you who have not travelled in the north, staying at the hotels up here is an "experience". For the low, low price of $199 a night, you too can share a room with a complete stranger (you'd better hope you both like the same tv shows, and that your roommate doesn't snore). Luckily, I haven't had to room share yet, but I've heard some horror stories about random roomies who chain smoke in the room, and come in at all hours of the day and night.

Also included in the $199/night deal is a day in the hotel with no running water. You'd be amazed at how quickly the toilets fill up in a hotel with only 3 occupants. There should be a sign in the bathroom that reads, "Use your one flush wisely."

Despite the showerless joy of staying at the hotel, I really did have a useful and fun trip to the H.B. I wish I had taken more pictures though (the only pictures I managed to take were of some ridiculously large molluscum contagiosum, and of a healing wound post-frostbite).

Instead, here are some pictures I took during my last trip:


A little kamotiq (sled), with an even smaller kamotiq pulled behind it (with what appears to be a figurine of the "Duff Beer" Man sitting beside Sketelor...is that what children play with these days? Where is Dora? Diego? Spiderman? It appears they enjoy the finer things in life, and stay at the better hotels with running water)


An adorable little guy riding a polar bear sled

Speaking of polar bears, I didn't see any, but there was one in town last week who just wouldn't leave, despite much noise making and prompting by the locals. Thus, he met an untimely demise. I wish I'd gotten to see one (through a window maybe...they're not "friendly little creatures"...they kill people).

My trip ended on a surprising note...I ended up coming back to Iqaluit not on my scheduled First Air flight, but on a medevac with a patient who came into the health centre this morning. Thank goodness for pacing pads, and thank goodness for you, Lifepak 12.

Wednesday, January 16, 2008

Free Publicity!

The National Review of Medicine was nice enough to include this blog in their current story about physician bloggers. Check it out here....

Sunday, January 6, 2008

Beside the Chip Aisle

There are a few clues around town that it really is winter. Those outdoor thermometers they sell down south have frozen up on cold days, only registering to -40. When you walk out the door in the morning you get a little bit of bronchospasm that reminds that the lungs prefer heated and humidified air. The days are short, but now getting longer. And most of all my favorite display of the season has appeared at Northmart. The centre aisle of the store, an aisle reserved for the best seasonal merchandise, is now a sales lot for ski-doos. You know it's winter when the ski-doo aisle is next to the chips!




We had a great holiday, and even managed to get a couple of days away from work. My Mom came up for a visit, which was nice (she even made us dinner a few times!). It was a fun, but quiet christmas. We had another couple over to share christmas dinner with us and went to bed early. On New Years we went along with most of our friends down to the Legion to celebrate! It was a fun night and a great experience, and only in a small town is the Legion a centre of socialization!


The New Year marks the half way point of our stay in Iqaluit. It's been a rewarding, challenging and fun experience. It's also been a good lesson for us in the benefit of taking some risks to see new things and meet new people. Since we've arrived we've made many new friends and had lots of interesting experiences. We've been involved in a move to a new hospital and have met and helped many patients here in Iqaluit. Hopefully the new year brings us not only more of the same but also more of the interesting and challenging things that can't be predicted but which make life so interesting.

Happy New Year everyone. We wish all our readers a safe and prosperous 2008.