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...

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

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.

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!

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.

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.

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!

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....

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.