Adventures In Medicine

Updates...

2008-10-03T12:21:00.000-07:00

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...

City Rehab

2008-08-06T20:26:00.000-07:00

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??

Beginnings Ends and In-Betweens

2008-07-11T14:02:00.000-07:00

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....

Way way up

2008-07-01T16:00:00.000-07:00

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.

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

2008-06-25T22:32:00.000-07:00

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...

You call that 'up north'

2008-06-23T09:34:00.000-07:00

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!

Real life, or something like that

2008-06-08T17:31:00.000-07:00

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...

Some posts need few words....

2008-05-28T15:06:00.000-07:00

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!!

More Snapshots

2008-05-23T13:29:00.000-07:00

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.

Through the looking glass...

2008-05-20T22:16:00.000-07:00

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)

Snapshots

2008-05-12T13:48:00.000-07:00

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.

A quick post

2008-05-10T12:48:00.000-07:00

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!

OBS up here

2008-05-04T09:00:00.000-07:00

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?'.

Scenes to remember...

2008-05-02T08:59:00.000-07:00

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.

It feels just like a vacation...

2008-04-26T08:56:00.000-07:00

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....

Charts

2008-04-10T17:43:00.000-07:00

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!).

Pics from Pangnirtung

2008-04-06T07:39:00.000-07:00

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.

Odds and ends on a Sunday afternoon

2008-03-30T09:15:00.000-07:00

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

2008-03-28T09:59:00.000-07:00

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)

2008-03-19T18:48:00.000-07:00

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...

2008-03-15T15:01:00.000-07:00

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

2008-03-14T01:18:00.000-07:00

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

2008-03-11T08:29:00.000-07:00

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...

2008-03-07T11:03:00.000-08:00

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

2008-03-05T15:51:00.000-08:00

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)

2008-03-02T14:46:00.000-08:00

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.

I've never done that before...

2008-02-26T17:10:00.000-08:00

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....

Long time no blog

2008-02-23T12:17:00.000-08:00

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!)

See you on the dark side of the moon

2008-02-22T12:18:00.000-08:00

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...

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

2008-02-20T12:02:00.000-08:00

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.

Not your average beach

2008-02-13T11:34:00.000-08:00

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!

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

2008-02-07T10:35:00.000-08:00

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!

Sorry we don't have that!

2008-02-01T23:57:00.000-08:00

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...

Clean Water

2008-01-24T15:11:00.000-08:00

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...

Time to hit the Beach!

2008-01-17T16:30:00.000-08:00

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.

Free Publicity!

2008-01-16T10:02:00.001-08:00

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

Beside the Chip Aisle

2008-01-06T11:03:00.000-08:00

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.

At your service...

2007-12-22T12:54:00.001-08:00

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

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

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

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

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

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

All dressed up with some place to go!

2007-12-16T08:07:00.000-08:00

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

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

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

Here's a pic from the event...

Northern Images

2007-12-10T11:40:00.000-08:00

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

A White Christmas

2007-12-08T11:00:00.000-08:00

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

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

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

Appropriate Apprehension

2007-12-01T13:01:00.000-08:00

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

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

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

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

How you know you work in a rural hospital...

2007-11-26T16:14:00.001-08:00

Click on picture to enlarge

Northern Images

2007-11-25T09:31:00.000-08:00

Old Whaling Station, Pangnirtung Nunavut, November 2007

Am I really that fat?

2007-11-19T05:48:00.000-08:00

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.

The restless sleep of TB in the arctic

2007-11-18T17:25:00.000-08:00

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.

Reviews

2007-11-13T04:04:00.000-08:00

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!

Jamaica, yea mon

2007-11-12T07:50:00.000-08:00

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!

Time to replenish our Vitamin D

2007-10-27T05:07:00.000-07:00

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

The hive at night...

2007-10-24T21:22:00.000-07:00

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

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

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

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

Why low risk obstetrics isn't...

2007-10-18T22:30:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

Lighting up the night

2007-10-13T06:19:00.000-07:00

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

Only in Iqaluit...

2007-10-12T15:59:00.000-07:00

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

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

We apologize for any inconvenience this may cause."

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

Thank you."

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

Hall Beach

2007-09-30T10:13:00.000-07:00

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

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

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

Here are some of the highlights of my trip:

Arriving at the airport

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

The health centre

The lovely health centre staff

Some adorable sled dog puppies

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

The town

Community centre

The mall (ie: Northern)

The co-op

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

Churches

The hotel (pretty swanky! great food)

A crazy looking vehicle

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

The dump on the beach

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

The spoils of the hunt!

Cariboo skulls

Cariboo skins

A seal skin being stretched out

Ummm...walrus?

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

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

The little differences make things interesting...

2007-09-22T16:10:00.000-07:00

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

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

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

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

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

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

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

Odds and Ends

2007-09-07T09:53:00.000-07:00

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

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

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

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

The Fall of Summer

2007-09-03T07:29:00.000-07:00

Labour Day

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

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

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

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

A Nunavut Primer

2007-08-28T17:51:00.000-07:00

As we settle into our new community, the ebb and flow of daily activities begins to feel more familiar. However, there were certainly some terms, concepts and customs here that I did not understand at all when I first arrived. I thought I would write about them before they become so obvious to me that I can't remember why I found them puzzling in the first place. Please note that the following represents only my understanding of what these things mean. Feel free to correct me if you are a Nunavummiut reading this and snorting a $2.50 can of coke out your nose in laughter.

Going out on the Land: Pretty obvious, but this means that someone is going out into the wilderness, often to hunt or fish. This is not the same as someone taking a canoe trip in Algonquin Park. When someone goes out on the land, it's possible that you have absolutely no idea where they are or where to find them.
As in, "That TB patient who needs to start treatment and stay in the isolation room? We can't send him down, he's out on the land and we don't know where he is or when he'll be back."

Country Food: Food obtained through hunting and fishing. Country food includes caribou, seal, beluga whale, polar bear, arctic char and and walrus. This food is healthy: the meat is generally lean, and the fat consumed from sea life contains omega-3 fatty acids. It is a much better alternative to chips and pop. Here, people use every part of the animal. I have a hard time understanding why some animal rights activists are so against letting the Inuit hunt and kill animals here. This is their tradition and way of life, not to mention their source of (healthier) food! Plus, I have tried some caribou and arctic char and they are delicious.
As in, "Country foods are healthier than the McCain Deep n Delicious cake from the Northmart."

??????: Seatbelt. Why the question marks? Because I doubt there is any Inuktitut word for seatbelt. No one uses them here. In the words of one local, "If the cops see you driving around with a seatbelt on, they'll stop you for sure, because it can only mean that you're trying to avoid getting in trouble for something you're doing." Hmmmm. All I can say is, I always wear my seatbelt when I'm in a car or a cab, because have you seen the potholes on these roads? I'd also be surprised if there were an Inuktitut word for "carseat", because all the babies I've seen being driven around have been in the back of their mothers' amautiit (see below) at the time.
As in, "Why would you need a seatbelt in my cab? There are no stoplights here. Plus, I am a good driver, I come from Quebec!"

Sticks: Cigarettes.
As in, "I smoke about 5 to 6 sticks a day."

Water truck: The truck that brings water. Some of the houses here don't have running "town water" and instead have an adjacent water tank which is filled up on a regular basis by the water truck as it makes its rounds through town. The water truck gets refilled at the "Booster Station" where the guy driving the water truck climbs atop the truck, opens the hatch and fills the truck using a giant suspended hose. The water truck can pump 90 gallons of water a minute.
As in, "I got stuck behind the water truck on the road to Apex. Man, that was a traffic jam."

Amauti: These are one of my favourite things here. An amauti is a coat or parka with a place for a baby or toddler to stand in at the back. There is a hood that can completely cover the baby and the mom's head, keeping the baby warm. I love seeing babies peeking over their mothers' shoulders while they are in the amauti. To get the baby out of the amauti, I've seen moms bend at the hip and let baby slide out like a seal. The kids seem to love being in there. I'd definitely like to get one of these, but I think I might be considered really kooky wearing one around Vancouver (note: they do have both summer and winter amautiit, so I can definitely get a climate-appropriate one if I want). You never know though, the amauti might catch on in Vancouver and become a trend, although I wouldn't be suprised to see Vancouverites carrying their dogs around instead of babies.
As in, "Check out that baby in the amauti. Could these kids be any cuter?"

A carving (in whalebone) of a mother with a baby in her amauti

Ii: The Inuktitut word for "yes". Pronounced "Eeeeeeeeeee." This is so much easier than saying "yes" or "I agree." I feel like such a chump for expending all that energy when all along I could have been using a single vowel sound.
As in, "Wanna go to wings night on Wednesday?" "Eeeeeeeee."

2438B: Your address. Your entire address. There is no street name, no indicated direction, no cross street. The address, in its zen-like manner, simply "is". This makes things very easy in town, because when someone asks where you live, you quote them a number and they instantly know the exact location of your house. This causes no end of problems when trying to give your address to people outside of Iqaluit. They cannot fathom a place with no street names. Ok, fine, there are street signs, but no one actually looks at them or even knows what's written on them. The only thing they're used for is as a place to lean when you're outside having a smoke.
As in, "Hi there (insert name of cab driver), how's it going? I'm heading to 695A. Oh, by the way, did you know your backseat has no seatbelts?"

The View From Here

2007-08-26T11:58:00.000-07:00

It's busy here in Iqaluit. The hospital is always humming and there is lots of work to do. Even though we are at least as busy as we are at home we've found time to explore, spend time with friends, and even go to the gym (my squash game is slowly improving). Here are a few recent pictures from our summer in the arctic.

On a nice day the view over the rooftops and out onto the bay is spectacular.

Sunset on the street outside of the hospital.

Arctic cotton blowing in the breeze.

Rocky landscape at Sylvie Grinnell Park.

The waterfall in the park. The best fishing in the area is right below these falls (although I haven't caught anything yet). When I took this picture the fish were jumping and rolling at the surface. Maybe I need a fly rod!

A pool of water on the tundra.

Sunset on another beautiful day.

The Race for the Pole

2007-08-23T08:00:00.000-07:00

Early Arctic Exploration was driven by the quest for the Northwest Passage, a hypothesized trade route through the arctic that was to link Europe and Asia.
Starting in 1576 Martin Frobisher lead 3 expeditions with the explicit goal of finding a passage through or around the top of the North American continent. Passing into a deep inlet on Baffin Island, Frobisher thought he had found the passage. Alas, the inlet was a dead end, but was to bear his name ever after as Frobisher Bay. Although he realized his error as he reached the end of the inlet he was astonished by the gold he found in the area. He filled his ships with the gleaming rocks and returned to England only to find that they were mainly iron pyrite fools gold (later used to pave roads in Kent). After the second world war an airstrip and permanent settlement were developed on Frobisher Bay and given the same name, and the settlement was later renamed Iqaluit.

In the 1820's Sir William Edward Parry mounted some of the earliest expeditions to reach the north pole. Using the most advanced technology of the time, the HMS Hecla an early ice breaker that survived several episodes of being trapped in ice, and canned food, a break through in food preservation, Parry managed to reach as far north as 82° 45' N and as far west as 113°46' W.

Perhaps the first ship to navigate the passage was the Octavius, an English trader that had travelled to the Orient and then attempted a return through the passage. The ship was found adrift near Greenland in 1775 with all of the crew aboard but frozen and long dead. The ship had apparently been trapped and drifting, frozen in the arctic ice for 13 years before finally completing the passage.

Numerous other expeditions were mounted, most charged with finding a passage for the sake of both exploration and economics. Some of these, such as the overland explorations of John Rae, did serve to map the arctic frontier. Others, such as the Franklin Expedition, ended in disaster.

The majority of these early expeditions were undertaken (and funded) with economic purposes in mind. As expedition after expedition failed to achieve success at the passage it became clear that a north-westerly trade route between Europe and Asia, while certainly plausible, was not going to be economical. This subtle shift in thinking actually heralded the arrival of a new type of explorer in the arctic, an explorer who was more concerned with accomplishment, achievement and personal prestige than with national economy.

Roald Amundsen finally traversed the northwest passage in his ship Gjøa completing the voyage in 1906 after 3 years. He had wintered his ship at a natural harbour that was populated by local Inuit people (now called Gjoa Haven). While his ship was iced in he spent much of his time learning about survival in the arctic environment, skills that would help him become the first man to achieve the south pole in 1911. From the Inuit he learned how to survive in the arctic, how to wear appropriate clothing, how to navigate on a landscape with few features that did not shift with the winds and the seasons.

The quest to reach the north pole was one based more on notoriety than on any solid economics. Located on an ice cap sitting on a sea over 4 km deep, there would be little of value to retrieve from a polar expedition. This was of little concern to the adventurers who tried. Seeking fame (and perhaps the fortune that fame can bring) several men made polar quests between 1900 and 1910. Dr. Fredrick Cook claimed to have reached the pole in 1908 although his claim was not widely accepted (he had also claimed a first ascent on Mount McKinley that is still somewhat controversial, though generally thought to be discredited as fraudulent). The first expedition to reach the pole (and to be commonly accepted to have done so) was lead by Robert Peary who reached the pole on April 6, 1909. Peary's expedition too relied on Inuit guides, Inuit foods and Inuit clothing. Controversy still exists over which of the 2 claims (if any) is credible.

In the intervening (almost) century since the last of these exciting events, the arctic has been for the most part a quiet place. Briefly important after the second world war as the USA and USSR aimed missiles at each other across the pole, military installations, radar systems and infrastructure were developed. For the most part however, the arctic has remained little changed, mainly inhabited in the Canadian archipelago by the Inuit, who have lived here for a millennium.

Over the last few weeks a great deal of fuss has been made about the idea of arctic sovereignty. Canada believes that the northern archipelago of North America belongs to Canada alone, the US thinks the (potential) northwest passage is an international waterway, and the Russians just sent a submarine to the sea-floor at the north pole to plant a flag, declaring their jurisdiction over the area (as a proposed extension of their continental shelf). The rhetoric is heating up, and fast. Canada's Prime Minister, Stephen Harper, has been touring the north, shaking hands, kissing babies, and making grand announcements. To beef up our claims of sovereignty Canada will be purchasing new armed ice breaking coast guard ships, an arctic deep water port will be built in Nanisivik, and a military training centre will be established in Resolute Bay.

Global warming has again opened the door to the economic possibilities that exist here in the arctic. Perhaps a navigable northwest passage will emerge. Perhaps there are resources that can be extracted at a profit. Again great national and economic powers are flexing their muscles and laying claim to territories far removed from their own homes. It is difficult to know how things will evolve, but history tells us that the arctic will not give up it's treasures easily and that great tragedies await those who arrive unprepared or unwilling to listen to those with experience in the north. All of the most successful arctic explorers relied on input from the local people, and learned the techniques of survival that the Inuit had practiced for a thousand years. It will be interesting to see if that sort of collaboration will take place again, or if the imperialism of the nations involved will trump any such efforts. If the latter is the case it may just be that the extreme environments of the arctic sort things out for themselves, again.

Mawage

2007-08-19T16:33:00.000-07:00

Mawage. Mawage is what bwings us togever today. Wuv, true wuv that bwessed awangement, that dweam within a dweam.
-Priest from "Princess Bride"

Today is our first wedding anniversary! We've made it a whole year. I am always in awe of people who have stayed married for 20, 30, even 40 years and beyond. To be able to ride the hills and valleys of marriage, and to adapt and change with your spouse takes patience, work and a good sense of humour. So far, this year has been pretty easy, but I'm sure time will not be so kind to us forever, given the likelihood the future will hold challenges far greater than I can imagine right now. And imagine I do.

What would happen if one of us got sick (and I mean really sick)? What if one of our (future) kids gets really sick? How stressful will it be to raise even a perfectly healthy child? What if one of us was no longer able to work? What if one of our parents requires a great amount of care in the future? How will we change down the road? Will we still like each other in 10 years? Where will we live? What if the whole world ends up flooded by global warming and our house falls into the sea?

It would be an understatement to say that my worries get a bit out of control. I'm sure Aaron would agree- he's heard them all, from the sublime ("Would we go crazy if we won the lottery and had nothing to do anymore?") to the idiotic ("What if my intubating hand gets eaten by a polar bear while we're in the arctic?").

All I know is that I am deeply grateful that we've had one successful year of marriage (and some pretty sweet wedding pictures to go along with it). Some people don't even get that much.

We're also lucky that we can spend this year together in Iqaluit practising medicine. Last year, if you had told me I'd be spending the night before our first wedding anniversary doing a general anesthetic for a stat C-section (on my own!!!), I would have laughed at you. Also, I was too busy worrying about seating arrangements, hairdos and the colour of jam (is it okay if it's light pink? should it be dark pink?). This year is an incredible opportunity to learn together, and from each other. Happy anniversary Aaron, you are a great friend, teacher, and husband. I love you!

Sunday Bloody Sunday

2007-08-12T17:18:00.000-07:00

It's Sunday night, and I'm feeling a little sick to my stomach. Was it the ham and maple baked beans? Some gastro I picked up in the ER? No. It's simply that it's Sunday night, and I have to go to work tomorrow.

I don't know why I get this way, but I can tell you, it's nothing new. I remember feeling like this as a little kid. We'd be driving back from yet another Sunday dinner at my grandparents' house, and I'd be strapped into the back seat, staring out into the dark, listening to 80's ballads playing on the radio. As much as I love the song now, I still get a bit nauseated when I hear "Don't Dream It's Over" by Crowded House. Sunday night would trigger an increased heart rate, a drop in the pit of the stomach... because I had to go back to school the next day. The weekend fun was over, the drudgery of math class, piano lessons and homework was beginning anew. And I was someone who liked school (and did well in math class). Can't say I ever liked those piano lessons, but that's a whole other topic.

But I'm an adult now, with the freedom to make my own decisions about what to do with my time, with (finally) a real job, and without 4 pages of times-tables to complete before tomorrow. Yet every Sunday, it feels exactly like I'm heading back to roll call the next morning, and I dread the hours before the weekday starts.

I find it curious that I hate Sunday night so much, because there are a whole bunch of reasons I could choose to like it.

For one, it signals the start of a new week. The troubles of the previous week are left behind (well, except all the lab reports generated from previous office visits). Patient yelled at me? Whatever! Drunk guy tried to spit in my face? OK. Hypotensive patient tried to die in the OR? So last Wednesday.

Counter to this dislike of Sunday night is the fact that it should be the best part of the weekend. The grocery shopping has been done, the gym has been visited, the weekend plans completed. Time to sit back and relax. Time to watch the Magical World of Disney or Desperate Housewives. By spending the night worrying, I'm cheating myself out of some quality down time.

However, the most compelling reason for me to start liking Sunday night is that I'm worrying for nothing. It takes all of 3 minutes for me to get settled back into work Monday morning. If I'm doing clinic, I grab a cup of coffee, sit at my desk and flip through those lab reports, and think to myself, "This really isn't so bad after all."

I think it's time to take back Sunday night. I'm going to go make some hot chocolate and watch a re-run of Desperate Housewives (yes, we do have cable in Iqaluit) and enjoy the simple fact that I have a tomorrow to look forward to. And no math homework.

The Cosmopolitan North

2007-08-04T07:57:00.000-07:00

Do you live in a city? Can't imagine being more than 4 blocks from Starbucks? Need to be able to get to a yoga class 5 days a week, and replinish the wardrobe of LuluLemon outfits frequently? Do you like to watch foreign cinema, or go to the ballet on a regular basis? Do you enjoy dining at a multitude of different resturants on a regular basis?

If you answered yes yes yes yes and yes you're probably an entrenched urbanite, and probably get a bit uncomfortable if you roam outside of the city (Where are the highrises, the people? Where can I get a venti half-caf mocha with a pinch of cinnamon, hold the foam?!). Many people who live in cities find it difficult to fathom how people who live in smaller places do it. What is there to do? How do you meet people? Where do you get a coffee??? If you are really an urbanite this is an important question, and you probably shouldn't get out of range of the hum of a city. However, if, like most people in cities, you're more city-dweller than an actual urbanite, it's a question worth considering.

Dr. H. and I lived in Vancouver for the past 2 years, and like most people we were more city-dwellers than urbanites. While we enjoyed Vancouver as a city (it's a nice place!), we didn't really take advantage of it in the urbanite sense. We shopped at the grocery store near our house, ate at the resturants near our house, got our take out from our regular places (mmmm Banana Leaf), and never (not even once) managed to go to a ballet. The difference here is crucial. A true urbanite, a trendster in clothes that are so cool the average person can't even figure out that they are cool, with a tall-exotic caffinated energy infused beverage in hand can't be removed from the city. Open land is to urbanites as holy water is to vampires. But city-dwellers are a different story. While city dwellers may not have experience living outside of the city, it's an experience they might actually enjoy.

Iqaluit is a small place. It only has a few stores, a few resturants, one movie theatre, and far less than 1% of the population of greater Vancouver. On the surface it seems there is far less to do, far fewer people to meet and that it might be a boring place. A closer look shows that it's actually not true. Iqaluit, and many other small spots, have just as many grocery stores and resturants, and movie theatres as we frequented in Vancouver. It's also a very social place. In Vancouver I could wander around for days and never run into anyone I knew. In Iqaluit I see someone I know every time I go anywhere, and usually get introduced to whoever they are with. It's easy to meet people here, and very social. In the 2 weeks we've been here so far we've probably gone to as many dinners with friends, potlucks, and other social gatherings as we did in the last 6 months in Vancouver.

Sure, there are some downsides to small towns: less privacy, and craving for a Tim Horton's coffee chief among them, but overall it's a nice change. We're enjoying it a lot, and would recomend that anyone who's living in the city but contemplating something different to give it a try. Change is invigorating!

Whose patient is that??

2007-07-29T09:58:00.000-07:00

University Hospitals are often battle grounds; each service trying to duck, dodge and weave their way around direct responsibility for any patients. It's in the name of the patient census, the numbers, the 'teaching', the fairness of the situation. It's in the name of all sorts of nonsense, but rarely (rare as in the limit of x as x approaches zero) is it in the name of patient care. Much of my training took place in just such a place where endless debates about whether a particular patient with pneumonia and diabetes belonged on respirology, or if the patient actually had diabetes and pneumonia and therefore should be admitted to the general medicine service took place.

One night, while a junior resident on a general surgery rotation, I was asked by the doc in emerg to see a patient with abdominal pain. The exam, the labs and the imaging all added up to a diagnosis of choledocholithiasis. For those not initiated in the nuances of the multi-layered complexity of a university hospital it may seem to make sense that general surgeons, the surgeons who deal with the abdomen specifically, would be a good choice to take care of such a patient. The uninitiated might not know that an obstructing gallstone is a battleground, in fact the battleground, where general surgeons and gastroenterologists of the academic variety wage an ongoing war: A patient with a stuck gallstone needs 2 procedures, an ERCP to remove the offending stone, and a cholecystectomy to remove the offending gallbladder. The surgeons believe that since the ERCP needs to take place first the gastroenterologists should admit the patient (and therefore take primary responsibility for them), do their procedure and then consult the surgeons to remove the gallbladder. The gastroenterologists, on the other hand, believe that the surgery, being the bigger of the 2 procedures, should mean that the surgeons admit the patient (taking primary responsibility) and consult them to do ERCP prior to the surgery.

The battle is waged daily (and nightly) in the emergency department, and although direct engagement between the primary adversaries (the two attending doctors) is rare, they freely dispatch their underlings to wage a war through proxy. When things look grim and a patient might actually be admitted one of these great generals might even phone down to the emerg to chew out the emerg doc in an effort to restore a more favourable balance to the conflict.

The causes of the ongoing conflict are many. People are overworked, overstretched, tired, angry and hungry. The residents, foot soldiers in the conflict, are indoctrinated in the importance of being a wall, protecting the service from admissions and keeping the census low.

After seeing the patient I prepared for the buff and turf. I arranged my arguments and evidence like a row of grenades and called my general for the final battle orders. I've got a patient down here in emerg., consulted for abdo pain but turns out to have an obstructing gallstone. I'm going to call GI and try to get them to do the admit. I'd been through the battle before, I knew this was how it was all supposed to go. On the other end of the phone I heard only a moment of silence, and then a slightly confused Why? ... I'll come down in a couple of minutes and see the patient with you.

The general surgeon working that night happened to be a particular human and humane man. He saw the patient, agreed with the diagnosis, agreed with the treatment, but disagreed with the disposition. Why would we get someone else to do the admission? The emerg asked us to see the person, to help them. How does it help the patient to see a whole other team of people and to sit here in emerg for another 3 or 4 hours all just so we can have one less person on our service? His point was well taken, the real question was more about the patient in front of us than with the politics of the place she was in. In actual fact it typically took less time and effort for both us and the patient to simply do the admission than to wage the ongoing war.

In rural medicine I don't have to deal with these issues in my own hospital. If I'm working in the emerg and want to admit to someone I just do it, admitting them to myself and caring for them in hospital. Occasionally I face these roadblocks when I'm trying to get assistance over the phone, or to transfer a patient. Should a trauma patient with altered level of consciousness go to neurosurgery, emergency or ICU, when they're transfered to the University Hospital? The reality is that what the patient really need is to get to the next level of care, under whom they are admitted is likely of limited importance (since all these players will be involved in their care regardless). I find the human approach (an appeal on alternate grounds) is best, since the politics run too deep for an outsider to get embroiled in. The patient is sick, I say, I'm in the middle of nowhere and I don't have a CT scanner, a neurosurgeon, or an actual ICU. I need to transfer this patient to you because I've done everything I can here and it's not enough, so I'm asking for your help.

It's beyond the petty politics of hospitals, the bad feelings about division of labour and the history of the various players. It's outside of politics and speaks a language that is common to most doctors, worry about a patient, stretched to the limit of what you are able to do. It usually works...

Walking on the tundra...

2007-07-27T13:39:00.000-07:00

The north is usually portrayed as cold, snow-covered, desolate and barren. But while the summer here is short, it is a season full of beauty and life. The tundra, drifted over all winter with snow and ice, turns green and red and purple and yellow. A symphony of colour unleashes itself in a short carpet of wildflowers that covers everything.

Dr. H and I arrived here in Iqaluit almost 2 weeks ago. It's been very busy, interesting, and often fun. We've been working a great deal, but did have time to take a break and go walk among the endless tiny flowers that cover the summer landscape. Here are a few pictures from our walk.

A northern mosquito makes a feast of my finger (the things I'll do for a picture!).

A ship unloads it's supplies in the harbor. Notice there is still ice in the water, and even today I noticed a few lingering pieces. There are no roads into Iqaluit and in general all goods are flown in at great cost. The short summer shipping season offers a chance to bring in goods at much reduces prices. In addition to dry goods, and general supplies, ships bring in vehicles, heavy equipment, fuel, and all the supplies for building any new buildings.

Tiny flowers cover the ground.

Rocks, grass and flowers.

More flowers.

And more flowers.

The row of look-alike houses leading towards our place. Locally these houses are sometimes referred to as 'lego-land'.

Looking out over the landscape...

ᐃᓄᒃᓱᒃ

2007-07-24T17:46:00.000-07:00

I can't believe we've been here for only about a week, because it already feels like a month (or two). It's been exciting, scary, fun and, at times, downright bizarre.

Here are just a few of the things I've seen/done/experienced in the last week:

- Worn a jacket and gloves in JULY
- Given a general anesthetic to a pregnant patient in the 3rd trimester for an acute appendix (ack! the pregnant airway)
- Passed the skeleton of a dog, lying next to the road, on my way to work every day
- Intubated and put a central line in a septic patient
- Been swarmed by mosquitos (how is this possible when it's this cold?)
- Eaten a piece of beluga fat
- Treated more STD's than I can count; unfortunately, Nunavut has about 13-20 times the STD rate of the rest of Canada
- Fallen in love with just about every Inuit baby I've seen (these babies are ridiculously adorable)
- Had the best waffle of my life. That's right. You heard me. If there's one thing this town is not lacking, it's delicious waffles.

Here's a picture from a walk Aaron and I took right near our place. There's a little inushuk (the Inuit spelling is more like inuksuk) on the rock at the top of the hill.

Give them a hand

2007-07-22T12:24:00.000-07:00

I like teaching medical students and residents. Some parts I'm good at; in particular I like to think I'm good at teaching people how to approach problems in a logical way, how to cope with incomplete diagnostic information, and how to deal with the (at times overwhelming) vagueness of family medicine. Some parts I struggle with. Teaching technical skills is one of those areas.

Sewing up a complex laceration, putting in a line, repairing a tear after a delivery, disimpacting a shoulder dystocia, all of these are important skills for future family docs to have. I'm reasonably good at technical procedures, not the best, but certainly adequate. I know how to do procedures, but the problem is that it isn't my brain that holds that knowledge, it's my hands. How do you do a hand tie? My brain hasn't the foggiest notion, but my hands perform the task reasonably well. "Wow that was a tough shoulder dystocia Dr. J., can you explain how you did that turn-around-thing?". Hmmm, well I can tell you in theory what I did, but the actual chain of events happened in my hands, not my head....sorry Dr. Resident....

I try to show students, step by step, guiding their hands as best I can (when the situation is non-emergent), but I'm sure I still fall short. As a resident I had some brilliant teachers who could describe the performance of technical procedures in exquisitely simple language, knowledge flowed from their mouth into my hands....alas, I impart no such skill to the students I encounter.

If only my hands could do the talking...

Above the tree line

2007-07-19T15:41:00.000-07:00

We finally made it to Iqaluit after 5 days of frantic packing, 2 flights and 3 hotel stays. It's been a long week and it's still not over yet!

We are still living out of our suitcases but we're loving the apartment we're renting here. It's bigger than our old apartment, and the layout is much more appealing. The rents are quite high (we're paying more than we were in the city) and the houses are all extremely functional; in the minus 40 weather there is no place for esthetics, it's all about staying warm and making it through the winter. Right now the weather is actually quite nice...the highs are between around 5 and 10 degrees Celsius, and apart from a bit of rain, it's been pretty clear. The weather is funny...you can literally see the fog rolling in and out of the bay. There is a stark beauty to this place and the walk to the hospital in the mornings is really stunning.

I am doing anesthesia in the mornings and clinics in the afternoons. Aaron has done some emerg shifts and is getting organized on some projects he'll be working on up here over the year. I have to admit it, I am totally exhausted. Mental overload. I think I feel more comfortable in the operating room than I do in the family medicine clinic. I guess I am just used to having my little spot in the OR with all my familiar drugs and airway equipment and my monitors. The clinic is a completely different beast and I'm a bit overwhelmed by the breadth of stuff that comes in. To any specialist who has ever maligned a family doc, I challenge you to spend a week (or a day...or even an hour) in a family practice and ever feel justified in bad-mouthing a family doctor again. Luckily, everyone at the hospital has been absolutely lovely and helpful and welcoming.

We've been too busy to take any pictures but I'm sure there will be many posted here soon (along with some insightful comments from Aaron). For tonight, I'm going to make some dinner and then retreat to the bedroom with the tinfoil-covered window (to keep out the midnight sun) for some sleep, and get up and do it all over again tomorrow.

In transit...

2007-07-12T11:05:00.000-07:00

The packers are here, our stuff is in boxes, and the movers come tomorrow. Almost everything we own is going into storage as we head north. The adventure begins....with the usual slight hitches and nervous anticipation....
Dr. J.

The Badlands

2007-07-07T07:06:00.000-07:00

Last week Dr. H and I travelled to Calgary for the Canadian anesthesiology conference, and to visit her parents before we head up north. While we were there we decided to take a trip to Alberta's badlands. Not being from the praries I had always assumed that the landscape was rather flat until you got into the foothills of the Rockies. Not so... The Badlands have really interesting geography and are anything but flat. On our day trip we went to the town of Drumheller, the Royal Tyrell Museum (a great dinosaur museum!), and did a driving tour of the Badlands, stopping at several canyons, a suspension bridge, a ferry, and hoodoos. After a long day we headed back to Calgary and experienced a June Alberta snowstorm, out of nowhere 1 km of the highway and surounding fields was covered by 6 inches of snow.
Here are some pics we took along the way...

A view of the western side of the Rockies.

Calgary from the air.

Drumheller is home to "THE WORLD'S LARGEST DINOSAUR!!!", and here's Dr. H on his foot.

I couldn't resist this Godzilla-esque shot...

Wildflowers...

A prairie dog poses for the camera.

Horse-thief Canyon.

Dr. J.

Dr. H.

Some old barns...

The colourful landscape...

The badlands...

Hoodoos...

Changing the way we think about addiction

2007-06-30T22:00:00.000-07:00

It's Friday evening, 19:30, and you're the only doctor left in the emergency department. It's been a busy day and you're tired, but you don't finish for another hour and a half. You are still working up 2 patients with chest pain, and 2 weak and dizzy's, one of whom arrived by ambulance without any actual medical information. There are still 10 charts in the 'to be seen' pile and you know the evening rush will soon follow. You're flagging...

One of the nurses, equally exhausted, walks away from curtains shaking her head and hands you the chart of your next patient. The face sheet lists the reason for visit as 'Needs Dilaudid Rx'. You walk in and see the patient, obviously agitated, pacing the room. "How come it takes so long to get help around here? What kind of emergency room is this? This place is full of idiots!" Struggling to get a word in you try to take a history. After some hard work you glean that the patient is usually on Dilaudid Contin 12mg BID (or 'Dilly 12's', as the patient refers to them) for chronic pain due to a chronic leg ulcer and osteomyelitis of the tibia. "My stupid doctor went away for the weekend without filling my per", the patient says, "Just give me a week or so worth until I can get in to see him, I haven't even had any today, and I'm in PAIN!".

You do a detailed physical exam and find a large, deep chronic wound on the patients shin with significant surrounding cellulitis. You also note that the patient has track marks around the left elbow, and appears to have significant oral thrush.

Addiction can be a frustrating issue for doctors and other medical professionals. Most doctors are ill equipped to handle most patients with active addiction, and for many doctors the above patient is a nightmare. That frustration is evident in many popular med-blogs, which frequently contain posts venting about patients like the one discussed above. It's useful to consider where that frustration comes from because it clearly makes the jobs of many doctors miserable, and it also gets in the way of good patient care.

Frustration in caring for addicted patients comes from a number of places:

Addictive behavior is often manipulative, and manipulation makes people angry.
Doctors often don't have an approach to managing patients with addiction.
Doctors often feel like they cannot help patients with addiction, and are therefore wasting their time.
Addiction is a common disease and most people have at least one friend or family member who has struggled with addiction. Patients with addiction can bring up uncomfortable memories and feelings for doctors.

Developing approaches and strategies to effectively treat patients with addiction results in benefit for both patient and doctor. The patient accesses effective, evidence based care and allows the treating doctor to feel like they are offering the best available options to the patient. I am not arguing for the Emergency Room to become the main treatment ground for addiction, however as it frequently sees patients who are struggling with addiction it makes sense to develop approaches to treatment that start in this environment, both in the interest of good patient care as well as in the interest of job satisfaction of the people who work in the emerg.

Like many other conditions that we treat with modern medicine, addiction can be understood in terms of a bio-psycho-social model. That is, the inputs into the condition of addiction come from a number of places. Does addiction run in your family? Did you grow up in a high risk environment? Were you exposed to potentially addicting drugs in utero, or during your youth? Do you work in a high risk profession (like being a doctor)?

All too often the issue is polarized into an argument of 'It's a choice!' versus 'It's physiology and genetics!'. It's both, just like Type II Diabetes, a condition that has a lot of common ground with addiction. Type II diabetes is a condition resulting from some combination of genetics, family eating patterns, social situation, patient choices and patient environment. Both are diseases that involve elements of patient personal choice, as well as patient physiology. Good treatment for both addiction and type II diabetes involves far more than just medications (though in both circumstances medications often have a role to play). Usually the most effective approach is a team approach. In the case of a diabetic that might be a doctor, a nutritionist, a pharmacist and a personal trainer. In the case of an addict it might be a doctor, a counselor, a peer support group and a parole officer. In both cases the system works for the patient when the system works together.

Addiction is a long term, chronic condition. Gone are the days of sending people off to treatment centres for the cure. Treating addiction is not a win-loose proposition. Management of over the long term involves helping patients move towards change and abstinence, once abstinence is achieved it involves relapse prevention and management of relapse. Over the long run it involves reducing both the duration and frequency of relapse. When relapse happens (and it does happen because it's part of the long term reality in addiction) it makes sense to approach it from a management standpoint. Just like managing a diabetic who comes in with an A1C of 12% after a year of good control, it makes sense to figure out what happened, what changed, and how do we make changes to get things back on track.

Addiction is common, with lifetime prevalence usually estimated at around 5% of the population. Addiction is associated with a lot of serious medical issues including Hepatitis C, HIV, cirrhosis, brain injury and premature death. Considering interventions that may allow patients to avoid these serious consequences makes sense on both economic and compassionate grounds. Emergency room doctors have the misfortune of usually seeing addicted patients at their worst, and rarely see them when they improve. It's a tough environment to convince people to take an interest in addiction, but it's an area where it makes sense to develop approaches to the issue.

Most doctors have been taught to recognize the patient I presented earlier in this article as drug seeking, and that the treatment options are either to provide a small amount of narcotics, or to tell the patient they can't have narcotics and discharge them. It's a conflict oriented approach that both frustrates the doctor, and the patient.

My own approach to patients like the one above is to frankly tell them that in my assessment they seem to have an addiction problem and that it looks like it's having some serious health consequences for them (in this case both the infection, and the HIV that the thrush hints at). I tell them that I'm glad that they came into for help and offer them help. I offer them medical detox, and tell them that I'll go to bat for them to get them the help they need. I tell them to think about it, that it's their decision, and I'll come back in a few minutes to see what they want to do. (In clinic I take a bit of a different approach I won't get into here.) The benefit of the approach is that I feel like I've offered the patient the best treatment possible, and I've hopefully caused a moment of ambivalence for the patient where change might be possible.

The patient presented above is fictional.
If you are struggling with an addiction and want help talk to your doctor or click on the links to alcoholics anonymous, narcotics anonymous or cocaine anonymous on the right, and find a meeting near you. Change is possible!

The Northmed Index (or please don't sue me Harper's magazine)

2007-06-27T10:30:00.000-07:00

I like to think of myself as a minimalist for stuff. I function fine with what I can fit in a suitcase for a month or more, and rarely think 'wow, I wish I'd brought along X'. There's only a month left until we move from Vancouver to Iqaluit, and that means it's time for packing. Let the good times roll; packing is one of the most stressful activities around. Today an estimator for the moving company came by to see how much stuff we have to move up north. It's a real dilemma, do we take a little or a lot, do we store everything or take it along? Although the moving guy confiently said 'You've got less stuff than lots of people, I still feel like we've accumulated clutter since we came to Vancouver. Moving will be a great way to thin it all out. Here are a few facts and figures about our house, our stuff our city(s) and our life.

Vancouver coordinates: N 49 16' W 123 7'
Iqaluit coordinates: N 63 45' W 68 31'
Size of Vancouver: 114 square kilometers
Size of Baffin Island: 507,451 square kilometers
Average Janurary temperature in Vancouver: 3 C
Average July temperature in Vancouver: 18 C
Average price of a home in Vancouver (March 2007): $705,141
Final selling price of the tear-down, former grow-op house across the street from our apartment: $910,000
Number of rooms in our apartment: 6
Number of TVs: 1
Number of Computers: 4
PCs: 2
Macs: 2
Percentage of computers that can complete a functional boot up: 50%
Percentage of functioning computers that are Macs: 100%
Average February temperature in Iqaluit: -26.4 C
Average July temperature in Iqaluit: 7.7 C
Minimum operating temperature of the Macbook computer: 10 C
Population of Vancouver: about 2,000,000
Population of Iqaluit: about 8,000
Number of RAV lines in Iqaluit: 0
Number of RAV lines in Vancouver: 0 (still under construction)
Number of hospitals in Canada (approx.): 830
Number of hospitals in Nunavut: 1
Percentage of Canada's total area occupied by Nunavut: 21%
Number of Canadian hospitals further north than Baffin Regional Hospital: 1 (Inuvik Regional Hospital)
Suicide rate for Canada: 14 per 100,000 per year
Suicide Rate for Nunavut (2006): 123 per 100,000 per year
Approximate return airfare Toronto to Iqaluit: $1750
Approximate return airfare Toronto to Bangkok: $1750
Average January temperature for Bangkok: 32 C
Number of days until we move to Nunavut: 19
Percentage of packing completed to date: 0%

Aquariums Galore!

2007-06-20T20:20:00.000-07:00

Yesterday I went to the Vancouver aquarium with my brother, sister and nephew. I admit that I am an aquarium nerd and have a salt water tank at home, though it has suffered from neglect of late (don't worry, the fish are very happy swimming in the algae.....happier in fact than in the algae free tank they used to live in when I was spending more time on this hobby). One of the amazing things about the Vancouver aquarium is that it has a great deal of cold water exhibits from local environments here on the west coast. While reefs, are usually associated with the tropics, the cold water reefs of the west coast are colorful and full of interesting marine life....
Here are a few pics I snapped along the way....

A beluga whale....I don't really think these guys should be in captivity, but they are, and here's a picture.

Mmm, it's a jelly (that's a Bob and Doug MacKenzie reference that Canadian readers will hopefully get).

My nephew posing like the aquarium ad (He is a monstrously tall 1 year old in case anyone is wondering).

Cold water fish and anemones.

Another cold water tank.

My aquarium, before it became an algae jungle.

Advances in Northern Medicine

2007-06-19T09:26:00.000-07:00

Frostbite is a common injury both in northern settings as well as in more unexpected places. Working in the arctic over the last 6 months I've seen quite a number of frostbite cases, but even when I was working in Vancouver I'd see the occasional frostbitten patient. That's right, Vancouver, Canada's tropics, has frostbite. In Vancouver frostbite is uncommon, but working on the Downtown Eastside I did see a couple of cases in homeless folks who had weathered a cold night outside with wet feet in poor footwear.

An article in this months Archives of Surgery, entitled Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy, describes the use of intra-arterial tPA in patients with frostbite injury to a digit and demonstrated impaired perfusion. The article concludes by proclaiming that this is the first clinically significant advancement in the management of frostbite in more than 25 years. Indeed, as any northern doc can tell you, management of frostbite is limited.

A patient presents to the emergency department after passing out in a snow bank. Surprisingly his core temperature is adequate, but his hands appear white and frozen. At present the standard treatment for this patient involves:

pain control, usually with IV narcotics
rewarming of his hands by immersion in saline warmed to 42 degrees C
treatment of any hypothermia (with external, and often central rewarming)
debridement of any blisters containing clear or white fluid (these blisters represent more superficial injury, and contain PGF-2A and thromboxane, both of which can cause deeper injury through inflammation)
Hemmorhagic blisters are left intact as debridement can lead to increasing depth of injury, though aspiration can be considered.
Administration of an anti-inflamatory drug (Ibuprofen)
Tetanus booster if required
Telling the patient that they may not, under any circumstances, smoke (most people are able to not smoke when their fingers are at risk)
Surgical consultation (though early surgical intervention is avoided if possible, as even horrific looking injuries sometimes recover well)

The article suggests that the use of intra-arterial tPA may represent an advance in therapy that may save digits. This is exciting news to anyone who deals with frostbite, because at present effective interventions are limited, and poor outcomes can be disabling. There are limits to the study however, (small size, non-randomized, case control design, restriction to a single highly specialized institution) that prevent this from being a definitive and practice changing study. Certainly these results warrant a larger, multi-centre, randomized investigation. Given that many frostbite injuries occur in the periphery where timely access to intra-arterial thrombolysis is non-existent I do wonder if an arm of such a study examining systemic thrombolytic therapy might be warranted (though the risks of systemic therapy are also greater).

The blog debate continues...

2007-06-15T22:51:00.000-07:00

The debate around blogs and libel law continues in today's Globe and Mail (Canada's national newspaper, in spite of my props to the Nunatsiaq News on my links bar). The article, entitled 'Media stardom is pricey', discusses the relevance of these issues here in Canada, and points out that we Canadians may not enjoy all of the same legal protections as our American colleagues, particularly with regard to libel resulting from posted comments from readers.
It's worth a read...

Here is the comment I posted to the G&M website about the article....

Blogs are, at present, an important communication tool for young people. Whether they will go the way of the 8-track or the television remains to be seen.
As a physician maintaining a medical blog (northmed.blogspot.com) I am always thinking about not only any potential libel/slander issues, but also about issues of confidentiality. For me personally this has meant a non-anonymous blog, with editorial style pieces about issues in my particular realm of medicine, as well as more personal pieces and pictures. Confidentiality of course precludes any posts about patients, but to date I have also avoided any posts about fictionalized patients that might be misunderstood as a casual reader as non-fiction.
Over the past 6 months a number of medical blogs, offering very informative views into the culture and life of medical professionals, have gone off-line due to concerns about both legal and professional issues.
At their core blogs offer freedom of both freedom of speech and freedom of press to anyone who chooses to exercise that right. Of course there are limits (confidentiality and libel chief among them), but the standard to which blogs are held should be the same standard that any adequate small town newspaper may be. Erosion of free speech and free press is a serious issue, and blogs may exist on the razors edge of that debate...

The gasoline on the fire...

2007-06-11T08:06:00.000-07:00

Burnout: A psychological term for long-term exhaustion and disinterest, in the context of work.

In the six months since I started this blog I've received a number of comments and emails from people who tell me they enjoy reading because they think this is one of the few physician blogs out there not suffering from burnout. In reality it may be that people mistake venting, present in many blogs and as much as possible absent from this blog, as burnout. Regardless, it's interesting that many people, of both medical and non-medical backgrounds, perceive so many doctors as being burned out. Burnout is an important issue for both individual doctors, who change careers, loose income, and live unhappy lives as it's end result, and also for the public because burnout chips away at an already precarious physician supply, and disengages otherwise excellent docs from the business of caring for patients. It's certainly an issue worthy of examination.

For most doctors (myself included) burnout is an idea that's loaded with personal experience, either our own or our colleagues. A year ago I found myself in a situation at work where I was at risk of burning out, and as a result had to do a great deal of forced introspection about the causes of and solutions for burnout. Much of the discussion below is based on my own experience, rather than any formal research.

Burnout is an issue that is well hidden in medical training. The general assumption during medical school is that everyone should be grateful to be there and that since medicine is a noble calling that everyone will surely love what they do. Sure there might me a lecture or two over the four years of medical school on career satisfaction, but like most of the soft content (meaning non-testable, and non-scientific), these lectures are poorly attended and easily dismissed. Even with these lectures in place most young medical trainees view themselves as different than their predecessors. With different priorities, different work styles, and different career choices, many young doctors enter practice feeling that they are not at any risk for burnout.

Medical students and residents are frequently confronted by burned out doctors during their training. These are the doctors who wander the halls spewing hatred about their patients, their colleagues, their hospital, their career, their medical association, their salary, to any and all who will listen. They are also the quietly unhappy doctors who trudge on, day after day, but in quiet moments advise trainees to select a different field, or a different road then they. Throughout medical training thoughtful introspection is actively discouraged in favor of the long view, and delayed gratification. The end result is that young doctors, after completing their residency, enter a field with a very high rate of burnout, ill equipped to either identify or deal with potential problems. Their only role models when it comes to burnout have been the frustrated, burned out docs who loudly, or meekly trudged on. Because any ability or willingness to self reflect has been thoroughly quashed during their training, they have trouble both identifying and coping with work related stress. Some enter practice already shouldering a fair amount of burnout accumulated during difficult residencies.

Although there are many causes for burnout I will focus on only 2 (lack of power/voice, and vicarious traumatization) that I believe are major contributors in the medical workplace, and for physicians in particular.

Lack of power is an issue that leads to burnout in any workplace. When you don't feel your decisions or effort is appreciated or acted on by those around you, when you don't have any control over your workplace, it's difficult to feel that the work you are doing is worthwhile. Medical residents, who are typically told where to be, when to be there, and that their efforts (however well intentioned) are simply inadequate are particularly vulnerable to this stress. Practicing physicians often have more control over their time, and more ability to make their own decisions, but can suffer similar stress in their workplace. Doctors who work in large organizations are often treated like replaceable cogs in a large machine, and although they may see real front line issues in their workplace their attempts at solutions frequently fail to percolate upwards through the filters of bureaucracy. People who feel their job is irrelevant tend to simply go through the motions, and get little personal satisfaction from work. It's a recipe for burnout.

Vicarious traumatization is an issue that many physicians are unfamiliar with. Put simply, it is that idea that being in the presence of someones suffering (particularly in an intimate way such as the doctor-patient relationship), can cause suffering of it's own. Overt examples include being present at the unexpected death of a young person, or being involved in a case with an unexpected bad outcome. More subtle examples include caring for patients who have been severely abused and hearing their stories in detail, witnessing the results of significant violence, and caring for patients on an inevitable collision course with tragedy. Unfortunately many doctors view ideas like this as intolerably flakey and prefer the age old methods of denial and compartmentalization in dealing with any unwanted personal emotional response. Particularly at risk environments for this type of burnout include any place where abnormal events occur with such regularity that they become normalized. Any workplace where tragedy is met with responses like 'Get used to it, it happens all the time here, and we don't have time to stop and talk about it.' is likely to be full of this type of burnout. Normalization of the abnormal also poses a significant risk for trainees who work in many environments for only a short time and who may not be able to participate in any of informal support mechanisms that might exist. Most doctors are exposed to situations that put them at risk for vicarious trauma. Unfortunately most are also well schooled in suppressing any such response and not dealing with their own emotional well-being. Again, a recipe for burnout.

Dealing with situations that cause burnout, and dealing with actual burnout is difficult. It requires introspection. It requires recognition that doctors do have emotional (and non-rational) internal responses to stressful situations. It requires developing workplaces that are responsive to the concerns of front line workers, and have active programs to deal with unusual (or usual) stresses. It requires that abnormal situations be named abnormal, and debriefed accordingly (workplaces that say this is impossible because they don't have enough time have a staffing problem). It requires that doctors participate in debriefing. In workplaces where these supports don't exist, it requires individuals to carefully consider whether they can maintain their own health in such an environment.

In my own situation, after a careful examination of the particular stresses of my workplace I made the decision to change my environment. I stepped out of a job that I enjoyed, but had some significant and major stresses that I felt could not be overcome. After debating the issue for a while, I felt that the most healthy thing for me was to move on (hence a northern adventure slated to begin this summer began about 6 months early). I think that part of why this blog is devoid of burnout is because I am actively trying to address issues that could lead to burnout upfront.

Burnout is a challenging issue. It forces us to confront our own reactions and feelings, and to make some difficult decisions. It always troubles me when I read about doctors who hate their job. Almost invariably they are suffering from workplace burnout, and simply aren't sure how to deal with it. There are too many options, and too many jobs in medicine for anyone to be stuck in an environment that is intolerable. Hopefully as we move towards recognition of burnout as a widespread and important issue we can help physicians develop the personal tools to cope with difficult situations as they arise, and workplaces that support this process.

Self-care is not a soft subject and should not be treated as such. Doctors can't provide good care to patients when they themselves are unwell. We all have a duty to bring our best selves to our work and to our lives, and this involves giving self-care more than the short change it currently receives.

Odds and Ends

2007-06-08T13:57:00.001-07:00

I arrived home in Vancouver after four weeks in Inuvik last week. Like my previous trips north it was an amazing experience. The Western Arctic is vastly different from the Eastern Arctic not only in it's landscape, but also in it's cultures and peoples. In the east most of the traditional culture is Inuit in origin. Inuvik on the other hand sits at a cultural junction point where Inuit, Gwich'in and Dene peoples all meet. While I was in Inuvik I had the opportunity to speak with a number of Elders from various backgrounds and learn a little about the areas traditions and life.

Speaking with Elders about their experiences of change over the last century is one of the real priviliges of spending time in the north. It is often amazing what people have lived through, and wonderful to hear their perspectives. In our society speaking with older people about their experiences isn't something that's often emphasized. I remember speaking to World War One Veterans about their experiences as a grade school student, but with no real appreciation of what a precious and limited resource their memories and views were. I hope that my appreciation for the living past is something I'll take with me through my life. (And maybe one day when I'm old some grade six kid will interview me about the times before computers; 'That's right, we did math on paper.....what's paper?!?, well let me tell you it was made from trees, yup there were so many trees we could just cut them down and grind them to pulp by the thousands!')

In mid July Dr. H. and I will both be heading up to Iqaluit for a longer term contract. We are looking forward to it a great deal, and hope not only to learn more about northern medicine as we work, but also to learn about the culture and people we will have the privilige of meeting along the way.

In case anyone thought they'd get away with out being subjected to the endless slideshow, here are some pictures of my brother Shawn and I fishing in beautiful BC!

Gone Fishing...

2007-06-05T19:24:00.000-07:00

'I wonder what they're biting on today?' It's the middle of the week, and the lake is empty, it's overcast and a light rain is making the surface of the water ripple. 'I'd try one of those Mepps spinners.' Wild speculation, an endearing trait of all fishermen, but the weather is right so it's a safe guess.
Flip the bail. Fishing rod up. Flick your wrist. Swishhhhhh. Click. Splash. And reel.
Repeat.
Ahhhh, feel the blood pressure fall.....

As usual my lousy fishing karma reigned supreme. The 'big one' was as elusive as always. Oh well, it's more about the rythm of casting and calm anyways.

"Glad to see you're not wrecking your coronaries with doughnuts, Roy," said Pinkus. "I've tried to tell the girls but they won't listen. They're lucky, of course, in that the estrogens lower their incidence."
"I'm not hungry," I said. "I think I've caught what the BMS [best medical student] had. I'm gonna die. I just timed my respirations: thirty-two a minute."
"Die?" asked Pinkus. "Hmm. Say, did that BMS have a hobby?"
The head nurse picked up the chart, turned to the special section created by Pinkus, called "Hobbies," and said, "Nope. No hobby."
"There," said Pinkus. "See? No hobby. He didn't have a hobby, do you understand? Do you have a hobby, Roy?"
With some alarm I realized that I did not, and said so.
"You should have at least one. See, my hobbies are directed to the care of my coronary arteries: fishing, for calm, and running, for fitness. Roy, in my nine years on this Unit, I've never seen a Marathon runner die. Not of an MI, not of a virus, not of anything. No deaths, period."
Samuel Shem
The House of God

Things that make you go hmmmm...

2007-05-30T11:30:00.000-07:00

Sometimes little conversations can change the way we see the world in little ways. I tend to be a bit chatty when I'm walking around the hospital and drum up conversation where I can. I admit I'd rather talk with an Elder about what it was like to grow up living on the land than talk about a sore throat. Sure, maybe it's thinly veiled work avoidance on my part, but I think it's where I often learn meaningful things about other cultures (and surely, that's useful for talking about future sore throats, with future patients....or so I tell myself).

The other day I saw someone quietly sitting at one of the hospital windows watching the world go by with a great big smile. "Nice day, eh?" I said. He turned and gave me the biggest smile I had all day and said "It's the first time I ever saw trees!", and turned back to his watching of the budding trees swaying in the light breeze.

No moral, no lesson, but it had me smiling for the rest of the day.

Up the Delta

2007-05-27T11:07:00.000-07:00

This past week I had the opportunity to visit one of the smaller communities in the MacKenzie Delta called Aklavik. Aklavik is a small hamlet of about 630 people, with a very interesting history. It's location in the delta historically made it a natural spot for trading and commerce. In 1959 the government determined that a new centre for commerce in the Western Arctic was required, as Aklavik was prone to frequent spring floods, and had little room for expansion. The result was the the building of Inuvik.
At one point Aklavik had it's own hospital and a large Anglican Cathedral called All Saints, both pictured above. This Cathedral burned down in the early 1970's and was replaced with a much smaller structure, as by that point the community was no longer a major centre. The hospital has long been replaced by a nursing station.

Aklavik is also home to part of the legend of the Mad Trapper of Rat River (also known as Albert Johnson. The story is interesting and worth reading. Basically the Mad Trapper was the subject of an extensive manhunt, lead by the RCMP in the early 1930's. The search roamed over large portions of the western arctic and ended with a gunfight in which The Trapper was killed, and he was buried in an unmarked grave in Aklavik.

My visit to Aklavik was far less exciting, but still very enjoyable. I got to meet a number of elders and learn about there experiences groing up on the land, and the fascinating transition they have made to their current lifestyle. Oh, and I managed to do a bit of medicine while I was there too. Community visits are always enjoyable, and I always manage to learn something new. Below are a few pictures from the trip.

Small planes are still the backbone of northern travel.

Aklavik from the air.

A street in Aklavik.

The melting river, with the Richardson Mountains in the background.

A now abandoned church.

An eagle on the ice (I'm more sure on this bird ID, but correct me if I'm wrong).

The Aklavik nursing station.

The Aklavik airport (now departing from gate 57, terminal 3....).

The MacKenzie Delta from the air. It's amazing that anyone can find their way among the tristing streams and lakes.

A walk around Inuvik

2007-05-23T20:20:00.000-07:00

Spring has arrived here in the north. The last few days have been beautiful, sunny and warm. I've taken some time to walk around Inuvik while the weather is nice and see the sights. It's a pretty little town and I thought I'd share a few pictures...

Here's the brightly sunlit hallway to emerg. as I left the building around midnight yesterday.

Some sort of berry....I like these macro shots.

A little house on a side street.

The hospital is perched above this lake.

That white blob is a snow goose I believe.
Addendum: Clare (who has some birding expertise) has corrected me on this pic. The blob is a gull. Thanks Clare!)

Ahhh, a canoe hidden in the woods. Could anything be more Canadian!

This pretty little bridge is on a path along the lake.

Outside of the visitors centre sits this plane on a pole. I haven't figured out it's significance yet but I thought it was kind of fun. The propeller spins in the wind....

This is the Inuvik Community Greenhouse. It's a co-op project that turned an old arena into a greenhouse. Now residents have a place to grow their own fresh produce in the summer months.

The Inuvik cross country ski club.

MacKenzie Street....the main drag.

I captured this shot of the sun at the horizon walking back into the hospital around 3AM.

Bud break on a hillside of trees.

Over the next few days I'm travelling to one of the small communities in the area to do some clinics. I'll update the blog with more stories and pics when I return...

Morbidity and Morality

2007-05-21T18:20:00.000-07:00

A patient stumbles through the doorway of the emergency room. Her gaunt appearance and look of fear draw your eyes towards her. She's thin and appears to be barely keeping her balance. She's dressed poorly for the weather. Fearing she might collapse a nurse quickly guides her to a stretcher. Her vitals are HR 170, BP 90/50, RR 38, T 36.7C, O2 100%. She seems confused, and somewhat agitated and cannot give you a history. She doesn't appear to have any injuries on physical exam. As you turn to the desk to order further investigations she asks you for a drink of water.

Medicine can be a detective game. Histories, physical examinations, labs and imaging are the clues we use to put together a story and a diagnosis. Sure many cases are straight-forward but the tricky ones can also be the most gratifying. A good night, and a tough case, can leave you feeling like chief CSI of the Emergency Department, and a bad night can leave you feeling like Barney Fife. There is a certain gratification in putting it all together (like House MD, minus all of the unethical and illegal behaviour).

Much of this detective work hedges on the assumption of an anatomic, or physiologic basis for disease. Modern medical training highlights the biological basis of disease; an abnormal urine dip here, an lousy blood gas there, and the case is beginning to add up. But what about when it doesn't add up? What about the times when the patients symptoms don't match the biology of the situation? What do doctors do where medicine and morals meet?

The idea that disease is caused by faulty personal morality is not new. Madness caused by spirits, or demons has been described since written history began. How such creatures gained access to an individual depends on the society in which the events took place. Perhaps it was a misdeed, perhaps it was karma, perhaps it was simply a sneeze (bless you) that let the demon in, and the madness begin. Often the root of the disease was slightly more complex. Often the real cause was a lapse in personal morality. Not surprisingly many early treatments for diseases involve the release of these 'bad morals' through act or ritual. Trephanation, pictured on the right, was used to release from the head not only medical problems (blood clots), but also moral problems (bad spirits).

We of the medical ilk like to believe such superstitious thinking is a thing of the past. Medicine has scienced itself up over the past few decades and our thinking about disease and causality of disease has changed along the way. In the past medicine included any number of diseases caused by 'weakness of mind', 'weakness of spirit' or other equally morally loaded terms. Madness, anemia (chlorosis), schizophrenia, depression, anxiety; all of these diseases have historically been in part attributed to moral causes.

It's interesting to consider how the above mentioned diseases migrated from the realm of morality into the realm of biology, and what that has meant for them in terms of their medical treatment. For the diseases mentioned above, improved understanding of underlying pathophysiology, and improved pharmacologic interventions has drastically changed the way they are approached and treated in modern medicine.

I've previously argued that moral thinking has a far greater strangle-hold on modern scientific medicine than we think it does. Certain diseases (or conditions) continue to be judged more in terms of morality than biology, and as a result are often not treated at all in the context of modern medicine. Two examples are addiction and obesity. Although both commonly present with a particular set of symptoms, and both are frequently life threatening, they are often untreated because they are the fault of the patient. This is in spite of the fact that for both of these conditions there are interventions (both pharmacological, and non-pharmacological) that have been shown to be effective in rigorous and well conducted trials (the bastion of modern scientific medicine). These days no good addictions medicine presentation is complete without a PET scan showing the biologic basis of addiction. Although well intentioned it is unclear (to me) if these scans exist in order to better direct treatment, or just to justify it. Although the pathophysiology of addiction is on it's way to being as well understood as depression, for many doctors it remains a disease of fault (and therefore a disease untreated). I am not arguing for ignorance of the behaviours associated with these diseases. Far from it, I am arguing for effective intervention into these very behaviours.

One of the difficult questions we must ask ourselves in medicine is 'is fault relevant?'. Does it matter that someone with addiction, at some point, choose to use drugs? Does it matter that a diabetic continues to consume 2L of pop (that's soda for you Americans) a day? Does it matter if a patient with lung cancer smoked for 50 years? Does morality (in the guise of causality and hence fault) have a place in medicine?

The case I started this article with could easily be a case of diabetic ketoacidosis, or it could just as easily be a case of cocaine overdose. The real question is (aside from obvious differences in medical treatment); why does it matter?

Now if only they would make me smarter...

2007-05-20T18:05:00.000-07:00

If a woman rebels against high heeled shoes, she should take care to do it in a very smart hat.
George Bernard Shaw

Since it was a long weekend, I decided to try something new and make myself some scrub hats. I am tired of the flimsy, disposable blue bouffants at work, and the strange propensity for nasty hair tangles to form beneath them. Plus, what can make a child more at ease before surgery than seeing his anesthesiologist in a colourful and fun scrub hat? Look, dancing monkeys! Enjoy your myringotomy tube insertions!

So after a thorough but low-yield google search on how to sew scrub caps, and a trip to Fabricland, I went from this:

to this:

I definitely have to credit Michelle from the Underwear drawer for her instructions. I free-handed the pattern shown on her webpage to help cut out my material. I also had experiment with the sewing machine seeing as how I hadn't really used it before. This sewing machine was my mother's and is apparently 37 years old. Still works like a dream.

Note: on careful inspection, you may observe a copy of Smith's Anesthesia for Infants and Children, unopened and abandoned on the table. Making scrub caps counts as studying, no?

Here are the others I made:

I am most proud of the rainbow one, which has red piping sewn on using double folded bias tape.

Interestingly, the blue scrub cap has a picture of a cat about to dig into a bottle of "fever candies". I find this a bit questionable. Sure I want children to take their pre-op acetaminophen, but do I want them to think it's a tasty treat? There's also a depiction of a cat and dog shooting through the sky on a syringe. It's possible that while designing the pattern, the creator of this fabric was taking some "fever candies" of his own.

Odds and Ends

2007-05-18T21:13:00.000-07:00

Over the past few months a number of well written and widely read medical blogs have closed up shop. Barbados Butterfly, Dr. Flea, and Fat Doctor were all favorite reads of mine and I was sorry to see them go. Although each left for a slightly different reason, their departure highlights (I think) some special issues around medical blogging.

Blogging itself is an interesting idea. Part reporting, part opinion and part diary, bloggers post online for anyone to read. I admit when I started this blog I thought my family and friends would be the main readers with maybe another northern-type doctor stumbling acroos the page from time to time. I've been amazed that people from all over the world seem to be interested in reading what I write. I wonder if the suprising popularity and penetrance of the above, discontinued, blogs is part of the reason for their demise.

Unlike many medical blogs, this blog is not anonymous. There is a real life picture of both of the contributing authors in the top right hand corner, and anyone who is internet savy can likely obtain at least a real world name and mailing address for us. There are a couple of reasons this is not an anonymous blog, but the formost is that I felt the blog was far too specialized to attain true anonymity. Although I could have posted anon., anyone interested could have figured out a very short list of doctor couples travelling between Vancouver and the arctic. I also wanted to post actual, experiential content (including pics) and much of this by it's very nature precludes anonymity.

Patient confidentiality must always be formost in the minds of physicians. It is of course possible that patients, their families, or other hospital staff can stumble into a medical blog, and might recognize sensitive and confidential information, were it to be posted. With this in mind any patient information in this blog is not just anonymized, but fictionalized. Patient confidentiality simply precludes the discussion of specific real life cases in a public forum. It does not, however, prevent discussion of fictionalized cases, based on long term experience, but not on any actual patient, and containing no details attributible to an actual patient. Since I've been up north I've seen a number of fascinating once in a life-time kinds of cases, but I've not commented on any because as with this blog, I believe them to be too unique to be anonymous in any meaningful way.

As I've watched some of my favorite blogs disappear, it's made me glad this blog isn't anonymous. I've always tried to steer my posts towards that which I wouldn't mind a stranger, my boss, my collegues, or my patients overhear me say.

It will be interesting to see in which direction medical blogging moves over the near future. Will it become a liability that our insurers recommend against? Will it continue to be a window into the triumphs and tragedies of medicine? Will it remain an outlet for those doing their best in systems that seem designed to bring out their worst? Or will it simply fade away...only time will tell.

In the mean time I'll try to continue to post good material, and for those who have concerns about this blog....please read the disclaimer at the bottom of the page...

The 5 reasons I blog meme has inspired me to start working on a series of posts about addiction. Since I started practice addiction has been an area of medicine I've been very involved in, and I realise I've posted little on the subject. I hope to post the first post in this series later this week.

Finally, for those who are worried about the saftey of my camera with the recent lack of pictorial posts, rest assured, it is safe. I've recently had some major internet issues here in Inuvik, and have had a great deal of difficulty posting pics. It seems the internet is again working well, and I will continue my endless slideshow in the near future.

Sisyphus...minus the rock

2007-05-16T16:45:00.000-07:00

Today, despite the fact that I was post-call and could have taken the day off, I decided to go to work and help with sedations for the MRI suite. It was a interesting and frustrating day, and it left an impression on me (witness the fact that I am posting on here - a rare event! I can guarantee it won't be as interesting or well thought-out as what Aaron has to say, but I have the password to this blog and I'm gonna use it).

One thing you get accustomed to very rapidly as an anesthesia resident is learning to interact with a group of nurses/doctors/techs who have never met you or worked with you before, and therefore tend to view you with a)curiosity b)suspicion c)indifference d)a combination of a,b and c. To make things worse, more often than not the group you are working with is close-knit, has a routine, and the members of said group have worked with each other for say, oh, TEN YEARS, before you interject your little self so innocently and unknowingly. This is hard. It gets easier the more you do it, but it's still hard. It's like climbing a hill every day, and just when you get to the top, you somehow end up starting over at the bottom of an ever-so-slightly different hill the next day.

That being said, I thought the people working in the MRI suite were very nice and patient with me. Cause the thing is, the MRI is a big magnet. I know that. You know that. We learned that in medical school, on tv, or in a magazine. But knowning that in your mind, and the reality of standing next to an extremely powerful magnet while trying to sedate small children are two very different things.

When I got to work this morning, I started off by meeting the MRI staff, meeting my anesthesia staff, and filling out a form to say that I had none of the following: a pacemaker, a metallic foreign body in my eye, a tattoo (I can just hear my mom sighing with relief), previous experience as a metal worker, a bullet lodged somewhere within me, an IUD, and various other things that just don't belong in an MRI (think anything ferromagnetic that could be ripped from your body, or that could heat up inside). I watched the MRI safety video, which was both highly informative and completely terrifying. It had a lot of fancy words in it, many of which I have only a marginal understanding, including: gantry, MRI quenching, gating, and units in Gauss. I looked up the definition of Gauss. It appeared as follows:

a unit of magnetic field strength that is approximately the strength of the earth's magnetic field at its surface (the earth's field is about 0.5 to 1G). The value of 1 gauss is defined as 1 line of flux per cm2. As larger magnetic fields have become commonplace, the unit gauss (G) has been largely replaced by the more practical unit tesla (T), where 1 T = 10,000 G.

Um, yeah, I totally knew that.

So after all that, I was ready to go. We poked some children with some needles (sorry!), pumped in some Propofol and off we went to the scanner. This is where something seemed to go awry for me at various points throughout the day. For one thing, it's quite dark in the MRI suite. It was hard to read the infusion pump and connect all the monitors in the semi-darkness. For another thing, I kept thinking I was going crazy whenever I'd get too close to the magnet and suddenly, my name badge was floating, or my watch was being lifted off my wrist. I almost carried a vial of Propofol into the room before an astute nurse asked me what I had in my hand and did it maybe have a metal top? Oops. That would have made a sweet little projectile...and could have seriously hurt someone.

At one point I leaned over my little patient to adjust his nasal prongs and everything flew out of my pocket: several syringes, my nametag (yet again) and my pen, which landed (thankfully) stuck to the side of the MRI tunnel, and well away from from anyone's face. This, combined with a few difficult IV starts, a fair amount of crying (not by me), and a reduced amount of sleep, made me at times wish that I was somewhere else. And that I was someone else.

I got through the day with the help of some coffee, the kindness of the staff in the MRI suite, the patience of the anesthesiologist I was working with, and a cinnamon bun. And tomorrow I get to do it all over again...in a different room, with a different staff, and a different set of nurses. And no magnet (thank god).

Five Reasons I Blog

2007-05-14T09:45:00.000-07:00

In the comments section of my last post Liana, from Med Valley High (an excellent blog!), tagged me and asked me to post the 5 reasons I blog. There are various reasons I started this blog, and other reasons I keep posting; I've given it some thought and come up with the 5 best reasons I can think of.

1) I enjoy writing.
A General Surgeon I know once told me: "When I'm looking at residency candidates I look for someone with, at most, one interest. General Surgeons don't have a lifestyle that's compatible with interests, so I don't want a well rounded person. A well rounded person will be an unhappy general surgeon."
Medical schools insist on taking well rounded candidates. One instrument, two sports, and a summer trip to Europe describe a surprising number of candidates. As you traverse the high wire of medical training you have less and less time for pursuit of any interest other than medicine. The job of medicine taxes the passions of life. Prior to medical school I enjoyed writing, and in particular philosophical writing. In medicine the only writing that is encouraged is scientific reporting, a mode entirely devoid of wit and prose. I blog because I want to take back my right to write...

2) I am easily excited by new things.
I admit that I am the kind of person who could spend an hour looking at moss on a tree because it is interesting. When my wife and I go for a walk in the park it's like she has a two year old, I stop and look at everything. I started this blog at a transition point in my life and career, moving from inner city medicine to remote medicine. Transition points are always where the action is, and I began this blog partly in response to my excitement about this particular new thing.

3) I believe it is important to question the philosophical basis of modern medical practice.
Medicine, and in fact all of science, rests on certain underlying philosophical assumptions. At present one of the main philosophical trends in medicine (and in wider science) is the idea that only that which is objectively (or measurably) true is actually true. Personally I believe that this is a flawed concept, and undermines some fundamental elements of modern western medicine.
The questioning of the philosophical underpinnings of thought is an important exercise, and can lead to debate that surely advances understanding. John Cairns, famed British biochemist, asserted in 1988 that objective data he observed in E. coli favoured Lamarkian rather than Darwinian evolution. He published his findings under the heading of selective mutagenesis. Although he was initially scorned by the scientific community for failing to accept the modus operandi of the day, his questioning eventually lead to breakthroughs in understanding the complexity of modern genetics.
Medicine is full of yes men and as doctors we are susceptible to the lure of the next, best, thing. In my blog I seek, in part, to question those yes's.

4) I blog to remember
It's easy to let the days slip away without really thinking about the events at hand. I hope that by blogging I'll create a record of interesting thoughts and events that I can go back and read in the future, and think about these interesting times.

5) I want to share my interest in some unusual types of medical practice with a wider audience
Both inner city medicine and remote medicine are challenging, fun, and rewarding. However, they're rarely mentioned in medical training. I love the work I do, and hope that someday someone reading this blog stops and says 'Hey, I'd like to try that'. Medicine is a cool job, that requires skill, thought and introspection. Too often medical trainees are exposed to unhappy, burned out doctors who poison them against various parts of medicine. I hope my blog reminds people that medicine is also challenging and fun.

Those are probably the 5 big reasons I blog. There are of course other factors; I take a lot of pictures and I need to subject you all to my endless slide show. Thanks to Liana for the subject of this post, it's forced some introspection, and also inspired me for some future posts on topics I'd gotten away from.

Sleeping by Daylight

2007-05-12T08:44:00.000-07:00

At the extremes of latitude the days and nights obey a different cycle than most of us are used to. During spring the sunless days of winter steadily lengthen until the world remains alight 24 hours a day. Inuvik is situated well above the arctic circle, and as the solstice nears, the days here are long. There is a time of dusk around 3AM, but even then it the sky remains fairly bright.

Since I have been here I've found my usual day night cycle thrown off a little. The light is energizing, and plays havoc with any internal chronometer I might have. I find myself wondering why Conan O'Brien is on TV so early, only to remind myself that it is not really early at all but only a trick of the light.

On call last week I was paged back to the hospital just before midnight. The sky was still bright and there were still people out and about enjoying the day. I spent a couple of hours at the hospital admitting a patient, and when I wandered home at 2 AM it was like an early evening dusk. Luckily for me I can sleep anywhere and anytime, so the light doesn't disrupt my sleep at all. The funny thing is that with so much light, I just don't feel like sleeping as much as usual...

Here's what Robert Peary had to say about the arctic sun as he tried for the pole.

It must be remembered that during all this time we were in the region of constant daylight, in the season of the midnight sun. Sometimes the weather was foggy, sometimes cloudy, sometimes sunny; but there was no darkness. The periods of day and night were measured only by our watches—not, during the passage of these channels, by sleeping and waking, for we slept only in those brief intervals when there was nothing else to do. Unresting vigilance was the price we paid for our passage.
From: The North Pole, by Robert E. Peary

Peary's ship, The Roosevelt, at Cape Sheridan

All around town...

2007-05-08T17:34:00.000-07:00

Since arriving in Inuvik I've been working mostly in the emergency department. So far it's been a nice place to work; the hospital is beautiful, the other doctors and nurses are very nice, and there is good back-up available. I haven't been out and about in the town too much so far, but thought I'd share a few pictures of my visit to the western arctic so far....(as some of you have probably noticed, I'm a bit obsessed with taking pictures).

In Norman Wells I took this shot of me on the bank above the mighty Mackenzie River.

The end of the winter road means no more easy travel.

Spring arrives...

Norman Wells against the backdrop of mountains.

The school in Inuvik.

Inuvik's famous church.

The colourful Inuvik Hospital.

Weathered In...

2007-05-06T20:57:00.000-07:00

One of the most difficult things about the north is getting there. Canadian weather is not made for fair-weather travellers. I have been lucky so far in getting to Iqaluit and had not been weathered in or out of anywhere (though Dr. H. was weathered into Iqaluit for several extra days when she came to visit). The trip up to Inuvik ended up being a little more challenging.

On Friday I began my trip to Inuvik flying from Vancouver to Edmonton. I arrived in Edmonton around midnight, and surprise surprise Edmonton was having a blizzard. Now I have only been to Edmonton a couple of times in my life, but in my very limited experience it seems to be having a blizzard about 66% of the time (or 2 out of the 3 times I have been there). After a safe landing in Edmonton I spent the night in a hotel near the airport and arrived at the airport bright and early to continue the trip northwards. Edmonton to Yellowknife went without a hitch, and from Yellowknife we flew north to Norman Wells. Norman Wells is a small town on the MacKenzie River with a very interesting history. It has fairly extensive oil and gas reserves and during the Second World War the US Army built a pipeline to export the oil for strategic purposes. At one point it was quite a centre of activity in the arctic. Today it is a small sleepy town of about 800, although the petrochemical business continues.

When we landed in Norman Wells it was in a bank of heavy cloud and snow. It was quite an ambitious landing by the pilots and they warned us in advance to expect turbulence and that we would abort the landing if it proved too hazardous. After a successful landing the snow got even thicker and the air crew told us they wouldn't be able to continue on to Inuvik. We had the option to stay in Norman Wells, or return to our point of origin to restart the journey the next day. After a long day of travel I opted to be weathered into Norman Wells and checked into a surprisingly nice hotel there (The Heritage Inn).

After a couple of hours the weather cleared up and I spent a nice afternoon walking around the town, watching the river as it gets ready to break-up, and checking out the historical vehicles in front of the visitor centre. This morning I resumed my trip and landed in Inuvik around noon.

Of course I don't believe in getting stressed about the weather, so I thoroughly enjoyed my afternoon, weathered in.

(I'll put up some pictures of Norman Wells once I get on a computer with a USB port...)

A Canadian tradition

2007-05-02T22:15:00.000-07:00

In Canada little else is considered as important as playoff hockey. Work slows down, drivers slow down. Radios and TVs are tuned to the game. In a nice resturant somewhere a a man has taken his wife out for dinner. He gets up to use the washroom, and wanders by the kitchen and gets a glimpse of of TV. He's never seen again (well, actually he can be seen nightly sleeping on his couch for the next month). As Canadians we feel we own hockey, and during the playoffs it is all we talk, think and breathe (even the weather takes a back seat).

Everyone has their team. Personally I'm a Toronto Maple Leafs fan. As disappointing as they are year after year, I keep on cheering for them, always thinking that next year will be the year. Like many Canadians, once my team is out of contention I cheer on the remaining Canadian teams patriotically hoping that they bring the Stanley Cup home.

This year my beloved Toronto Maple Leafs turned in an uninspiring season and failed to make the playoffs at all. Since the Leafs had long since abandoned the ice for the golf course, I decided that being a recent transplant to Vancouver, I'd lend my support to the Vancouver side. Yesterday, after some resourceful detective work, my friend Kevin and I managed to get a couple of tickets to game 4 of the Vancouver Anahiem series. Really, there is nothing like live playoff hockey. The crazed fans, the cheering and jeering, the tension in the air as the puck drops. The game was great (although the Canucks lost in overtime), and the crowd was wild. Like so many things, playoff hockey is a tradition best experienced in person...

Odds and Ends

2007-04-29T16:32:00.000-07:00

Here's a picture of Dr. H. and I that a fellow in Havana drew while we were walking around the old city. The resemblance is striking...

Here are some pics that remind me why we wanted to move to Vancouver in the first place....

Finally, the new website for Nunavut Physicians is now up. I've linked it here and on the side bar. As I've said before it's a great place to work, and worth doing a locum in. Check it out...

When a change in the weather means less for dinner

2007-04-27T22:58:00.000-07:00

The issue of climate change has been all over the news recently. In Canada our government has just announced a new environmental plan that proposes real reductions in carbon emissions over many years, though falls short of the Kyoto Protocol (to which Canada is a signatory). All major political parties in Canada are developing comprehensive environmental plans in what looks like a run up to an election. For the first time in Canadian history it looks like the environment will play a major role in the election.

For many Canadians an environmental identity is important. The idea of the Canadian wilderness is almost omnipresent in Canadian literature, poetry, and media. The idea of camping, cottaging and canoeing are part of Canadian collective consciousness. Whether we live in Toronto, Vancouver, Temiskaming, or Pond Inlet, we all seem to have the idea that the wild part of Canada is closely accessible.

In the past we may have assumed that our wilderness was so vast that it was immune to the effect of man, and exempt from our doings. Over the past 50 years it has become fairly clear that this is untrue. Severe erosion of shoreline on the east coast, dangerously hot summers in Quebec and Ontario, alternating floods and drought in the Canadian mid-west, the swath of destruction of forests by the pine beetle in BC; Most Canadians are aware of some element of local environmental stress.

The northern part of Canada is particularly vulnerable to environmental changes. Most predictive models show polar areas warming at a rate far in excess of tropical and temperate areas. In northern Canada this means changes in sea ice, changes in permafrost, changes in local vegetation, and northern migration of the treeline. All of these examples are already starting to happen. One of the tangible results of even the subtle early changes that have already occur ed is that the territories of large animals have shifted. Changes in the location of the floe-edge mean changes in where the fish, seals and polar bears live. Changes in seasonal sea ice, and increased freeze/thaw patterns means migration routes of caribou have shifted. From an armchair in the south it is easy to sigh with relief because these animals are adapting to changes. For a resident of the north, who may rely on these animals for sustenance it is a far different story.

It can be difficult for those of us in the southern part of Canada to remember that some Canadians still rely on game for food. In the south hunting is a guns debate, and an animal rights debate, but in the north it is really a food debate. When groceries cost 4 times what they do in the south (would you pay more than $10 for 2 litres of milk?), more economical means of food acquisition are called for and this means game hunting. This year in Iqaluit it was common to hear 'there's not much game this year', 'it's been hard to find caribou'. Traditionally a nomadic people could and would have followed the moving game, but settled life has it's own complexities.

As the environmental debate and agenda in Canada evolves I think we can learn much from looking northwards, towards people deeply involved with and affected by the environment. We can remember that it is not just a debate about cars, and florescent light bulbs, and industry and carbon taxes. It is a debate about food, and it is a debate about how we, as Canadians, interact with the wilds that are deeply part of the Canadian collective consciousness.

To finish, a little Canadian poem...

I PASS where the pines for Christmas
Stand thick in the crowded street,
Where the groves of Dream and Silence
Are paced by feverish feet.

And far through the rain and the street-
cries
My homesick heart goes forth
To the pine-clad hills of childhood,
To the dark and tender North.

And I see the glooming pine-lands,
And I thrill to the Northland cold,
Where the sunset falls in silence
On the hills of gloom and gold!

And the still dusk woods close round me,
And I know the waiting eyes
Of my North, as a child's, are tender,
As a sorrowing mother's, wise!

Northern Pines
by Arthur Stringer

The ought problem in medicine

2007-04-24T07:00:00.000-07:00

The is-ought problem is a philosophical argument first discussed by David Hume, that challenges the use of statements of what ought to be, versus statements of what is. Hume challenges the translation of what is (the observable) into what ought to be (the moral). His description of the problem (a single, elegant paragraph), challenges the very derivation of moralism (in any form) from what observably is. Hume seems to believe that is and ought are not as closely related as most moral arguments make them seem, and that the determination of what ought to be is far more complex than the simple extension of what is.

There is a great mythology in medicine that patients 'ought' to behave rationally, and that they will somehow behave rationally if only they are compelled through argument of their physician. Rationality, through the physicians eyes, often involves the preservation of good health through the avoidance of detrimental behaviours, or through the treatment of disease. In the office this usually sounds like 'You should stop smoking', 'You should stop eating fried food', 'You should submit to screening for any number of various diseases', 'You should take better care of yourself'.

The usefulness of recognizing that this interaction is part of the is-ought problem is through recognition of the fact that much of the advice given by physicians is (in a philosophical sense) moral advice. The moral basis behind all of this ought advice is the presumption that patients ought to do what is best for their own health. In many ways this is a reasonable philosophical assumption; in other schools of thought the idea could be thought of as maximizing utility, or as a soft duty, within the confines of personal liberty.

The problem with this particular ought to is of course that it bears no resemblance what so ever to observable reality. Patients (in fact all people) simply do not make their choices in a way that optimizes health. I doubt I have ever seen a patient without a health impairing vice. People continue to smoke, lead stressful and sedentary lives, eat (delicious) fried foods, and generally take care of themselves poorly. Rarely is the moral advice of the physician heeded, though often it is given. You ought to do this, you ought not to do this, is a refrain throughout medicine. Often given, rarely heeded.

One of the premises of this medical moralism is the presumption that people will behave rationally. Again, this is a nice idea, but is in great conflict with observable reality. 'I know I've gotta stop smoking Dr. J.' my patients tell me. They have the capacity for rationality. They recognize that they are hurting their health. They recognize the implicit ought. '...but I just don't want to yet."

As a pretender to the hard sciences medicine gravitates towards rationality. In proving objective truth about health and disease it serves a great function. In inflicting the burden of rationality on to patients it goes too far. When I give my moral advice to patients, I am not surprised that they often take a pass. The rational thing to do of course would be for all of us to maximize our health. The problem is that rationality doesn't work well for non-rational people. So I understand why my patients wave at me with their cigarette in-hand when I walk to my car, as well as I understand why I continue to enjoy a big bowl of ice cream. Knowing what we ought to do, is in many cases simply besides the point.

Back from Cuba

2007-04-23T16:17:00.000-07:00

Yesterday we arrived back in Vancouver after a relaxing and refreshing vacation. Dr. H. and I had decided to take a vacation fairly last minute, and booked a resort online with less research than is usual for us. In a stroke of good luck, the resort we choose was beautiful and lots of fun. We arrived back in Vancouver relaxed, refreshed, and ready to get back to real life....well, sort of ready for real life.

Lately many hits on the blog have been from U.S. visitors. With that in mind I thought it might be interesting to post a few pics from Cuba, as Americans never get to see this very interesting place. Cuba has a very interesting history, worth reading about. At present it is a one party socialist republic, with Fidel Castro as Prime Minister. The cultural background is a fascinating mix of traditions brought to the island by both Spanish colonialists as well as African Slaves. Since becoming a socialist republic, Cuba has been under trade embargo from the USA. This has resulted in some interesting cultural twists in Cuba. For instance, the trade embargo has severely limited the import of cars to the island. As a result they have made the cars they have last, and the cars on the roads are mainly classics from the 40's and 50's, often with Diesel engines in them. This has also created a transportation shortage and there is wide spread organized hitchhiking and some very interesting buses, as partial solutions to the problem. Havana itself is a very beautiful place with much intact Spanish colonial architecture.

Cuba really is a fascinating place. Like any resort destination it is difficult to see the contrasts of poverty side by side with the often opulent resorts. Like so many things, tourism itself has both positive and negative implications for the local people. Below are a few pictures you might enjoy...

The resorts pool.

A camel bus in Havana.

Some European looking row housing in Havana.

A classic car, and it's proud owner.

A cigar makers bench.

The Tropicana show in Havana.

Time to return to real life....

Odds and Ends

2007-04-13T16:02:00.000-07:00

I'd previously posted about the interesting cars of Iqaluit, but failed to mention the excellent license plates of the territory. Here are a couple of pics. Too bad we don't have such cool plates in every province!

I'm back in Vancouver now for a few weeks before heading up to Inuvik for May. It was an uneventful trip back and this time my luggage arrived with me. Mine is the one on the middle of the conveyer!

Dr. H and I are taking a week long trip to Cuba, so the blog will be a bit quieter than usual for the next week. Stay tuned when we get back for more posts!

So you saw that fire in the sky...

2007-04-12T12:04:00.000-07:00

Oh, it was wild and weird and wan, and ever in camp o' nights
We would watch and watch the silver dance of the mystic Northern Lights.
And soft they danced from the Polar sky and swept in primrose haze;
And swift they pranced with their silver feet, and peirced with a blinding blaze.
They danced a cotillion in the sky; they were rose and silver shod;
It was not good for the eyes of man - t'was a sight for the eyes of God.
It made us mad and strange and sad, and the gold whereof we dreamed
Was all forgot, and our only thought was of the lights that gleamed.

Robert Service, The Ballad of the Northern Lights
Woodcut by Mark Summers

The Northern Lights are one of the treats of northern Canada. They are whimsical, and fickle, and appear only when they choose. When they do appear they are entrancing. On this last trip to Iqaluit I had a couple of occasions to see the northern lights.

When I am covering Obstetrics in Iqaluit, I typically sleep at home unless things are busy or someone is near delivering. Home is only a 5 minute walk from the hospital, and most of the calls back to the hospital are not emergent. Babies rarely deliver precipitously, and when they do they usually do with or without a doctors presence. Delivering babies is a nice job. Mainly I am there in case things go wrong, in case a shoulder gets stuck, in case of a post partum hemmorhage, in case of anything other than a normal delivery. Most deliveries are, in fact, normal and in those cases I am simply in the background and usually enjoying being present at the event.

beeeeep beeeeep beeeeep, my pager wakes me from sleep. I am a slow thinker in the wee hours and usually take a second to get my bearings. On the phone the nurse tells me Hi Dr. J., we have a 20 year old primup, just came in, she's having good contractions and is at about 8cm so no rush. No rush means I have time to add a layer of long underwear, because even a 5 minute walk is cold on a -30 C night. My walk to the hospital takes me out the front door of the apartment building, and down across a large gully. The bottom is dark and the edges keep the lights from the building from creeping in. No rush means there is time to look at the sky. Even without the northern lights the sky is big, free at the edges, not confined to a frame, untamed. Twice on this past trip that walk to the hospital was full of fire in the sky.

It's hard to explain what the northern lights look like. I had my camera with me both times, and probably could have taken a picture. My camera has lots of settings, and would probably capture an instant of the lights. It wouldn't capture the movement though, the dance of the lights. Regardless, I didn't take any pictures. There was time, I was in no rush after all, but it simply didn't occur to me. I stood and watched the light play in the sky, and after a while resumed walking. Into the hospital, to catch a baby, hoping to have no cause for my pressence in the end. Hoping the lights were a good omen.

The cars of Iqaluit

2007-04-10T06:41:00.000-07:00

As most people likely know there are no roads into Iqaluit. Located on the shores of Baffin Island, 3 hours flight north of Ottawa, Iqaluit is as about as remote from you can get from automotive production. In the past transportation here was mainly based on taxis, and for $5 per person you could ride to anywhere the road might take you (stopping along the way to pick up other passengers heading to other destinations).

There are only 2 ways to get cars into Iqaluit: By sea-lift, the yearly shipping of goods from Montreal to Iqaluit by barge during the summer, and by air. Yes, believe it or not, people do actually fly cars into the city. As Iqaluit has grown and become a capital city there has been an influx of cars. As there are only about 40km of roads in and around town, and no highways, it is a bit surprising that cars are as popular as they seem to be. I would guess that the number of cars per km of roadway in Iqaluit is approaching that of other cities in Canada. During my last cab ride, I was surprised to hear the cabbie say that we would be taking a detour due to rush hour. There are no lights in town, but the 4-way stop was 5 cars deep in all directions. With skills no less than I would expect in grid-lock at Bay and Bloor, he zipped through 2 parking lots, around the back of another building and cleared us of the rush.

When I arrived here in Iqaluit I expected to see cars focused on utility, perhaps pickups, perhaps small cars that would cost less to ship. What I did not expect to find here were Hummers. In fact there are 3 Hummers here in Iqaluit, and Volkswagen buses, and all sorts of other cars you would never expect to find. It seems that in such a remote place the novelty is not just owning a car, but owning a novel car.

Below is perhaps the most novel car of all. I have no idea what it is used for or why it is painted this way (if you know please enlighten me!), but it always makes me laugh.

Learning the hard way

2007-04-09T17:46:00.000-07:00

Lately I have noticed an increasing number of posts on medical blogs about medical students and residents being treated badly by the people who are supposed to be teaching them. At "medschoolhell" (a domain name that already suggests poor treatment) we read about the cruel whimsy that many medical students are subjected to by those who have power over them. Over at Panda Bear MD we read about how a senior and experienced resident is treated poorly, and then made to pay (by unfair evaluation) for not accepting the behaviour as appropriate.

Almost all medical students and residents will be able to describe being abused in some way during their training. In many ways the medical training system is set up in such a way that this abuse is predictable. The medical education system is complex, and subject to it's own set of peculiar social rules. Some of the factors that lend themselves to various forms of abuse include:

Medical education follows a strict hierarchical model.
Most medical teachers have received no education in teaching.
Many medical teachers were themselves trained in abusive environments.
When subject to abuse, medical trainees are often forced to disclose up the chain of command, with the first disclosure often to the abusive person them self.
Medical trainees can be subject to significant reprisals for reporting abusive behaviour.

Evidence based medicine is a mainstream medical concept. Clinicians attempt to practice what has been shown to be effective through well conducted research, while discarding those practices shown to be ineffective. For some reason, however, this thinking has not gained any hold in the realm of education. The idea of evidence based education, or teaching using techniques that have been proven to be effective, is simply not a part of medical culture. In fact most medical teaching is based more on culture than on evidence. As a medical trainee any lament of poor treatment is likely to be met with 'I had it harder in my day', from whoever lives one rung up the ladder.

In addition to the necessary learning of factual information, decision making skills, and physical techniques medical education undoubtedly provides a function of socialization into the doctor role. It is this reason more than any other that is used to justify the maltreatment of trainees as an initiation rite, vital to the future functioning of the trainee as a doctor, rather than simply abusive behaviour. In fact, while maltreatment probably serves a memetic function, passing the abuse forward generation through generation of doctors, there is scant evidence that any initiation rite, abusive or otherwise, plays any important role in the actual practice of doctors.

Maltreatment itself exists in at least 2 important categories; that which is part of a supposed educational process, and that which is not. The latter is easier to deal with (in that is more easily shown to be inappropriate), and includes overt rudeness, hostility, threats, degradation, sexual harassment and physical abuse. These behaviours are objectionable to society in a broad sense, and resonate as inappropriate with virtually everyone. It is hard to imagine that it would ever be appropriate for a bank manager to throw a stapler at a teller as a logical consequence for an error, yet it is not unheard of for a surgeon to throw a scalpel at a trainee who has made a mistake (both acts are probably criminal assault). Behaviours that are not socially or societally acceptable aught not to be justified as teaching or initiation. As a group of adults, doctors of any level of training should be required (and require of themselves) to treat one another within the bounds of normative behaviour.

Maltreatment in the guise of education may seem a stickier point, though once dissected is equally unpalatable. The act of pimping (for the uninitiated, the act of rapid fire questioning until the point of error or beyond), first credited to Dr. Walter Koch, is such an example. In reality pimping probably stretches back to time immemorial. Hippocrates probably pimped Polybus about which of the four humors was most responsible for abdominal pain, and indeed the pimpers will often try to pass off the technique as Socratic questioning, or learning through induction. The essence of the Socratic method of course is that it is a dialectic technique, and probably most applicable to philosophy and non-absolute arguments (though of course Socrates did use his method to extract mathematical ideology from the non-educated). Medicine, at least in the way it is usually taught, is absolute in so much as the doctor at the top is the one with the right answer. So as a Socratic dialogue, pimping seems to fall short.

The idea of teaching through negative reinforcement is also frequently used to justify questionable teaching behaviours. Negative reinforcement, as logical unpleasant consequences of an unwanted action, does exist in medicine, though the term is often used to mean public humiliation or shaming. Indeed negative reinforcement has been shown to be a successful educational strategy...mainly in rat models. Applied to adult learners however, negative reinforcement, shaming, and humiliation produce only short term behavioural changes, that usually reverse once the negative stimulus is removed (i.e. when you move on to a new rotation.)

As a medical teacher I am far from perfect. I have a short attention span at the best of times, and lack many of the 'answers' that students seem to be searching for. I am sure that I frequently frustrate students when I say 'there really is no right answer.', or go off on a tangent with a patient telling me about some fishing trip they took 5 years ago (really, that is more interesting than how many salads they are eating these days). I will say though that I make an effort to be patient with students, to tell them they are doing a good job, and to try to build up their confidence. I admit to them that I too forget the results of the COMMIT study, and still (somehow) manage to practice medicine. And above all else, when I see a student or resident being bullied (because I think in the end we probably all see that this is all just grade 6 style school yard bullying) I attempt to extract them from the situation.

I think it is high time that the EBM folks stepped up to the plate with a new initiative: EBE (Evidence Based Education). There is simply no room for bullying and antisocial behaviour in medical education, not only because it is morally wrong, but also because it is simply ineffective.

Eat your heart out, Farley Mowat

2007-04-08T11:13:00.000-07:00

Some of my own personal fascination with the Canadian arctic probably began when I read some of Farley Mowat's classic books as a teenager. His descriptions of the landscape and people are compelling. In recent years Mr. Mowat has been critisized for embellishment of the truth, but the flavour and texture of his words still draw me in. One of the experiences I hope to have while in the arctic is to travel away from the community and see how the people who live here travel and hunt on the land.

Yesterday the pediatric resident who is in Iqaluit at the moment (Matt) had a chance to go out hunting with some local folks. They did the hunting, and he took some great pictures. He asked to borrow my camera for the trip, and in return let me post a couple of pics on my blog. So thanks for the pics Matt! Here are some pics from their trip. Hopefully I'll get to go out on a similar excursion sometime!

Difficult doctors, difficult patients

2007-04-06T10:51:00.000-07:00

Most professions have their share of built in code-speak, and medicine is no exception. Those little phrases that sound like one thing but mean another, if you linger in the hallways of a medical office or hospital for any length of time you'll hear them floating down the corridor. One of the most fascinating phrases in medical code-speak is the 'difficult patient'. The medical noviate might easily be excused for thinking a difficult patient would be one with multiple complex diseases. Indeed, while that patient may indeed be complicated, they are usually not what medical jargon would describe as difficult.

I first encountered the term as a medical trainee. Dr. J., my preceptor of the day would say, be careful in there. This one's a difficult patient. With the sage words of warning in hand, I'd cautiously open the door to the exam room and peek inside. Even though I'd been warned, I never knew what I'd encounter on the other side. Sometimes the patient on the other side was angry, sometimes demanding, sometimes threatening to sue. Sometimes, however, it was hard to figure out why the patient was supposed to be difficult at all. The term difficult patient seemed to me to lack precision, so I started thinking about what it actually meant.

Patients who demand narcotics often obtain a label of difficult (often in bold red letters on the front of a chart), and these patients comprised much of my early exposure to the 'difficult' crowd. At first I thought the term might mean 'any patient who makes me angry', and many of the so described patients did seem to push the buttons of the people applying the descriptor.

As I progressed in my training I ran into other groups of 'difficult patients'. One group had the special code name 'non-compliant'. Sometimes I would peek around the door to see a nice little old lady with diabetes. How are your sugars?, I'd ask. Oh they're fine, don't worry too much about me. I brought you all some cookies today!, she'd reply. Are you doing okay with your pills? Well, I don't always take them because I feel good most of the time. Pleasent as apple pie, and not taking any of her doctors advice, I was forced to expand the definition to 'any patient who makes me angry or doesn't do what I say'.

Still, there were more 'difficult patients' to come. In fact there was a whole othe group of patients who were perportedly difficult, and required forewarning. For this group of patients the preceptor of the day would pull me aside and say This is a difficult one! They have such and such diagnosis, and we've tried everything. The diagnoses in question were a short list: Chronic pain syndrome, fibromyalgia, irritible bowel syndrome, dysthymia and chronic fatigue syndrome some of the most common. And so, the definition expanded again to 'any patient who makes me angry or doesn't do what I say, or who I can't fix'.

The final group of 'difficult' patients the group many of my preceptors seemed to fear the most. These were the patients in whom the presenting complaint was vague enough or subjective enough that there was no clear path of medical action. And the definition expanded again.

By the end of my medical training 'difficult patient' had come to mean 'any patient who makes me angry or doesn't do what I say, or who I can't fix, or who I don't even know what to do with'. As you might imagine such a wide definition lead to a lot of difficult patients, and a lot of stressed out doctors. As a resident some of the offices I worked in seemed to have labled half of their patients as difficult in some way or another, and the doctors working in them seemed to be nearly pulling their hair out with the stress of it.

Now I'll admit up front that for whatever reason I have a certain fondness for some of these 'difficult' folks, but as I finished up residency I gave some serious thought to why these patients were considered difficult, and what I could do in my own practice to preserve my own (already thinning) hair. If you boil it all down to it's essence it seems that all of these so called difficult patients fall into 2 groups: patients who are in some form of conflict with their doctor, and patients for whom the doctor has no idea what to do with. For each of these situations I've tried to use a few simple stratagies to keep from getting stressed out.

Some degree of conflict is unavoidable, but conflict itself is manageble (although doctors tend to be a highly conflict averse group...that could take up a whole other post). The most important point in conflict management is that it takes 2 sides to really have any conflict worth writing home about. So if an issue is really not that important I don't join the conflict at all. I've found that there are a few easy things that I can do to make almost all of my encounters with so called 'difficult patients' actually very pleasent.

Let the patient have their say. If I think a patient is angry because they feel unheard I try (and it's hard) to keep my mouth shut for 5 minutes and listen to their story. Usually the story is over in 2 minutes, and the frustration on both sides decreases.
I give my best treatment options to the patient, but I don't take it personally if my patients choose a different path.
I apologize when I have inconvinienced my patients, and I empathize when my patients are inconvinienced by things beyond my control.
When I don't know the answer I say "I don't know the answer".
I try to have a non-medical conversation with my patients on the way to and from the waiting room.

In the end I think some of my patients probably think I am a little simple, but for the most part I seem to have avoided much of the stress in practice that seemed so ubiquitous to me as a medical trainee. Sure my hair is a little thinner than it used to be, but I think that's mostly a matter of genetics, and I'm back to thinking of 'difficult patients' as the ones with 10 different diseases at the same time.