Rx: jail

So I sent one of my patients to prison today. I mean, I didn’t convict or sentence him or anything, but one of the things military doctors have to do sometimes is certify their own patients as medically-fit for detention. (As opposed to civilian GPs, who don’t have to sign-off when civilian patients go to jail – there’s docs at the jail itself for them.) First one I’ve had so far.

25-year-old, history of alcoholism since at least high school; on counselling and probation for the same since last autumn, conditional on staying dry and sober for six months. Found in violation of probation around Christmastime, and sentenced to three weeks in prison, starting as soon as I sign him off “fit for cells”.

It’s one of those gray areas in medicine and the doctor-patient relationship – obviously some might object and decline a medical assessment that would send them to jail, and some might not be so willing to trust a doctor who’s bound to pass them on to prison, but it’s one of those things where patient consent isn’t necessarily the final word.

Of course you have the usual commandments, “Consider first the well-being of the patient”, “first do no harm” and all that, but being in uniform you also have your responsibility to the military. It’s the third key principle of Canadian military ethics everyone learns inside-out in Basic Training, “support lawful authority”. (The first two being “Respect the dignity of all persons” and “Serve Canada before self”, in that order.)

The other thing they drill into you in Basic Training – at least, the version for medical officers – is that you’re not just a doctor for the patient in front of you, but you’re also looking out for the broader military at large. It’s more than the responsibility to community that goes without saying to all physicians in general – you actually have a duty to consider how your patient’s health might affect mission objectives, required military tasks and the rest of the team.

Not that this is just a military thing. Emerg physicians do this all the time too, giving (usually) inebriated belligerents a once-over before police take them off to cool down in the Drunk Tank. When I was working Emerg I never had anyone refuse a check-up; of course they knew as soon as I signed off they’d have to face the music, I guess they figured they’d already been caught, no sense delaying the inevitable. Most were all “been there, done that”, just going through the motions anyway.

Back in Inuvik and Masset it used to be the most frustrating thing about Emerg, getting called out in the middle of a (usually) Friday or Saturday night. Nurses in the North are really good at sorting out all the real emergencies, and taking care themselves of the worried-well coming in at ungodly hours of the night. But for the “fit for cells” and all the medico-legal baggage that comes with it, a doctor had to actually give the blessing.

At least it got easier the longer you worked there – you’d get to know the regulars and their background stories with each visit, so you’d get quicker and better at picking out what was for real, and what was same-old same-old. You’d also get to know the cops bringing them in – at least, the ones who tended to worry most about patients/prisoners going bad in holding cells; the more veteran ones grow their own spidey sense for “sick” and “not sick” and can make the call without having to stop by Emerg.

You’d also get to know the court schedule – the night before, you could be sure at least one person out on bail would try to pull something to get out of their day with the judge. Suicide attempt, drinking binge, you name it. Of course when they do, they get admitted involuntarily; judging by the number of times they’d later leave against medical advice, it’s probably no better than taking the jail time.

Anyway, I guess the complicating thing with this case today was, he’d been set up with an addictions counsellor and psychiatrist since his first violation, and still had some follow-up appointments to attend; if he goes to jail, he’d miss one.

Bit of a judgment call – what do you think? I figured, if he still was breaking probation despite counselling and Psychiatry, one missed appointment wouldn’t change anything with him; maybe 3 weeks in jail will actually hit home and do the trick. What’s more, interfering with a sentence imposed by “lawful authority” for the sake of counselling that isn’t working anyway (yet?) wouldn’t exactly send the right message about the justice system.

He didn’t seem all that bothered about it, kind of the like the ones I see in Emerg actually. “Been there, done that”; no surprise for him apparently. Likely I’ll be getting used to seeing it too.

The Arctic is… very North

They say when you return home after living somewhere totally new, you can’t help but come away a little more insightful, a little more experienced – but you won’t pick up on those new insights or experiences until you’ve gotten back to your same-old routines again. You come back and start about, business-as-usual, when you realise you don’t do or see things quite the same way as before, and that’s when you cash in on the investment of going abroad – whether it’s overseas, the next city over, or another neighbourhood in a different part of town, you can’t help but adapt and change a little, and hopefully in a good and useful way.

So, one week after finishing Family Medicine in the Arctic and coming back to the South – I can’t say I’ve picked up on what’s changed yet. Maybe I shouldn’t be trying too hard to find a gee-whiz insight to take out of it. Before I left I read something in the November issue of the Walrus, that suggested there might not be that much to say about the North.

The lure of travel is so often the lure of storytelling upon one’s return. Such tales are usually exaggerations, embellished by time and comfortable circumstance, the facts adjusted to suit the conceit of adventure… [But] the Arctic… it is a place to be awed by, not boastful about. In a sense, the Arctic is special because it does not lend itself to exaggeration… thus it does not play well in the salons of the South.

But there’s got to be something I’ll pick up on, eventually. You can’t not see things a little differently after spending 3 months in places like Tuktoyaktuk

or Aklavik

or Fort McPherson

or Tsiigehtchic

or Ulukhaktok

and adjusting to January life in 23 hour/day darkness – and to the 10-15min of extra sunlight you gain every day, so by March it’s still daylight at 10.30pm, leading up to summertime Midnight Sun

and taking the plunge off the shoreline and driving on the river ice road – exactly what it sounds like, a road of ice when the river freezes over

and meeting people on the plane who can point out the window and not just say “that’s my house”, but “there is my homeland“

and living out of a oil pipeline compound, looking over a desolate, frozen Arctic Ocean – like an outpost colony in the middle of nowhere

and dining at an oil pipeline compound buffet – two (!) steaks and a pile of shrimp (if you’re in the middle of nowhere, you might as well eat good – though the thought of shipping beef and shrimp all this way gives you pause)

and trying to revive a bleeding patient in the cramped cabin of a Beechcraft King Air medevac, when you’ve already used up the hospital’s entire supply of blood and the eight bags of saline you have on board

and receiving a sculpture from a Gwich’in elder, she made herself out of a whale neck bone and shells – a thank-you for getting her walking again and able to go back to her family’s bush camp she’s lived on since surviving residential school

and marvelling at what has to be the most integrated First Nations, Inuit and non-Aboriginal community in Canada, where Inuvialuit, Gwich’in, white people and a token Asian (me) shop at the same overpriced North Mart

and dine on deep fried Chinese food by an ex-Syrian army chef at the Roost, hail the same flat-fare taxis driven by Lebanese and Nigerian cabbies, and race pennies and oranges and feast on bannock, doughnuts and caribou meat at the town’s Muskrat Jamboree

and learning how to dog sled, and mush the huskies along – “cha” for left, “chee” for right and “hike” for faster

The Northwest Territories government gives you a certificate when you cross the Arctic Circle

The Order of Arctic Adventurers bears witness that having demonstrated the initiative, integrity and bold adventurous spirit of the true Arctic explorers who have crossed the Arctic Circle, will hereafter be recognised as an honourable member of the exclusive Arctic Circle Chapter, Order of Arctic Adventurers

and just looking at that map, a projection still unfamiliar that we never learned about in elementary school geography, and never gets on the national weather forecasts, I can’t help but marvel – the Arctic is very North. And Canada is very big.

I’m sure there’ll be more interesting insight later.

On-call Caveat Doctor does not sleep… he waits

Friday night, on-call covering the 15 acute care and the 25 long-term care beds, and Emerg, which is the main source of business overnight. The Inuvik bar (I understand, there’s only one) closes at 2am, so I know better than to bother getting too comfortable at home before then. Lucky the cafeteria puts out the day’s leftover urn of coffee and some bagels and jams just outside the shuttered gate – there never seems to be any cream (fresh cream is hard to get in the North, I guess – don’t see too many cows around) or peanut butter (maybe they lock it up for liability issues from peanut allergies?) but at least there’s some CoffeeMate and strawberry jam for a nice midnight snack.

Two patients so far tonight: a 90-year-old with a sore hip, coming in for an X-ray from the boonies – she was supposed to arrive during the day when the X-ray tech was around for routine films, but her flight was delayed so she’ll have to wait ’til morning – and a twentysomething with some weird chest tingling that’s not heart- or lung- or muscle- or bone- or nerve- or infection-related. He says he just quit smoking, so maybe it’s that, but it wouldn’t be doctor-ly of me to get him to start smoking again and see if it goes away, so he’s happy to try to sleep it off, knowing it’s not obviously anything too serious tonight.

The TV in the lounge right now is playing an eHarmony advert every commercial break – apparently you can review your matches (29 dimensions! Whatever that means) for free. “But only for a limited time! So join now.” I wonder if I would actually match with anyone. Any fellow late-night lonely on-call geeks out there? I guess there’s one way to find out…

Up, up and away

Well, after what I said last time, maybe Arctic medicine isn’t all the same after all.

70-year-old with abdominal pain, roughly correlating with her on-and-off bowel habits. Over the past year she can go up to weeks at a time without a poo. On paper that might sound like a good thing, especially for her daughter having to bathe and toilet her, but when it gets to the point she’s bloating up because she can’t even pass gas, that’s not good. Might have something to do with her past history of bowel cancer, or if it’s not something sinister like that, it could be scarring in her belly from previous surgery, or even just slow bowels, a side effect of all the pain meds she takes.

Most anywhere else in Canada, it would be a simple matter of paperwork to get a CT scan of what’s going on inside and figure it out. Maybe have to sweet-talk a radiologist too – part of the game, jumping through the hoops protective radiologists (usually rightfully) put up to dissuade unnecessary procedures (and having to get up to read them). But over here, it’s paperwork, phone calls to the next hospital up the chain, a sympathetic surgeon in the city to take them on, and getting the patient on board – that is, on board both the plan, and the plane:

Two-and-a-half hour flight to Yellowknife. Just made it out as the sun was setting, catching a cool Arctic tailwind on the way in. It’s a fairly well-thought out setup: a standardised “sled” you can load the patient straight off the hospital bed, cart it over and secure it in the cabin, with mounts for monitors, oxygen ports and IV bags. Luckily it was a pretty stable patient – just the week before, another patient needed a breathing tube and ventilator. (There’s a mount for that too, but any turbulence or shakes risks the breathing tube slipping out. You’re definitely in a tight spot – figuratively and literally – if you have to put one in in the air.)

Watching the cabin pressure’s a concern along the way. Most airliners fly at 35 000ft or so – the higher you go, the less dense the air, so you can go faster with less fuel. But to keep everyone inside breathing, the cabin’s pressurised to keep enough oxygen around. Still lower than air pressure on the ground, but ok for most people. But with patients (like this one) with blocked bowels, trapped air bubbles expand with the lower pressure – not good. Not the same sudden death they say people with collapsed lungs risk by flying (and even that’s up for debate), but definitely not comfy. At about 25 000ft, we’re able to keep the cabin pressure the equivalent of 6 000ft – less bubble-bursting than airliners’ usual 8 000ft.

Flying lower means flying through thicker air though, which cuts your speed down and jumps your fuel use up – more to consider on these long flights out. You realise how spread out the North really is and how way out you are when you have to think about how far you can go for medevacs like this. Inuvik to Yellowknife – if you can picture flying everyone in Winnipeg to Vancouver, or Houston to New York for medical imaging, that’s about the same distance. Heck, you’re closer to Russia than you are to Ontario up here.

We’re met at Yellowknife airport by the local ambulance service. About 30-below, cooler than Inuvik’s balmy -5 this afternoon. I’m glad they keep spare down-filled Canada Goose jackets for unprepared hangers-on like me. It’s a quick ride to the hospital and a straightforward transfer in Emerg, and that’s that. I swear I recognise one of the Emerg staff from somewhere – she’s wearing a Calgary Health Region scrub top, but I’m sure I’ve seen her at UBC or Queen’s before. The North really is a hodgepodge of visiting temporary staff – residents like me, locum doctors, etc.

So there you have it – you could say Arctic CT scanning is a little different from usual urban CT scanning. But far away as it is, between staff coming up from all over “the South” (heh, “the South”… visions of yokel accents, hot rods and Confederate flags in the rest of Canada), two hospitals and an air ambulance, it’s actually a painless and seamless service.

Hey, this Arctic blog post is just like a regular blog post

I guess what’s most striking about medicine in Inuvik so far isn’t how different it is from “down South”, but how it’s pretty much the same in the day-to-day. Sure, you worry about things like botulism after people eat bad muktuk (fermented whale oil), the tuberculosis rate is ten times the national average, and you get more pedestrians frozen to death than killed by cars, but for the most part, Arctic medicine runs like “regular” medicine. An Arctic pneumonia is still a pneumonia, an Arctic heart attack is still a heart attack (or maybe it’s Takotsubo cardiomyopathy, like last week), an Arctic broken hip… etc.

Some of the cases so far could’ve happened just as easily back at St Paul’s or at Toronto General: a 96-year-old grandmother recovering from a hip replacement, with worried family needing encouragement to keep her moving; a 40-year-old first time mum with a labour that isn’t progressing well; an 11-year-old boy anxious about bullying; a 4-month-old wheezing and too sick to cry; a 16-year-old on a Saturday night needing a medical ‘ok’ to sober up in the RCMP drunk tank; an 83-year-old with deepening dementia I needed an interpreter to figure out. It was a Siglitun interpreter instead of, say, Cantonese or Polish, but again, dementia is dementia wherever you are.

It’s a pretty impressive setup if you’re used to medicine in the rest of Canada. There’s often a sharp distinction between (usually rural) limited-service community hospitals, and (usually urban) referral centres. When you train in the city’s specialised, academic teaching hospitals, ones proudly Achieving Global Impact with The Best Medicine, it’s almost ingrained to see the smaller, community hospitals that send your way as something, well, less than “The Best Medicine”. They’re sending you patients because they can’t handle them – pfft, wimps.

So when you come to a town of a mere 3 000 – towns that size don’t even have hospitals down South – and you’re the one taking patients and fielding calls from the towns around you, it’s a bit of a change. They opened this hospital just three or four years ago, and with construction costs expensive as you’d expect having to ship or fly everything up to build, you can be sure they would’ve pared it down to the bare essentials. So when you look around and see everything – a full operating room suite, labour and delivery rooms, laboratory, long-term care ward, transition hostel and chapel – you know they’re not frills or luxuries in a proper regional hospital.

Dr D explained the case. Yes, keeping the place running with “frills” like Obstetrics and Surgery costs money, because you have to have a surgeon, an anaesthetist, OR staff, equipment and post-op wards. Say $3M a year in Inuvik – about the same as the hospital’s funding deficit, apparently. Vs cutting the surgery and anaesthesia service, and just aerovacing everyone, every case, to Yellowknife. But that also means sending every surgery away, and every labour and delivery too (since there’s no surgery or anaesthesia). Cost? Turns out, about $2.8M – but that doesn’t include the increased workload on the surgeons and OR in city hospitals.

But it’s more than that. What price can you put on feeling safe in your own home, knowing the care you need is available nearby? Especially among traditional First Nations families, what price on having your loved ones nearby when you’re sick? Keeping elders near their children and grandchildren, passing on traditions and languages that don’t have cultural centres or schools to protect them? Or having nonna in the delivery room at granddaughter’s birth? Healthy communities need full medical – and surgical – care.

There’s an established pattern: first the surgeon leaves, because there aren’t big exciting cases to do. Then the anaesthetist leaves, because if there isn’t surgery, why are they there? Then you can’t have Obstetrics anymore, without an anaesthetist. Then GPs withdraw emergency and on-call service, because if something happens when they’re on-call and there’s no emergency surgery or C-section capacity, there’s little you can do. And when a community can’t offer people emergency medical service in town, it scares off potential new residents, and locals – especially young families – move away.

You read so much about medicine being about the doctor-patient relationship, the privilege of being part of individual lives, stories; but doctors as a part of community sustainability, the lynchpin keeping entire towns and cities alive – that’s a pretty cool privilege too.

First taste of the North

But first, forgot to mention, one last taste of Victoria:

The Robin’s Hash from the Shine Cafe on Fort St: scrambled eggs, chopped sausage, tomatoes, spinach and melted feta cheese, with multigrain toast on the side. The joint’s always busy, I’ve only actually sat down and eaten there maybe half the time I’ve stopped by. But it’s ok: they have nice, bio-degradable paper packaging for their takeaway, so you don’t feel bad asking for takeout and adding a bundle of Styrofoam to the landfill that’ll take a hundred years to dissolve out.

Canadian North – flight 444 from Edmonton to Inuvik, trademark midnight sun, polar bear and shimmering northern lights on the tail. What happens when you fly a northern regional airline, assembled from abandoned Air Canada and Canadian Airlines northern routes, on an 80s-era Boeing 737 airliner with the front seats ripped out and converted to split freight- and passenger- service, operating out of unsecured airports, flying in the precious, limited daylight of the Arctic winter?

You get the best airline experience in Canada!

You still get real meals! Omelette with sausage and bacon under a mushroom sauce, with home fries, and peach yoghurt and fresh peaches and granola on the side.

With real cutlery!

Seriously Delicious. They call the service “Aurora Class” – which isn’t the same as “First Class”, because every one in every seat gets the same hot towels, same yummy meals. No second-class third-rate service for people in steerage; everyone gets to fly high around here.

The menu offers translation into Inuktitut, in both Romanised form and syllabics. The syllabics aren’t actually native to the language, but a shorthand system invented by English missionaries in the 1840s to record Canada’s First Nations oral into writing – it’s just as foreign to the Inuit as the Romanised transliteration.

And, apparently, southern foods like tomatoes, chicken, beef, pork and pasta – “…”, lost in translation.

When reliable roads are hard to come by, the daily air service is an essential life line to every community along the way – which is why the plane does double-duty as freighter and passenger carrier.

And why the plane stops as much as it can along the way, like Yellowknife and Norman Wells, until the polar bear in Inuvik tells you – end of the line, you have arrived.

So the trip is a long-drawn, all-day affair – but, it also means you get fed at every segment en route.

Croissant, strawberry jam and yoghurt, and a stick of marble cheese – but the highlight is the inside lid of the deli box. Reminds me of the artsy and classy Canadian Airlines meal packages back in the day, they had a series with Group of Seven works and home-grown poetry. When I opened the box and spied the text, it was like opening a fortune cookie:

Where the environment is harsh, survival and success depend on simple answers to complex problems combined with a sense of humour to tie it all together. Pretty appropriate for medicine in the Arctic, eh? Words to live by… we’ll see how it works out over the next three months.

Mush!

The traditional northward-charging cry for those Arctic-bound – mush!

Quick stopover in Edmonton overnight tonight, and onwards to Inuvik tomorrow morning. Three months in the Arctic on another rural family medicine rotation – another magical place in the Canadian medical landscape, away from the luxuries of tertiary hospitals and on-demand specialist consults, where simple country doctors keep it all together with solid knowledge, common sense, teamwork and rational improvisation and risk-taking.

Of course the appeal is more than academic. The Arctic, the North… polar bears… aurora borealis… tundra… igloos… 40-below highs… total darkness save for a glimmer of twilight at noon… It’s not exactly the top of everyone’s list of places to be, especially this time of year – but I guess that’s exactly why it’s at the top of mine. Can you call yourself Canadian without experiencing the country, coast to coast to coast, at the height of winter?

I honestly don’t know what to expect (except the cold, of course), and I guess that’s part of the thrill too. The preceptor up there – a South African expat with an obvious sense of adventure – has a blog (Inuvik Weblog – Saving Lives Above the Arctic Circle) that gives a few slice-of-life snippets. “‘What do people DO in the arctic as the days grow colder?’ you might well ask. Sharing meals is one answer!” Looking at all the med students and residents that make this such a popular rotation, it’ll be nice not being the only learner up there too.

As far as what’s the talk of the town, Googling for “inuvik news” yields stories like Fuel shortage drying out Inuvik gas pumps (apparently last year’s annual shipment didn’t last as long as usual, and there won’t be another barge ’til later this year) and Angry mob runs 8 men out of Inuvik (80 drunk people mobbed some out-of-towners they thought were drug dealers). Population about 3 thousand, so I’m sure there’ll be more than enough to the town to keep busy.

Like every Canadian schoolchild, in grade 6 or so I learned, to memory, that “There are strange things done in the midnight sun / By the men who moil for gold / And the arctic trails have their secret tales / That would make your blood run cold”. But other than such lakeside cremations, what sorts of “secret tales” will come up? More Googling… last November’s Walrus had some features on the North. The editor, Ken Alexander – who’s never been to the Arctic himself either before – ponders what it would be like for fairweather Southerners like us.

The lure of travel is so often the lure of storytelling upon one’s return. Such tales are usually exaggerations, embellished by time and comfortable circumstance, the facts adjusted to suit the conceit of adventure or, worse, conquest. Been there, bought that. Even the timeless museums and art galleries of Europe and the many wonders of the ancient world are given a contemporary date stamp, consumed by the just-in-time travellers of our usurious global village.

But what of those few remaining places that exist outside of time, consequence, and progress, material or just spectacular, and that are not prominent on the expanding map of must-go-there? What if the Arctic, for instance, were to disappoint? After admiring a vast environment — at first sight monochromatically white, but with many hues suggesting a different order of things — what if, after a long day “on the land” or dodging ice pans “on the sea,” there is nothing to do in the Arctic but survive?

For the time- and story-afflicted traveller to be caught in a landscape seemingly without momentum, with little happening but the inching forward of a determinant environment, boredom will come from knocking. And with it comes wonderment at, not about, the stoic yet hearty inhabitants. Subjects for anthropology textbooks and those studying human nature, to be sure, but we Southerners are postmodern people so beyond conquering the environment that we cannot imagine being conquered by it, or, a finer point, being fearful of it.

In that silent land, the Arctic, there is little room for human error, and, if my recent readings are correct, it is a place to be awed by, not boastful about. In a sense, the Arctic is special because it does not lend itself to exaggeration. It is a region that determines human activity, and thus it does not play well in the salons of the South.

So – hard to know what to expect… and even if I did, hard to say if I would have much to say about it. Nothing to do but survive, there is little room for human error. Medically or otherwise, guess I’m about to find out how accurate that is.

Mush!