Indian River Trail

A little exploring in spite of the rain. 

Sitka's flora.

Merry 1st Christmas in Alaska!

photo credit: wifey

Jam session

Some friends from work invited us over to make jelly from this year's harvest of wild Sitka berries. It was really fun. We're hoping to make some from our own picked berries next year. Here's a shot I took with some creative lighting.

Clockwise from 11 o'clock: blueberry,  red currant, black raspberry, huckleberry. Middle: spruce tip.

One of the things I want to learn while I live in AK is how to cook fish well. There is so much quality fish here so I just have to. Here is my first attempt: pan-seared rockfish with lemon beurre blanc. Note to self: cooking with wine rocks. 

  

pre

reminds me of my other job

post

Mari gave it thumbs up. I'd recommend adding 1/2 the amount of lemon the recipe calls for.
By the way, this place rocks and Sitkans are very generous. This Christmas we've been given 12 jars of jelly, an assortment of baked goods, a bottle of wine, a pumpkin roll, and cookies.  Merry Christmas, everyone!

Bike commuting

Back when I was living in Lancaster one of my co-residents gave a really good talk on the benefits of bike commuting. After hearing him I decided that I would try to ride my bike to work year-round once we moved to Sitka. As you can see, commuting to work safely in a place that gets dark early and receives 80 inches of rain per year requires some extra stuff.

a) Reflective vest

b) Messenger bag to carry my stuff

c) Head light and tail light

d) Reflective tape

e) Rain pants

f) Rain boots

g) Studded tires—for good traction on ice in the winter

h) Front and rear rain fenders/splash guards

i) Rain jacket, of course

5 miles round trip with a few good hills

CPT I

Baby is 4 hours old. I witnessed his birth (by cesarean), suctioned his airway, dried him with a towel, examined him, and saw him make the critical transition from life inside the womb to life outside. Strong cry, good tone, he’s good, I said.
Pager goes off: “Come to OB floor now”.

Problem #1: Hypoglycemia; baby cannot maintain his blood sugars after feeding

Problem #2: Temperature instability; his body cannot maintain his core temperature and it is dropping

Mom is homozygous for CPT 1 deficiency; her body cannot make a liver enzyme that converts fat to energy. Dad only has one good copy of the gene that makes the enzyme. Mom didn’t have any problems with her 1^st baby but here we are.  The problem is that these symptoms could also be signs of a serious bacterial infection—sepsis. Time to multitask.

#1: Place baby under warmer.

#2: Baby needs to get glucose. I tell the nurse he is regurgitating his formula. His small stomach has no more room. We need to get a peripheral line—nurses are good at this, we’ll be fine.

Right arm: fail

Left arm: fail

Left foot: fail

Right foot: fail

Plan B, get an umbilical catheter. My colleague asks for backup. I have never placed one or seen one placed. Medical director to the rescue—masterfully succeeds in placing it. He leaves. It clots.

Plan C, get a scalp catheter. Senior nurse succeeds. I want to give her a hug.

#3: Call Anchorage, this baby may need to be medevac’d to a place that has a neonatal intensive care unit. Hope it doesn’t come to that—process including flight would take 4 hours.

#4: Chest xray, blood work, start thinking about antibiotics if baby doesn’t improve with intravenous sugar solution.  

#5: Breathe.  Note baby’s scalp catheter makes him look like a little unicorn.

Happy ending: baby recovered, he maintained his temperature and blood sugars, he didn't end up being septic. We stopped his IV sugar solution and took out his catheter after 36 hours, then discharged him home 2 days later. Few things are as amazing, beautiful, and stressful as birth. 

Lessons learned:

CPT-1 is a rare metabolic condition that is more common in Native Alaskan Inuit people.

How to place an umbilical catheter.

Carpe diem

I was wrong. All of you who asked whether we would have few hours of daylight during the winters in Sitka may recall me saying that wasn't the case. That is the case. Somehow I assumed that was only further North. But now that the sun is setting at 3:25 pm (and it's setting earlier and earlier) it feels like time is flying (though it is worse farther North). We notice it most on weekends because they seem to fly by so quick. It was starting to really bum us out--we kept on saying "where did Saturday and Sunday go?" I think we figured it out, though. What happens is that you wake up around 8-9, eat breakfast, don't really get out of the house until its close to 11 or 12. Now you have 3 hours of daylight (or sunshine if it's not a typical cloudy Sitka day). In terms of outdoors stuff all you can do in a few hours is a short hike. Then you get home and see its dark at 4 pm and you start gearing down as if it were 9 pm. Your brain does that automatically for you. You don't want to venture outside, you just want to get in your PJs and start winding down. Then your productivity really goes to crap and you're confused because you swear its got to be 10 but its only 7.

One good thing about this is that it makes you try to get more done. We're realizing we can't really lounge around in the mornings--we need to plan our days in advance, see what's going on, try to get out. Yesterday (Sunday) I woke up at 9 and said to myself "ok, you have about 12 hours", and throughout the day I would countdown to bedtime to keep perspective on where time was really going. It's the weirdest thing. Seize the day has never been more real to me. Revenge is sweet though; come summer we've got up to 18.5 hours of daylight.

The laying on of hands

I had my physical this week. It was interesting being a patient after having been an attending physician for the past 2 months. A few things surprised me:

(1) My doctor asking me about my family history caught me off guard—so much so that I forgot to tell him some important details. I ask my patients this question all the time.

(2) My doctor wore a tie, which I appreciated. Interesting, as I know about the studies showing that they carry lots of germs.

(3)  It meant a lot to me that my doctor did a thorough physical examination.

I don’t examine my patients during every visit. Sometimes its because it doesn’t seem necessary. Usually it’s because of time: medication refills, referrals, multiple medical complaints, status of chronic medical conditions, they take up a large portion of the visit. But I know the exam matters to patients because they have told me so. Patients here have complained to me about other doctors who skipped this part of the encounter. When I was training on the East Coast no one seemed to care about whether you did a good physical exam. The complaint was why didn't the doctor send me for an x-ray, CT, or MRI. I'm still not sure why the expectations in this area seem so different. I can tell you another reason why we doctors don't examine patients more often. When we're staring at labs that tell us that the patient’s diabetes is uncontrolled, or we see that their blood pressure is dangerously high, it feels like what the patient needs is education/reinforcement/motivational interviewing, not an exam. But having been a patient recently, I’m starting to believe that thoughtful examination of a patient can add a lot to the encounter: clues, information, trust. So maybe its time we started making it more of a priority.

Sitka from a floatplane
Mountains to the East, Pacific to the West. The airport is at 3 o'clock.
The bridge that connects it to Sitka is the John O'Connell Bridge.

At the center?

One of the few photos I've taken on manual setting...after my wife set it up for me.

7 weeks into my new job and I am really struggling to find balance. The scale is tipping way to the side of work. It’s a good job; I’m glad to have it, but I wish I could turn my thoughts about work “off” during weekends and when I get home. It would also be nice to work out every once in a while. I have never had this problem before and it makes me feel tense.  It’s as if my internal compass isn’t pointing true north. As a Christian I know I’m supposed to have Christ “at the center” but if I’m honest, He hasn’t been. I guess that’s why it was nice to go to a local church today and hear a message about worship. Worshipping God involves stepping outside of yourself and focusing on Him.  

Russian orthodox cross

Village Life

Angoon. This village of 450 (80 % Tlingit) people is located on Admiralty Island, aka "fortress of brown bears". It's roughly 40 miles from Sitka and a 30 minute flight by float plane (because the village has no landing strip). The island is 1600 square miles. There are an estimated 1600 brown bears. This is not a joke. It has the highest density of brown bears in the US. In case you are wondering, I am the family doctor for the village and yes, I carry bear spray. Most of the time I am consulted by the nurse-practitioner who lives there year-round. But 4 times a year I spend a week there seeing the most medically complex patients I have ever seen anywhere.

Smoothest landing ever

Angoon has had it rough and brown bears seem to be the least of its problems. In 1882 it was bombed and destroyed by the US Navy. Today there are very few jobs so most people here live off the land--eating what they catch, hunt, or harvest. But they can't just eat fish, deer, and berries, so a lot of what they eat is highly processed, long shelf-life, nutrient poor, calorie rich food. I haven't been there myself but I hear the grocery store is quite expensive and as you'd expect the produce isn't very fresh.

Angoon AK from the plane

If I'm honest I'm having a hard time wrapping my head around something. Much of Southeast Alaska is as beautiful and pristine as it is resource-rich. So I cannot comprehend why there is so much pathology in Angoon. It's not hard to understand the high rates of type 2 diabetes, obesity, tobacco, and alcohol. Much of the US is like that. But the autoimmune diseases just baffle me. High rates of rheumatoid arthritis (even in young people), lupus, and a very rare one: primary biliary cirrhosis. If you're reading this and are a board-certified rheumatologist or gastroenterologist I want to be your friend.

Welcome Dr. Vega! You ready for this?

Those of you in primary care--family medicine, pediatrics, geriatrics, internal medicine--know the importance of continuity in caring for chronically ill patients. Angoon has not had much of that recently. It's no one's fault, it just has not happened. So as always happens in situations like this, the patients get the short end of the stick. It's just messed up. I'm going to summarize my week in Angoon by saying I enjoyed every patient interaction without exception and I was heart broken and inspired by the stories I encountered. After seeing and caring for all these precious people one of my elderly Tlingit patients said "don't give up on us". I literally had to leave the room so I could get it together.

The way I see it

I recently inherited Mari's old camera. I think she got tired of hearing me tell her what to take pictures of. Here are my first pictures. Disclaimer: I have no formal or informal training in using a DSLR camera, however, I anticipate the photos will get better. Click on the pics for a full-screen view.

This batch of photos is from a whale watching cruise we went on today. Humpbacks live and feed off the Northwest coast, including Alaska and British Columbia. Come November and December, some of these whales migrate 3,000 miles to to the warm waters of Hawaii. Some of them do so to breed and others to give birth. Then they migrate back to the cold and food-rich waters where they came from. Researchers estimate that the voyage takes them around 30 days.

This is a view of Mt. Edgecumbe. It's a dormant volcano on Kruzof island, 9 miles west of Sitka.

I don't own a zoom lens. Sorry about that.

It never ends

Today's post title comes from my medical director who saw me immersed in paperwork late today and decided to stage an intervention of sorts. He brought me to his office and showed me some of his "to-be-done" pile. Which wasn't large by any means. In fact, last week he encouraged me to complete refills, review results, and address other things between seeing patients. Really? I've tried, but I'm working hard at just trying to stay on schedule, let alone do my busy work between patients. Nice thought though. But I think the point he was trying to make was that you have to develop a system of being efficient and of not letting things fall through the cracks without letting the work take over too much of your life. Which is good advice. It's taken so much work and determination to get up here and it would be a shame if I never got a chance to enjoy the place now that I am here.

Great Expectations

Orientation week is over and I now have a slightly more clear idea of what I'll be doing here. 

About one week a month I'll be the "OD" or officer of the day. Being the OD is like wearing a lot of hats. You attend to anyone who comes to the ER--then you decide whether they can be discharged, admitted, or "shipped out". Shipped out would mean someone is very sick and arrangements need to be made to medevac the patient to a bigger hospital with specialists. The closest would be Anchorage (about 600 miles) or Seattle (about 900 miles). It's an insanely expensive ambulance ride, I think in the tens of thousands. OD is also the hospital doctor so you would round on patients who are admitted. We have a 26-bed hospital with about 4-ICU beds, so it's very small compared to the 623-bed, 8 floor hospital where I trained in Lancaster, Pennsylvania. I've been checking out the number of people on the service and it seems to average about 12 which isn't too bad. Another responsibility the OD has is answering pages coming in from the health aides in the various villages surrounding Sitka. Finally, sometimes the OD attends to the obstetrics floor. 

Most of my time as a new family doctor, of course, will be spent caring for people in the office--trying to keep people out of the ER and hospital. I really like this part of my job because over time you get to really know people and learn about what motivates them, their backgrounds, etc. There are a number of Native Alaskan groups in this area with rich histories, traditions, and customs that I really hope to learn more about while I'm here.

Luckily for me, my job includes delivering babies. I'm on call for obstetrics every couple of weeks. Right now I don't have a good sense of how many women in my panel are of child-bearing potential, but hopefully over time that number will increase and I'll be able to participate in a lot of happy deliveries with good outcomes.

Last, but not least, I have a little village of 600 subsistence living people that I am responsible for. You can only get to this village by ferry or by plane and I'll be doing that about 3 times a year for a week at a time. The rest of the year I work in collaboration (by phone) with health aides and 2 physician assistants who live there year round and will call me with questions and prescription requests. This part promises to be very interesting so keep tuned!

Tomorrow morning I start my very first clinic.

4 Years In The Making

(This post explains how I became obsessed with the idea of practicing medicine in Alaska.)

A few years ago I spent a month working as a medical student at an small Indian Health Service clinic in Northwest New Mexico. If you have never been to the Southwest you have probably by now seen some of it on the TV series Breaking Bad. The views are devastatingly beautiful. The remoteness and open spaces are awesome and kind of scary. Now imagine being the only doctor working in a 7-bed emergency room for a catch area of 20,000 people in the middle of the desert. You have an x-ray machine but no CT or MRI or echo. If someone decides to deliver you will be the one to do that. You manage alcohol intoxication all the time. If someone comes in with a heart attack or a similar emergency your job is to find out what is wrong really fast with minimal technology and request for a medical jet to transport them to a tertiary center. As a medical student I was working shoulder to shoulder with doctors making calls like that. I even worked with the doctor who found the index case of Hantavirus Pulmonary Syndrome in 1993 in a young and otherwise healthy Navajo marathon runner. These doctors might as well have been the gods of medicine to me. So when I found out some had practiced in this even more remote and crazy place called Alaska they had my attention. One of the physicians told me about what it was like to work in Barrow (the northernmost US city where temperatures remain below freezing from October to late May) and another one told me about the really long Alaskan winter nights and close knit communities. It was like they were telling stories from a different world but it was all real! I think that was the moment I realized I was going to be a rural medicine family doctor. 

After that I started looking into this place called Alaska and somehow, miraculously, convinced my wife that moving there after residency would be a good idea. We spent a month in Anchorage and a month in Juneau during my residency and I accepted an offer to practice full-spectrum family medicine (that means working in the clinic, hospital, and delivering babies) in Southeast Alaska. We arrived here on September 30, 2013 and today was my first day of orientation. If all goes well I will be blogging about my first few months as a newly minted family doctor in Southeast Alaska. Maybe my wife will lend me some of her photos to add some color to this otherwise drab blog.