Out There

bush medicine

Posted in teaching by Pete on February 20, 2011

It’s a Saturday night and I find myself setting up my sleeping bag on the floor of a building in the Western Alaskan hub city of Bethel.  My infant son sleeps fitfully on the other side of the room.  We flew to Bethel to go to the emergency room at the hospital, the only hospital for hundreds of miles, and we are waiting until 5 or 6 am to go to the E.R.  Every so often we have these experiences that are so outside of the “norm” that I grew up with that I want to tell the story to let people get a glimpse of life in the bush.

Two weeks ago, we couldn’t use our usual babysitter because her son wasn’t feeling well, had a fever, and ended up being diagnosed with an ear infection.  On Friday of that week we were looking for a sitter and I called them up and they said he was better, he was fine.  I dropped our kids off and then flew off to Napaskiak with the boys for some high school basketball (I’m coaching this year).  On Monday I had to get to Atmautluak to test a student before their IEP became due.  I took them to the same sitter.  I returned home around 5 pm and my wife told me we had to pick up our kids ASAP because the sitter had called to report that our son had a fever.

I went and picked the kids up, and he didn’t look good and was fussy.  We got home and I checked his temp and it was normal.  A couple of hours later and it had climbed to 100 or 101, and we gave him some ibuprofen.  This brought it back down, but after 4 or 5 hours the fever and fussiness would return, and generally speaking each was worse than the one before.  On Wednesday morning I was planning on calling the clinic and getting him an appointment.  But when he woke up, he had no fever.  Hooray!  I thought his fever had broken.  No.  By lunch time he had a fever that was 102 or 103.  It was too late to call the clinic.  You cannot get an appointment unless you call in the morning, and they stop seeing patients in the early afternoon.

So I called at 9:00 on Thursday morning and got an appointment for 11:00 am.  I called Tammy and she said she would go with me to the clinic since I can’t drive (snowmachine or the school truck) and hold the baby at the same time.  I called our other babysitter and she agreed to take our daughter while we took our son to the clinic.  Tammy had to wait for her sub and then explain to him what she wanted done with her classes, so that when she arrived we were running late.  She hadn’t had time to have breakfast or lunch yet.  We piled all four of us onto my Polaris 550 with the sticker that reads “Not intended for use by more than two people at any time,” and drove to the babysitter’s and our count went down to three.  From there to the clinic, driving slowly because of the precious cargo, the new pistons in my snowgo (another story), and the difficulty seeing the dips and bumps and gulleys along the way.  Tammy was on a snowgo that turned over a few years ago and she has some (justifiable) fear of this happening to her while holding the baby.

A mile and a half later and we were safely ensconced within Kasigluk’s large new clinic.  We saw a health aide who gave the baby a thorough inspection.  The health aides use the “Community Health Aide Manual,” aka the “health aide bible,” to help guide their physical inspection and patient interview.  After checking temp, oxygen, ears, nose, throat, heart, lungs, etc, the health aide felt that maybe we should take Bobo in to Bethel to see a doctor.  Very quickly if you don’t know already, the community health aide is not a doctor, physician’s assistant, nurse practitioner, nor a nurse.  They are trained in some basic medical knowledge and trained to gather the data and then fax (yes I think they are still FAXing) the information to the YKHC (Yukon Kuskokwim Health Corp) hospital in Bethel, where a doctor or nurse practitioner or physician’s assistant will read the report and then respond with the course of treatment.  The clinics are stocked with the most common prescriptions.  If you want to know a lot more about the community clinics, the health aides, the physician’s assistants and others in Bethel who work with the village clinics to prescribe meds and medivac serious cases, you can check out the now defunct Tundra Medicine Dreams blog.  Lots of good writing from a P.A. who used to be on the Bethel end of the service delivery model.  The village clinics, as well as the YKHC hospital, are all a part of the vast Indian Health Service, providing free health care to nearly all of my neighbors.  YKHC serves as the primary hospital for something like 56 villages.

Back to the story.  They were concerned about Bobo’s chest and lungs, based on what they could hear in his breathing, and felt he should go to Bethel, and the doctor in Bethel agreed.  However, it was too late to get an appointment for that day.  Our options were to go and sit in the E.R., or wait to the next day and call at 8:00 AM sharp and get a same-day appointment.  The last time we tried to do this I called over and over and only got busy signals or voicemail until 8:45, at which time someone answered and said the same-day appointments were all taken.  On that occasion, Tammy then flew in with our daughter and sat in the E.R. from roughly 10 am until 4:30 pm without seeing anyone and then she gave up and caught the last plane back to Kasigluk.  Our girl got better on her own, and Tammy figured that sitting in the crowded E.R. full of very sick people was not going to help things improve. We weren’t sure what to do.  One of the health aides advised us that the E.R. gets very crowded in the evening but if you go before 5:00 or so you can usually get seen right away.  They also mentioned that a plane was coming in the next couple of minutes, and we should try and get a seat as the next plane wouldn’t come for several hours.  We had no change of clothes, not for ourselves nor for the baby.  We had 1 extra diaper.  We decided to go for it.  We wanted to do what was best for our boy.  Less than five minutes later, Tammy and Bobo got the last seat on the 6-seat Yute Air 207 for the 15 minute flight to Bethel ($88 each way!).

Upon arrival in Mamterillermun (Bethel in Yup’ik), they headed via taxi ($8) to the E.R.  She got there around 2:00 pm and it was crowded.  She saw the triage nurse who told her it would be a long wait to see a doctor, even by their standards.  But the wait for the chest x-ray would not take more than a couple of hours.  Also, she was able to schedule an appointment for a doctor the next day, so she decided to wait in the E.R. for the x-ray, then take a taxi ($8) and check in to a hotel ($170).  Tammy is not the last of the big spenders, but with airfare, hotel, taxis, 4 meals from restaurants, clothing and diapers from the store, our 40% share of the medical bills (YKHC is not a “preferred provider” with our school district health insurance despite being almost the only option for hundreds of miles, go figure)…the whole trip cost upwards of $700.  Bethel and the bush in general can be very expensive.  Small demand, but teeny tiny supply.  She also had to order food (first she’d eaten all day, around dinner time) for her and the baby, she went to a store with the baby (cab ride) and bought him a change of clothes, diapers, etc, and even bought some hand-made booties made by a woman from our village because in our haste we had taken him to the clinic in a snowsuit and pajamas but no shoes.

After a rough night during which his temp climbed as high as 104, they took a taxi to the 10:40 appointment at YKHC on Friday morning.  He was given amoxicillin for otitis media (bad ear infection) and the x-rays were examined and they were negative, no problems.  So just a flu and ear infection combination.  They headed to the airport after getting meds from the YKHC pharmacy around 12:30.  OH, and by the way while at the hospital Tammy saw people who had been in the E.R. when she arrived the day before at 2:00, they got there before her.  She asked when they were seen by a doctor, and they told her 4:00 AM!  So it would have likely been more than a 14 hour wait in the E.R. had they stayed, with almost no sleep surrounded by lots of very sick people.  I think they made the right call about getting a next day appointment and going to a hotel! At the airport they found out noone was flying due to fog and snow that kept going up and down.  To cut this part of the story mercifully shorter, they waited all day and did eventually make it home around 7:00 pm.  Yute Air told me around 4:30 that she was on the plane and on the way, so I headed over to get her using the school truck, and with Claire.  By 6:00 Claire was cold (truck has no heat) and my hands were getting seriously cold too.  These sorts of miscommunications are commonplace with the small Bethel airlines, more the rule than the exception.  I took Claire home, and found a message on the machine that she had left Bethel already, so I raced back to the airport and waited another half hour or so and then they came in (she was delayed because the plane went to another village before it reached KUK).  Hooray!!  We drove home, and though Bobo was still noticeably fussy and tired, he seemed much better already, not needing to be held every second.

This was not the happy ending we thought it was.  On Saturday morning, after giving the baby his 2nd dosage of amox, Tammy noticed his back was all splotchy.  She remembered the pharmacist telling her that if he had a rash, to stop the meds immediately because it indicates an allergic reaction that would start as an isolated rash, then move to a rash all over, then move to difficulty breathing if he stayed on the meds.  I was coaching basketball at the school and not reachable.  She called the on-call health aide (the clinic is closed on weekends but they have a clinic cell phone that is answered 24/7 for emergencies), but was told that they couldn’t see him unless it was an emergency, but we could bring him in on Tuesday (Monday is a holiday and they are closed).  He has been sick since Monday, today is a Saturday, we didn’t want to wait another 3 full days to get him on the right antibiotics.  We called the YKHC E.R. and asked how the wait was, they said it was terrible, and when told why we might bring the baby in the person said the health aide should take care of it for us.  I went and spoke with the health aide, a family friend.  She was sympathetic and nice, but it sounds like she isn’t really allowed to intervene after hours except for real emergencies.  I explained that I’m concerned about the ear drum rupturing, and the high fevers returning, and he has been sick long enough, he hasn’t been eating hardly any solids for several days, etc.  She said that sometimes they will drain (through a perforated eardrum) even after getting on antibiotics, and said “If it drains then it’s meant to drain.” She wasn’t very concerned.  I don’t say all of this as a criticism.  The health aides do a really good job.  They have saved our bacon more than once, even once when Tammy broke her leg and they helped get her on a plane in a snowstorm.  But the healthcare is not what you can get in most of America after a short car ride.  You may have to wait until Tuesday.  Or you may have to pay to get on a plane, and then a cab.  And then wait a long, long time.  I think the Indian Health Service gets away with it because (1) hey, it’s “free” healthcare (in exchange for natives giving up land claims and other claims against the State) and (2) Yup’iks don’t complain.  It is not a Yup’ik value to complain, or be verbally assertive, aggressive, or pushy, or to call their congressman.  Things simply are accepted that would be “unacceptable” in suburban, white America.  And that gets taken advantage of sometimes by the kassaq institutions out here.

These sorts of interactions between cultures can be pretty fascinating, and its the kind of interesting interplay you can get a lot of on the aforementioned old Tundra Medicine Dreams blog.  My neighbors accept suffering with a lot of patience and stoicism.  Some outsiders might even say fatalism.  As a speech-language pathologist (SLP) I deal with kids with speech (articulation) and language delays all the time.  And I know that kids with recurrent otitis media and perforated eardrums are far, far more at risk for delays, and even behavior problems, than kids with healthy ears.  I also know from my dealings with audiologists in this region, that they all say that they’ve never, ever seen ear problems like we have out here, in terms of severity but mostly in terms of rates of incidence.  It is very common for kids here to go to ANMC in Anchorage for ear surgery to repair perforated eardrums.  When I say very common, I don’t have a percentage, but maybe 10% of all kids?  Maybe more?  These are kids who have grown enough to have the surgery.  You can’t have it as a  young child because your eardrum is still growing and the repair may not work.  So they live several or many years with the hole before it is patched, meaning they go through a lot of developmental years without proper hearing.  So needless to say, this is one cheechako/kassaq/dad who does not believe that my kid’s ears are meant to drain.  Us kassaqs are arrogant enough to think we can control such things.

I flew in to Bethel with Bobo on the last plane before the ceiling (poor visibility) came down on Saturday, just an hour or two after the visiting basketball teams had flown home.  Our friend Deanna drove us over on our snowmachine because the truck wouldn’t start (it is below zero today and it’s not plugged in) and Tammy (a) doesn’t know how to drive the snowgo and (b) needed to watch Claire.  We actually strongly considered flying on to Anchorage, because it is possible to get a mileage ticket that will fly us from kasigluk to Bethel to Anchorage, and it costs no money and only 15,000 miles.  Remember that Tammy just spent several hundred dollars on Thursday and Friday.  It can actually be a lot cheaper for us to get on a jet and fly 400 miles to Anchorage where we have our own car, friends to stay with, and medical that is covered at 90%.  Crazy.  But the ERA flights from BET-ANC were done for the day, and I didn’t want to spend 3 hours in the terminal waiting for the 8:30 Alaska Air jet with Bobo so I decided to stay elsewhere in Bethel, after calling the E.R. and being told they were “slammed.”  The guy said it has been that way for 2 weeks since the flu has been going around. I figured its better to get a good night’s sleep and go in at 5 or 6 am in hopes that we don’t have to endure the 14+ hour long wait.  Hopefully we can make it home by the Sunday evening flight, with antibiotics in hand that fix my son’s ears but don’t give him an allergic reaction.  I am sure he is even more tired of this whole process than his parents!

Living and teaching where we do is such a unique experience in almost every way from the “norms” of our majority culture.  And there are tons of things we love about village life.  Other aspects are difficult.  It’s different out here, for better and for worse.  I need to remember that we are richly blessed to be able to hop on planes and get the help we need.  It was not at all this way in Kasigluk when I was Bobo’s age.

3 Responses

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  1. Marcyinak said, on February 25, 2011 at 6:44 pm

    Got your link from a friend’s blog. We lived in Bethel for 4 years and are now in Nome (for 4). Yes, the health care “system” in the bush can be difficult. And the eskimos (they say eskimos here, natives down there) don’t really complain…or they do, but don’t know WHO to really complain to.

    I want to put in my 2 cents though, as someone who has worked in health care. The long waits are not caused by the lack of qualified providers, it’s from the amount of people who use the ER as a primary provider. When this happens, a history has to be taken with EACH patient. With some of these very sick elders, this is more than time-consuming. Time and time again I waited for my regularly scheduled OB appointment in the YKHC waiting area (one of the three) and would witness whole families who had come in for one person’s illness, but “hey, while we’re at it, let’s take little Joe in to get his knee looked at, and Aunt Sally to have that abscess checked…”so instead of coming in regularly for PREVENTATIVE care, it has become a system of urgent care and the real emergencies (a baby with a high fever) get over-looked sometimes. When we lived there, a baby actually died waiting for the ER.

    Also, there is a “culture” with the providers at YKHC to not prescribe antibiotics (I’m surprised you got some actually.) I actually think this perpetuates the problem. I understand that they are worried about antibiotic resistence (especially because of the high rate of MRSA that is found in rural Alaska), but putting the care of children should be first and foremost. I was appalled that I could not get my child in to see an actual Pediatrician (they have them in Bethel, not in Nome) because my kid wasn’t chronically ill….so for well checks they needed to see a GP (which wasn’t that big of a deal since we were friends with several), but still….

    It’s a sad system. I hope your baby is feeling better. This rural Alaska insurance debacle is appalling too…

    Take care!

  2. Pete said, on April 5, 2011 at 4:29 pm

    Hi Marcy, thanks for the input. Your comment reminded me that I never gave an update. We made it in to the E.R. around 8 am as I recall. Bobo and I were both groggy in the morning and had to scramble to be sure and pack up, get something to eat, and be out of the office before the Monday morning influx of district office employees. I carried Bobo to the taxi, wading through a long drift of snow that went up to my thighs at times because of the heavy snow and wind from the night before. When we reached the E.R. there was noone else waiting! We were ushered in after perhaps a 15-20 minute wait, and spent another 45 to 60 minutes on the inside, but left happy with new antibiotics in hand, and reached the airport by cab around 10:00 or 11:00.

    We checked in for our flight with ERA Aviation and waited. And waited! The runways were all buried in snow, including Bethel’s, and they had to dig out before flying. After a couple hours we learned that Kasigluk’s airport was plowed, but the wind was causing it to immediately be covered again with newly drifted snow before any planes could get in and out. We eventually got a flight to Nunapitchuk, our neighboring village 3 miles to the east of us. This was followed by a wild ride in a sled from Nunap to our house. I was kneeling and bent over the baby to keep him in his blanket and out of the wind, and it took a lot of effort just to keep from bouncing/rolling around back there with my precious cargo. We actually caught AIR on some of those bumps. : – )

    Anyway, the story ends well. Bobo improved rapidly with the antibiotics and is still doing fine 6+ weeks later. I’d like to think “it wasn’t meant to drain.”

  3. Megan K said, on October 8, 2011 at 10:34 am

    WOW!!! Not sure what else to say. Reading that story makes me feel exhausted.

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