I Can Diagdraw!

I'll write a short post today before I ramp it up (maybe) for my last week here. Please marvel at both my drawing skills and my penmanship.

My patient told me he understood what I was getting at but I suspect he was tired of sitting in my office watching me scribble. It was like a game of pictionary where the winner gets a pin inserted in his femur. Fun!


In another story, people in Iqaluit were making small talk about how warm it is here today. It's 12 degrees.
Eat that, Toronto!

Welcome to Pangnirtung

The picture you see up there is the view of the fjord where the community of Pangnirtung is located. You can't see it because I don't know how to take timely pictures. It's just around the corner of the landmass on the right. The story of why I was able to sit between two pilots and take this shot from the front window of a very small plane is the topic of today's post. I was going to post about a hike that I took but this is way more interesting. Also, I actually have pictures to show. Because I remembered 3 days after losing my camera that my iPhone can take pictures. Because somebody reminded me. Because I'm slow.

As always, I'll start off by showing you a map because (and I hope this doesn't insult you) I assume that the majority of you are not super familiar with the geography of Nunavut. I know that I'm certainly not familiar with it enough yet to have non-embarrasing conversations. "Oh, you're from Hall Beach" I'd say. "That's not too far a plane ride I guess". Then I'm told that Hall Beach is actually not on Baffin Island at all and I'm mixing it up with Cape Dorset. But now I know where both those places are! And, more on topic, I also know where Pangnirtung is.

Pangnirtung ("Pang" for the in-crowd) is about 200 km north of Iqaluit. It's easily recognizable as the red dot on the map that is not Iqaluit. It has a population of around 1400, almost all inuit (like every community on Baffin except Iqaluit). Pang is at the entrance to Auyuittuq National Park and is also the home to an infant who put a small object in his mouth.

On the right you can see the plane I flew on to Pang. That's pretty much the entire cabin area. There's enough room for three medical personnel and there's a strecher for the patient underneath all those bags. On the top you can see an oxygen source and an IV pump and then on the bottom and at the back you can see a ton of bags. They contain pretty much all the equipment you'd think you would need in an emergency.

I was asked to accompany the regular crew (a nurse and a respiratory therapist) to pick up an infant who had put something in his mouth and had briefly obstructed his airway (bad) but then something happened and he was breathing again (good). We knew that the nurses in Pang thought that the object was still in his pharynx (below the mouth, above the trachea and esophagus) and that he was - for the time being - breathing okay. That was it. The nurse and RT were pretty amazing at their job and I was told that I only needed to accompany them "in the very unlikely case he needs a tracheostomy". Other residents should know what this means and how scary that 'unlikely case' would be. That yellow book at the bottom of the picture is my critical care handbook where I was furiously reading the same paragraph about tracheostomies over and over again as if somehow that way I could burn the skill into my muscle memory. I'll save the suspense now and say that that particular intervention was not needed, although something else was.

When we got to Pang, we got a ride straight from the airport to the health center (approximately 400 meters). It was on the ride that I realized that the nurse and RT wanted me to remove the object from the child's throat (or wherever it happened to be) before we got back on the flight. Whereas I was really hoping that somebody else (like a surgeon or something) would do it when we got back to the hospital. Of course, my colleagues were in the right. It would definitely be easier to solve the problem on the ground then to have to react to an emergency in the air. At the very least, we rationalized, we could stabilize the child by intubating him.

At this point, I should start explaining what all this means. To the left is a picture of the best possible view you could get of a throat. In case you thought that your throat is not disgusting, I hope this picture disabuses you of that notion. The large bit on the top is epiglottis and the two white strips in the middle are the vocal cords. The trachea is just beyond those cords. The goal of "intubation" is to put a tube into the trachea so that you can control what goes in and out of the airway. In our situation, this would be desirable because if you could get a tube in there, the object in the child's throat wouldn't be able to obstruct the trachea since the tube would be taking up most of the room. In that way, the airway would be "protected".

Of course, the task is much harder when the view is more like the one on the right. So this is why I had one of the biggest adrenaline rushes in my life - I wasn't sure that I could get the thing out and I thought that I might even push it down with my laryngoscope (what you use to look in the throat) and I wasn't totally confident about how easy it would be to get a tube in.

When we got there we had to get the kid sedated enough to take a look. It turns out that this child would be a really succesful heroin addict because we gave him enough of a similar drug (fentanyl) to put two infants in a very deep sleep but he was just high and happy and swinging his oxygen mask at our heads. This was very cute but not helpful. We finally got him to sleep using other drugs and then... the moment of truth...

...Which turned out to not be a big deal at all because the object (a lovely piece of jewelery) came out really easily and the child was totally well (but high) afterwards. Also, I'm overexaggerating the scariness of the situation for drama's sake because I did have a highly experienced respiratory therapist standing next to me who could have saved the day in probably any situation. But I was definitely scared out of proportion to reality and that is why it's burned in my memory and has become a super long blog post that is way less well written than I had originally hoped.

But, as may be evident, I'm really tired now and I haven't posted in a week (this actually happened last week) because it's been really busy and there's no way I'm going back to edit anything. So you're going to have to live with this. Here are some more pictures of Pang. 2 of them I took myself, one of them is an artist's rendition of the local wildlife.

Happy Nunavut Day!

I have to admit in advance that none of the pictures you're going to see from here on in are taken by me. The reason being that my camera is lost. This is sad because there were some good photos on there and I would have liked to have taken more. It's also sad because it means that I'll be forking over a couple hundred dollars for a new one. Shockingly, one of the stores in town sells disposable film cameras so I'm still able to take some pictures. Once I catch a flight back to 1998, I'll be able to develop them and show them to people. It's going to be awesome! In the meantime, Google Images will become a good friend of the blog. I've already learned that there is very little that I have seen or done in my life that Google doesn't already have covered. I'm not sure whether to be happy about that or sad that my life is nowhere near as unique as I once thought.

All that aside, July 9 was Nunavut Day! It was very well advertised via the following poster that I took a picture of*

Nunavut Day is the anniversary of the passing of the "Nunavut Act" in 1993 which, as you no doubt can not figure out on your own, established Nunavut as a territory independent from the Northwest Territories. Nunavut wasn't actually legally distinct until April 1 1999 but the passing of the act was deemed to be more significant so July 9 became the day to celebrate. As an aside to any non-Canadian readers, Nunavut is unique in that it is a territory that is semi-autonomous and self-governed by an aboriginal group (the Inuit). The word "Nunavut" means "Our Land" in Inuktitut.

But enough history, you probably want to know about the free hamburger I ate at the festival. It was delicious! The astute amongst you will note that the man in the photo is making pancakes and not, in fact, hamburgers. Apparently that's what they served on Nunavut Day in 2004, when the picture was taken. That's the type of inconsistency you will have to live with. Unless, of course, you band together and buy me a camera. Perhaps with a nice telescopic lens. You can get it shipped up to Iqaluit... it'll cost you more but think about all the different low resolution photos you'll see on a blog if you do it... just think about it.

I also can't show you a picture of the "seal pull" - a weirdly entertaining competition where women (only women) tied a rope to a few tires (the "seal"), sat down 30 meters away, and pulled the tires towards themselves. The fastest puller won... something. During the pull, there was one bystander getting really into it yelling "Inuit women are strong!!". It was true, they were strong. If pulling a seal across ice is anything like pulling four tires across bare pavement, then I gather it's a pretty difficult job.

Unfortunately, I can't say too much else about the Nunavut Day festivities as I was stuck in the hospital for most of it. I know that there was also a bouncy castle and a really cute little girl carrying a doll in her amautik (woman's parka where the hood is designed to carry a child). Google Images was actually able to recreate that last one. Just imagine a parking lot with a bouncy castle instead of a snowy tundra and it's pretty accurate. I don't know why, but I really like the amautik (see last post). I just learned what it's called so I'm proudly using the word. Amautik.

*There is a special prize in store for anybody who knows (or guesses) what the Inuktitut writing says.

Surprise! There's a child on my back!

There's a lot you don't expect when practicing paediatrics up north, especially in the first few days. This was represented beautifully when I walked from my office to the waiting room to get my second clinic patient on my first day. All I saw was a woman wearing what looked like a colourful jacket-vest with an oversized hood. And then her shoulderblades started to cry, which I admit I found odd until she turned a bit and revealed the source: the baby riding in her giant hood on her back.

I admit that I am dramatizing this a bit. I was in fact previously aware from exposure to Inuit art (like that piece to the left) that Inuk mothers wear their babies on their backs. I think I just forgot about it and also kind of thought that it was a historical thing. Wrong. It's actually pretty cool that this piece of culture has been preserved. Also, it's poetic because the mothers are showing up to my clinic literally carrying their problems on their backs.
Not that their babies are a problem, it's that their babies have problems.
That's why they're coming to see me, obviously.
Don't get up in arms so quickly!

And problems they indeed have. And then I get to play the "surprise" game back with the mothers where I "surprise" them by telling them that they are going to go on a much longer trip than they expected. I will explain how that works... now.

Several patients have come in with recurrent urinary tract infections with fevers. In infants, this is a concerning presentation because it could be indicative of something called vesicoureteral reflux (VUR) - a condition where the valves between the ureters and the bladder are incompetent and allow urine from the bladder to reflux back up to the ureter and kidney. When said bladder is infected, this refluxing urine can spread the infection to the kidneys where it can cause scarring and, eventually, bad things like high blood pressure.

So how do you test for VUR? With another acronym - a VCUG (voiding cystourethrogram). In this test, a catheter is inserted into the bladder (don't squirm... buck up and keep reading) and a dye is inserted in the bladder and xrays are taken. A normal exam would show all the dye staying in the bladder. VUR would look like this -->

Of course, as the picture helpfully points out, this is not a procedure that we can do in Iqaluit. Surprisingly (surprise!), in fact, because there used to be a fluoroscopy machine here (the special kind of xray used for this test). It hasn't worked for quite a while though. As always, it's a resource allocation issue.

So I get to wonderfully surprise parents by telling them that their child may have to go down to Ottawa to have the test done.

That's a long flight from Iqaluit but it's even longer from places like Arctic Bay or Pond Inlet (see if you can find them). These children have to fly up to 7 hours one way to get a test that children in "The South" take a couple hours out of daycare for. That was definitely a surprise to me. The government pays for the transport but gee golly it sure seems like a convoluted way to get what we generally consider a simple test. Also, arranging the whole process can take up to an hour in paperwork and phonecalls. I promise you, Sick Kids, I will never complain about your procedures again!

Eating Seal (and also working)

I promised it before, but you might have thought that I was lying. I did actually eat seal meat today. The guy who was living in the apartment until today bought several pounds of seal meat (it was on sale!) and then realized he couldn't eat all (or any) of it before leaving. He spent last night cooking up a seal stew, the smell of which was exactly what you'd expect. The upshot is that he left behind an entire large pot of seal stew, part of which I shared with my new apartment-mate for dinner tonight. It looks and tastes pretty much like liver - if liver is filled with small bone chips and is as tough as hide. Also, imagine that liver had less taste. Right now I'm in need of a toothpick.

Also, I went to work today. I showed up at 8:30 and there was definitely nobody expecting me. Well, nobody expecting me in the sense that there was nobody expecting to orient me or help me or anything. People clearly expected me there for work because my inbox was filled with pending consults and lab results. I spent the morning figuring out how to track down charts so that I could make sense of lab results with no clinical information attached and then learning how to triage my own consults. In the afternoon I finally got some orientation and now I'm ready to attack. I have 4 new consults lined up for tomorrow ranging from workup of a seizure to what appears to be a bronchiolitis follow up (hard to tell for sure without the referral sheet though).

Tonight there is a woman in labour with meconium-stained fluid. I expect that I'll be called in during the middle of the night. For the uninitiated, meconium is the first stool a baby produces. When it's in the amniotic fluid, it means that the baby pooed before delivery. This is bad because it is often a sign of distress. It's also bad because "breathing" in the meconium can be damaging to the baby's lungs. There may not necessarily be a problem but I will have to be around to possibly aspirate the meconium from the baby's trachea - something I have never done without a respiratory therapist around before. So...

On a less serious but just as gross note, here is a picture of my bowl of seal stew. I still have to get back to writing about my first day in the subarctic but for now I'm going to do a fetus a favor and review some neonatal resuscitation literature.

Airplane

As indicated before, my flight was delayed for several hours today. This gave me the chance to meet some new friends, including a man who is apparently the Nunavut minister of transportation (or environment?). I also met a nice lady who works as a toxicologist for the federal ministry of the environment. Little did I know that approximately 12 hours later she would force me to do a jig in a school auditorium. I may not get to describe that in this post but foreshadowing always earned extra marks in Grade 5 so I hope that Mrs Gordner is reading and that she still has the stickers with an seal saying "good job".

Here's a picture of a seal to reward you for reading through a full paragraph of text:

As an aside, I will be eating him for dinner tomorrow. Which brings me to my flight where I made friends with a young Inuk man. He told me all about the foods I should eat while in the arctic. Caribou is apparently tastier than beef, arctic char is fantastic, and beluga whale is the best food in the arctic (but only the skin of the whale and then only when totally frozen). I can already call him out on the Arctic Char since I ate some on the plane and it's like salmon with less taste. But I can't wait to try the others! Helpfully, he showed me where I can hunt for my own beluga whales as we flew overhead (see below):

I'd be lying if I said that I wasn't skeptical that I could successfully hunt a beluga on my own but, apparently desperate to continue conversation, I enquired as to the specifics. I now know that a shotgun is not good enough to kill a beluga. You need a gun that can shoot a bullet approximately the size of your fist. I considered asking where you could get such a weapon but decided against it as I didn't want him to think that I would actually do it and then have that awkward conversation with him later. You know the one: where your friend asks how the beluga killing is going and you have no good response? Yeah, we've all been there. Social interactions are a bitch.

It was just as well that the beluga conversation was coming to a close though as this gave him a chance to regale me about his addictions and his time in rehab. Ironically, I was simultaneously trying to read a review paper on addictions in children. I was skillfully able to change the topic by awkwardly having nothing to say in reply. Then I got a quick lesson in Inuktitut which was super helpful except that it's a hard language and I can't remember most of it. However, I do know that we all pronounce "Iqaluit" horribly wrong. Also, "thank you" is ᖁᔭᓇᐃᓐᓂ. 

I hope I see my friend again in Iqaluit (pronounced correctly) because he gave me a pretty good intro to the region.

The other thing I gained an understanding of (from looking out the window) is why Europeans never drove the Inuit from their homelands on the scale of other aboriginals: because the land is totally undesirable to them. The pictures above and to the right should give an indication of the amount of vegetation that grows in this region. Bear in mind that this is summer. The land is mostly bare with at least some snow cover year round. There are no trees whatsoever this far north. That being said, you can also see that the land is relatively untouched and is quite beautiful.

So there's a relatively lengthy description of my plane flight. Today was an eventful day filled with studying, tours, pricing, and the aforementioned jigging so it will have to be continued in future posts. Right now I have to go to sleep because tomorrow I have clinical responsibilities for the first time in nearly 2 months and there may or may not be an actual paediatrician around to back me up.

Pre-Boarding Reading

So I'm heading up north. That's really the theme of this blog - that I'm heading up to Iqaluit, Nunavut to practice paediatrics in a way that hopefully doesn't cause the Inuit to despise Torontonians. For my non-Canadian friends (and for certain special Canadian friends), here is a map of where I'm going with some helpful landmarks thrown in.

 

As you can guess, Iqaluit is not much like Toronto. I have reproduced that on a scale below.

This scale, the measure which is familiar and used by all of us from Toronto, gives you an idea of what I suspect Iqaluit will be like.

Anyways, I'm just killing time as my plane gets continually delayed. Now they're calling for boarding. First Air hooray! Be sure to follow my adventures by adding this blog to your RSS. Do that by using the menu above or look for and click on an RSS button anywhere on your browser. Enjoy this one-way discussion.