FIRST SOLO TRIP TO KAKTOVIK, MAY 20 - 24, 2013

One of the things I love most about my job as a public health nurse on the North Slope of Alaska is the opportunities it provides to fly in a relatively small airplane on a frequent basis.  Lifting off from Barrow last Monday morning with the other seven passengers in the Beechcraft 1900, the thought filled my mind, “this is what it’s all about.”  It’s not, of course, but in the moment it provides such a strong connection with feelings from childhood, of joy, excitement and an immediate detachment from the routine of daily life.  The flight to the village I’m assigned to, Kaktovik, first lands in Nuiqsut, a small village southeast of Barrow, in Deadhorse, near Prudhoe Bay where there are many activities related to oil exploration and then finally in Kaktovik on Barter Island.  It takes approximately 2 hours to reach Kaktovik from Barrow and three hours on the return trip with a total of six take offs and six landings, my favorite parts of flying. 

On the ground again, what my nursing job is really all about kicks into high gear.  There was an outbreak of pertussis (whooping cough) last winter here on the North Slope, so when packing immunizations for my trip to work in the clinic in Kaktovik, I included 30 adolescent/adult doses of the Tdap (tetanus, diphtheria, pertussis) vaccine.  The due list I ran before coming listed 39 adults who needed to be immunized with Tdap as well as a handful that needed PPSV23 (pneumococcal polysaccharide) and Zoster (shingles) immunizations.  I love the autonomy of nursing.  There are other nurses to ask advice of, but ultimately it is up to each individual nurse to decide what she wants to bring along.  I love that one has to think and plan ahead and has full responsibility for what takes place during the trip.

Being the only PHN nurse in the clinic for the first time heightened my awareness that if Kaktovik’s population was going to be immunized, it was up to what I would be able to accomplish Monday afternoon, Tuesday, Wednesday and Thursday, before flying out on Friday morning.  I’ve never experienced this same sense of responsibility before in a job.  I was very fortunate in that Mary, the clinic’s office assistant, was very willing to call and make appointments and knows everyone’s numbers by heart.  She’d quickly dial a number and say something like, “Hey, Robert, PHN is here this week.  You need a shot.  Do you want to come in today or tomorrow?  What time?”  Over and over, she called, until I had 35 people to see, the first three 15 minutes after I arrived, some first thing in the mornings and some in the evenings.  It was an intense week, working from 8:30 am and until 9:00 pm most nights, allowing me to keep up with the day’s charting and to be ready for new clients the following day. 

Mary, along with four CHA’s (community health aides), serve the community’s emergency medical needs, communicating with physicians at the hospital in Barrow and arranging travel for patients to fly to Anchorage when services there are needed.  

 Before leaving Barrow, I reviewed the faxed copy of the inventory of immunizations from the village clinic and then packed what I would need to replace the ones I would be giving while there.  Mary agreed to review the due lists with me and shared that 18 of the people listed on the adult list no longer live in Kaktovik.  It sounds as if people move from village to village, so deactivating them from the system so that they don’t show up on the due list would only make it complicated for another nurse when they want services in another village.  Better to let them change their addresses at that time.  It would be a good idea for me to call ahead prior to trips to Kaktovik and go over the list with Mary, preventing my bringing too many vaccines that cannot be returned to bulk storage in Barrow.  Temperatures of vaccines are monitored continually, but once in the village, there is no nurse to oversee how they are cared for.  The hope is that temperatures are monitored there and that they are not left out for any reason, but it would be risky to return them to Barrow, exposing them to another change in temperature during handling and transport.  I brought more Tdap than needed, but there is plenty of stock in Barrow and I’ll be able to use it on children who turn 11 years old prior to my coming before the vaccine expires.  There were 22 children on the immunization due list I ran for ages birth through 18, including a two month old girl and a four month old boy who I’d be doing complete well child exams on as well.  

Children’s vaccines include Pediatrix, a combination of Hep (atitis) B, DTaP (a lower concentration of diphtheria, tetanus, pertussis vaccine), and IPV (inactivated polio); Hib (Haemophilus Influenzae type b), Hep (atitis) A, PCV13 (pneumococcal conjugate), Rotavirus, MMR (measles, mumps and rubella), Varicella (chickenpox), HPV (human papilloma virus), and MCV (meningococcal).  The varicella vaccine is a live vaccine and needs to be kept frozen while stored.  It must be used within 72 hours of being out of the freezer and transported in the cooled, insulated immunization bag using during travel and put in the refrigerator at the village clinic. 

All of the children’s vaccines with the exception of HPV and MCV are required by the schools on the North Slope and most parents are very willing to have their children immunized.  It wasn’t all that long ago that their grandparents’ and great grandparents’ generations suffered and died from the diseases the vaccines prevent.  I’m always impressed with how they sit their children on their lap and comfort them, but also say “you are a strong boy” or “you are a brave girl” or “calm down, son” while I give them up to four shots in their thighs.  The parents then insist, after the crying stops, that they thank me.   I now understand the meaning behind their thanks.  To see photographs of children with polio or to learn of children dying from diphtheria and pertussis brings home the importance of the work I’m involved in here. 

INH, the medication given to treat latent TB infection, is also voluntary, although highly recommended.  I’ve never been drawn to sales and could never see myself working as a sales person, convincing someone of the benefits of purchasing a product for me, but I find a natural salesman coming out when sitting down with young clients and their parents when their child is of the age to receive the HPV or MCV immunization or when someone with a latent TB infection comes in for education about INH and is given the choice to begin a daily nine month regimen.  I always feel as though people have made an educated and wise decision when they choose to receive the vaccine or to begin the LTBI medication. 

I examined the two month old and found that her head was flat and generally misshapen in the back and on one side, and that she most likely has torticollis, a muscular condition that doesn’t allow full extension or flexion of the neck muscles on one side.  Flatness of the head can lead to or be indicative of developmental problems and torticollis is more difficult to correct the older the child, so the parents agreed to my writing a referral for her to the Infant Learning Program in Fairbanks.  A physical therapist will fly up to evaluate her and prescribe exercises that will help lengthen her neck muscle.  She’ll also encourage, as I did, tummy time.  Infants can develop flat areas on their heads by being on their backs for too long.  As she grows, ILP and I will evaluate her for developmental delays and the parents will be educated about things they can do to help her grow to her potential, both physically and mentally.  I felt fortunate to be able to examine this little girl and can hear Bertrand reminding me that we are often the only health care professional who sets eyes on these children, so it’s important to be thorough.

When I left Kaktovik, I was exhausted, but happy.  With Mary’s help and the community’s willingness, I’d been able to vaccinate 13 adults and 22 children, giving 62 immunizations in all as well as do the two well child examinations. 

One of my favorite moments was when I asked a little three year old boy what his name was.  “Are you Donald?” I said, looking at his health history.  He smiled and said, “No, that’s not my name.”  “You’re not Donald?”  “No, I’m Handsome,” he said.  During his appointment, I commented to his grandparents who had brought him about what he’d said.  They shared that that’s the only name he’s ever known…all of his family and all of the villagers call him Handsome.  I had to admit…he was a pretty cute little guy!  I love the last names of the Inupiat people.  Some of the common ones in Kaktovik are Aishanna, Akpik, Akootchook, Gordon, Tagarook, Rexford, Tuik, Soplu, Kayotuk, Kaleak, Arey, Brower, Lord and Tiluk.

Other memories I’ll take home are related to hunting this time of year.  Because the sun is high in the sky 24 hours a day, there is the strong possibility of losing track of time.  One of the health aides looked very tired one morning and shared that she and her boyfriend had been out duck hunting until well past 1:00 in the morning.  When waking at night, I could see people out on the snow covered tundra at all hours.  Many people are hunting ducks and geese now.  When asking clients if they were right or left handed, most responded that they were right handed, but objected when I suggested that I give their immunization in their left shoulder, saying that it was their shooting arm, both for hunting and for playing basketball.

On Tuesday morning, I set out for an early morning walk before the clinic opened.  I heard gunshot fire several streets over, so walked the other way and finally wound my way back to the clinic.  Mary came in and said that a polar bear had been between her and her neighbor’s house attempting to make breakfast of the small dog tethered there.  Fortunately, the polar bear patrol was called soon enough and came and fired a shot in the air, frightening the bear away.  The bear returned to the same spot at lunch time necessitating another shot in the air.  The next morning, my walk was very brief and just around the clinic building, glancing in all directions for the hungry bear.  I longed to be out in the sun, walking early every morning, but just couldn’t make myself another possible meal. 

I’ve learned that residents in Barrow are frightened of bugs and have had to do several recent home visits to inspect and clear them for one reason or another…lice in one case and an unidentified, but misplaced bottle of bugs in another.  On Thursday, an unpopular fly was discovered on one of the Kaktovik clinic windows.  All work ceased and all staff immediately ran as far away from the window as possible while attempting to restrain from shrieking.  One brave woman brandished a large book and charged the fly repeatedly until her aim procured his demise.  Between the shrieking and the laughing, I was able to ask about their fear of bugs.  Its history isn’t known entirely.  As children they were taught to be frightened of bugs by their parents and grandparents, so it’s the only reaction they’ve ever known.  A friend in Barrow who works as an educator for Fish and Game mentioned that school children have no interest in learning or doing projects about insects here.  She said that there’s no other place she’s ever worked where this is the case.

When at the airport in Barrow, I met an entomologist (one who studies insects) who had traveled with his wife from their farm in Ohio to spend a week in Barrow.  I shared what I had observed in Barrow and Kaktovik and he thought convincing them that bugs can be edible might be the right avenue to try.  He said that the large larva of the black beetle is especially good.  I’ll be sure to mention this next time I’m in Kaktovik = ) although I don’t think there are any black beetles on the North Slope.  I could bring some dipping chocolate and see if they felt like making desert with the flattened flies, but I’m 100% sure that don’t collect them to enjoy later.  Maybe some a la mosquito.  Or maybe a fly swatter.