Anatomy of a Saturday in Kuujjuaq

This all happened on Saturday, August 16, 2003.

1:00 am: I am doing some sutures with R., another permanent doctor up here in Kuujjuaq with a year’s experience. We are finishing sowing up of a little girl flown in from Kangirsuk during the evening, with a deep laceration in her chest wall. She rolled off a moving 4 wheeler and fell underneath; a metal shard or sharp rock cut her chest wall open, down to muscle: a 15 x 4 cm long laceration on a 8 year-old’s chest. There didn’t seem to be any crush injuries. After having cleared all other major injuries (C-spine, abdominal ultrasound, pelvic and chest X ray), we consulted the chief surgical resident in the South, with a digital picture sent on the Internet. It is full of earth matter and gravel, but it looks superficial. We sedated her with ketamine and proceeded with the cleaning. One hour of cleaning with surgical scrubbing sponges, 3 liters irrigation (and the greater part of my body soaked), 1 layer of 15 deep interrupted sutures and 1 layer of skin sutures. The antibiotics have been pumped into her before she left her village. I admit her to the floor and give her 48 hours of intravenous antibiotics, hoping that there will be no abscess formation on a little girl’s chest wall.

I go back to my transit hoping to catch a few hours of sleep, being first call on both Friday and Saturday, like they do it up here in Kuujjuaq.

8:00 am: Telephone call from Raglan Mine, close to Kangirsuk. The nurse in Raglan Mine is worried about a 45 year old miner who had episodes of chest pain overnight, and will fax me the EKG’s. She warns me that her fax machine is very slow. He is now chest pain free and has few cardiac risks, but what the heck... I tell her to give him the aspirin anyways.

8:30: Looking at the EKG. I don’t really like it, although he is chest pain free. Scratching my head, trying to decide whether it is just J point elevation or something real. Evaluating this patient in hospital involves getting him here, which means a plane.

8:35: Have decided to make him come. Am calling nurse in Raglan. Luckily, the Boeing 737 that Raglan Mines uses to get their workers to the Great White North is in. So with flight prescriptions of nitro prn, oxygen, IV boluses and morphine prn, he is flown with a nurse from Raglan Mine to Kuujjuaq, monitored, only them and the pilots, on the immense jet. Estimated time of arrival in Kuujjuaq is 12 noon.

9:00: Strange call from a policeman in Kuujjuaq. There is a man in a hunting-fishing expedition camp near George River who has broken a leg. They are asking for a med-evac onto George River to pick him up. I tell them to get him into the George River nursing station first, and then they’ll call me. I am not aware of the hospital being able to charter helicopters or such things to evacuate people.

In the meantime, I round on the patients admitted the previous day, which include a diverticulitis, the laceration sown up the previous night, a dysfunctional perimenopausal uterine bleed, an uncontrolled type 1 diabetic uncompliant to his insulin with new renal failure and with a gastroenteritis, and an 11 weeker with fever. The vaginal bleed and the 11 weeker can go home.

11:30: A pregnant patient has arrived, second baby, about 35 weeks and 3 days, not sure. She might have ruptured her membranes since 23:00 last night, but no contractions yet. Her husband mentions that on the last obstetrics appointment 4 days ago, the head wasn’t down yet. Leopold maneuvers reveal a head, or a very hard butt, down and well engaged. Exam also reveals a head – or a very hard butt – and dilation at 2 cm. Just to be sure, I call the radiology technician in for an ultrasound. Thank God - it’s a head. She even spends time checking for a cord around the neck. There isn’t. Estimated birth weight around 3 kilos. And it’s a boy... but the parents knew already. So the IV’s are in, and the ampicillin is going in. No contractions yet... Just to be safe, I call my back-up doctor (poor R. again) to tell him that there will be a delivery and that I might call him if something’s not right. R. is at the supermarket shopping for food, and is within 10 minutes walk if I page him.

12 noon: Our miner has arrived. Uneventful flight from Raglan. He is in the monitored room. He is chest pain free, and a very nice man. EKG’s are repeated, and they look the same. I fax them to the cardiology fellow in the tertiary hospital in the South, and he agrees that there is something funny, so we start the low molecular weight heparin and the aspirin. He tells me to keep the patient up here, monitored, and if there is recurrence of his chest pain, he should come down.

12:15: Panicked call from the nurse in George River. A 26 week-old pregnant lady has come into the nursing station in the village, bleeding and contracting. The nitrazine test is positive. I call R., who is still at the supermarket. He rushes to the hospital: we will have to send him, a nurse, an incubator and a full obstetrics and resuscitation set on a plane to George River.

12:40: R. is calling Air Inuit to arrange the med-evac. Another call from Kangirsuk: there is a little girl that has been coming in daily for crampy abdominal pains, with an equivocal exam according to the nurse; her urine is negative. However today jumping hurts, and her pain is worse than the days before. Which means... another med-evac onto Kangirsuk because it may be an appendicitis. Just a nurse on the plane this time, with flight prescriptions for NS boluses and morphine if needed.

13:30: R.’s med-evac to George River, and the other one to Kangirsuk, are leaving. The nurses on the floor are making the on-call nursing list to get more help with all the cases that are coming in. The pregnant lady on the floor is starting to have contractions. She is at 2 cm but progressing. Fetal heart is fine.

14:00: A young woman walks into the clinic, having stumbled on the stairs and hit the wall with her right fist. Wow, nice fifth metacarpal fracture! She had a boxing match with the wall! I call the clinic nurse in to help me do the reduction under conscious sedation.

14:30: Noukki, the Inuit safari organizer who had the fishing camp near George River, has arranged an amphibious plane to land on the lake near the camp and bring the man with the broken leg back to Kuujjuaq. They will land on Lake Stuart, near Kuujjuaq, at 16:00. I tell the ambulance driver. He’s never driven to Lake Stuart, so he’s going to go test the ambulance to see if it can get there on the gravel road.

15:00: It took a while, but we are doing the ketamine for the fifth metacarpal fracture reduction. The patient is completely high and seems to enjoy it... she doesn’t even notice my pushing on her finger. She is laughing about some orange men or something... When she wakes up, she has no idea how the ulnar gutter got there. Patients on ketamine are definitely entertaining. I decide to keep her a few more hours to make sure that she is fine, before she goes home with her husband.

15:30: The pregnant patient is at 4-5 cm. Contracting nicely, and fetal heart is fine. Mine’s a little tachycardic, but that’s besides the point. Maybe I should have used a little bit of that Versed for myself...sorry, besides the point again.

15:40: R. is back with the woman with the preterm contractions and ruptured membranes. She was at 6 centimeters in George River, and now she is fully dilated and pushing. The baby comes out... less than a kilogram and blue. However it still makes little tweaking sounds and it’s trying to breathe. It’s a baby boy. Extremely preterm. Straight onto the incubator to be ressuscitated. Intubated and ventilated by R. The heart rate is around 100. We are struggling to find umbilical lines, but we find them. R. inserts the umbilical line and pushes little boluses of NS and 0.2 cc of 1:10000 of epi. I get on the phone with the neonatologist in the South for more advice. We proceed with a little more ressucitation, but to no avail, the heart rate stays around 60. Finally we decide to withdraw after about 40 minutes of ressuscitation. The mother, an alcoholic who missed the timing for an abortion and drank throughout the pregnancy, is more interested in going out to smoke a cigarette than seeing the baby. R. takes the preterm baby boy away and gives it a little more sedation for comfort; the baby dies shortly after.

16:50: I am yelling at the uncontrolled type 1 diabetic admitted yesterday, who had left the hospital at lunchtime without telling anybody, unhooked the IV bag from the machine and went home to ‘eat cariboo’ while holding his IV bag. In fact, he is a known drug dealer and smells strongly of pot. I make a deal for him to stay in hospital to control his sugars better, and he agrees to stay. But when the nurse comes back to try to put the IV back in, he goes into a crying fit and leaves against medical advice. His blood sugars are off the chart. There isn’t much I can do, just hope that he won’t come back in diabetic ketoacidosis... at least not during my call...

17:00: The possible appendicitis and the broken leg had both arrived and were waiting. The ambulance made it on the gravel road, I guess... The little girl does have peritoneal signs, and has a white count. Her ultrasound is nondiagnostic. I decide to transfer her down South, where she is accepted by the surgeon. I call Challenger, the medical evacuation plane with doctors and nurses on board, to organize the evacuation by plane. The man with the broken leg is a 70 year old visiting from the South with a cardiac history and a AAA repair who has decided to enjoy life... and to go up North to fish arctic char. Unfortunately he didn’t catch any, and instead slipped on rocks in the middle of nowhere near a lake in George River. Inuit guides made a slab with planks, and carried his 250 pounds back on foot onto the lake where he got on the amphibious plane. He has a nice tib-fib fracture in several fragments, non displaced. With the help of the first year medical student, I place a posterior slab and call the orthopedic surgeon in the South as the patient wants to be cared for at home. He is accepted. Challenger agrees to take him down South. R. suggests trying to send the miner with the chest pain down, as he has had a bad experience with an unstable angina going sour up North. I call the cardiology people again, who accept him. He is accepted by Challenger as well. Estimated time of Challenger landing onto the tarmac in Kuujjuaq: 20:55.

The pregnant lady is at 6 cm and fetal heart is good.

19:30: R. finishes his notes, admissions and orders for the preterm delivery and asks me if it’s okay that he goes home to walk his dog and have some supper. No problem, I say. She’s at 7.5 cm and we’ve just moved her into the delivery room that was cleaned from the previous delivery.

19:40: As R. steps out of the hospital, the husband of the pregnant lady pops his head out of the delivery room room and says that she feels like pushing. I leave my notes on the counter, glove up and we set up the delivery bed. There seems to be ways to go, but her contractions are good. I tell the nurse to leave a message at R.’s home so he can come back and be around, just in case. But she pushes twice... and the baby is out! It’s a boy, 2740 g, a lot of vernix but looks otherwise fine. R. runs in, short of breath, but all is well, I didn’t need any help. No tear, well baby, no bleeding. I sweat drops of relief.

During the delivery, the cardiology people call back, saying that they have no beds, and could we please keep the patient up here in Kuujjuaq, as he is stable? I call them back and try to argue that I don’t have anything else than thrombolysis to sort him out, but they stand firm. I feel comfortable keeping him in and transferring him in a few days.

20:00: R., who is just about to leave, picks up the ringing phone while I am talking to Cardiology. It’s not a good call: there has been an unwitnessed 4-wheeler accident in Aupaluk: a 4 year old girl fell off the back seat without the teenager driver noticing, and was found on the ground unconscious for several minutes. She is now complaining of a headache and is vomiting. Being the best sport in the world, R. says ‘I guess I’m going to pick her up’ and starts calling Air Inuit to organize the plane evacuation. He also talks to the hospital in the South to get her accepted as well, which she is. At the same time, I am calling Challenger to let them know that there is another patient to be evacuated. They tell me that if that’s the case, then the fracture will have to wait for transfer because there isn’t enough room and there is a patient to be picked up in Puvurnituq before going down South. I announce it to the man with the fracture. R., who doesn’t even have his knacksack as he ran from home for the delivery, leaves the second time today to the airport for a med-evac.

20:30: Cardiology calls back and says that there might be some medical-legal implications. They will take the patient but evaluate him in the emergency room. They ask me to call the emergency room to warn that the patient will be there. I do; the emergency staff is asking for a transfer later the next day but I explain to her that Challenger has been called and that the time of arrival is fixed; however, it won’t be till the little hours in the morning. It seems fine.

20:40: Cardiology calls back and says that it’s been a crisis between CCU and the emergency room in the Southl. The staff in the emergency called the cardiology staff to block the transfer because they were too full. Fine, the man is stable, his qualitative troponins are negative, and he is chest-pain free. I call Challenger and announce one less patient, which means that the fracture can leave. Challenger will land here, pick up our patients that are already in Kuujjuaq, then pick up the other patient in Puvurnituq, then come back here to pick up the patient from Aupaluk from the plane when it lands.

The ambulance driver is already driving the broken leg to the tarmac to meet up with Challenger, before we send the little girl with the tender belly.

20:50: Challenger calls back, saying that finally, they’ll land here, tank up, leave for Puvurnituq with no patients, pick up the patient there, and then come back and pick up everybody at 23:30. We radio in our ambulance driver, who is upset, because he had to lift the heavy unsuccessful arctic char fisher alone.

21:00: Everybody is stable. My tachycardia is settling down, I had Ensure for supper, but it’s been a very good day of medicine. I can finally sit down and write the notes for the day.

23:30: On the tarmac at the Kuujjuaq airport. We are on time, meeting with Challenger, we are transporting the fracture and the little girl with the possible appendix (who isn’t so tender anymore?!?!) . We wait 10 minutes in Challenger, and R.’s second med-evac of the day lands. The girl is transported straight from plane to plane, with cervical collar and immobilization.

00:00: R., the nurse, the medical student and I are on the ambulance back to the hospital, with Challenger in the air on its way down South. It is the end of Aqpik Jam, a Inuit celebration in Kuujjuaq with concerts and traditional music, that neither R. or I had time to attend. Glass Tiger just finished their last song and there are fireworks illuminating the night sky. We are all going to bed, hoping to catch some well-deserved sleep.