There are lots of things that as a provider you have to think about here that aren’t a part of routine medical training. For example, the majority of the medical population that we serve lives in rural villages, most accessible only by flight. We see a lot of villagers who needed close follow up, but don’t necessarily need to stay here. So we have to figure out if they are safe to return to their village with less available medical care, or if they should stay. It’s a matter of figuring out how they can follow up in their village—whether it will be with a health aid or a PA or the radio. On a daily basis, I have to make sure patients have the proper prescriptions and ability to titrate their medication as needed (without having to fly back out here!), and to know what and how they would get follow up labs/diagnostic studies as well. Sometimes it entails filling out travel forms and other forms/means of communication to detail a longer-term plan, more phone calls to the villages, more faxes. Also, for anyone who I want to see a specialist, we have to figure out when one is coming to Nome, and if there are any appointment openings, or if they need to go to Anchorage. It’s sometimes hard to make a decision, because we can’t predict how things will go. If they are on the border, maybe they will they get better with time, or maybe they will get worse. Providers are often practicing on a thin edge and things can fall to one side or the other very easily. We have to make the best medical decision to provide appropriate, cost-effective care.
The good thing is that I can call or video conference the docs in Anchorage and run a case by them at any time—or I can talk with a colleague here about best practice. And everyone here is so helpful and so willing to answer questions, discuss cases. I never feel like I am bothering or interfering with somebody’s time. I love that the most—the collegial, work-together, understanding, kind spirit here.
It’s present both in the medical community and the whole community. People help each other out, invite each other for dinner or tea, or offer to help take care of whatever needs arise. Someone told me that of course Nome isn’t without it’s issues and politics, but when someone is need, people “forget” whatever misgivings or issues they may have between them, and drop everything to help a neighbor, a brother or sister, or a friend out.
I think there is something about living in a harsh place, a raw place–where instead of having everything and being able to be completely independent, people really need each other in order to survive—that brings people together in such a close, real way. There is also something freeing about a small community—you can come “as you are”, you can just be yourself. You don’t have to pretend you are something you’re not, or conform to a certain social expectations. And people are generously accepting, friendly and embracing. You also have to figure things out, you have to resolve issues, and you have to communicate (more so than in a big city where you can escape from too much closeness or uncomfortableness). It’s refreshing and hard and good. It keeps people accountable in many ways, as well. It’s really raw, because sometimes people live in close proximity with people who really hurt them. It takes a lot to know how to deal with that. And you can’t hide much here, because everybody sees what’s going on. Everybody knows who left town, who went where, who was in what store, who said what. When I have a difficult conversation with a patient (or anyone, anywhere), I know I will see them again. It’s so, so vitally important to be honest and open, and professional, and in all this, it’s paramount to be kind. I love this poem on kindness–especially the end!
by Naomi Shihab Nye
Before you know what kindness really is
you must lose things,
feel the future dissolve in a moment
like salt in a weakened broth.
What you held in your hand,
what you counted and carefully saved,
all this must go so you know
how desolate the landscape can be
between the regions of kindness.
How you ride and ride
thinking the bus will never stop,
the passengers eating maize and chicken
will stare out the window forever.
Before you learn the tender gravity of kindness,
you must travel where the Indian in a white poncho
lies dead by the side of the road.
You must see how this could be you,
how he too was someone
who journeyed through the night with plans
and the simple breath that kept him alive.
Before you know kindness as the deepest thing inside,
you must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you see the size of the cloth.
Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.