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Arctic Medicine Gary Podolsky MD Much has been written in the medical literature regarding arctic and sub arctic field conditions, which mainly concerns well-equipped expeditions for scientific exploration or commercial concerns. 1 A medical practice in the Canadian North presents some unique medical challenges that differ from those encountered in other areas and may be regarded as another type of "wilderness medicine". Circumpolar medicine includes the effects of the Northern Latitudes on populations living in many countries including Russia, Finland, Norway, Greenland, Canada, and the State of Alaska among others 2 . These countries share the same environmental problems: extremely cold winters, isolation, and dark winters, but have different socio-political situations. Indigenous peoples living in the North-Amerindian groups Inuit, Sami and Mongolians differ in their ethnic backgrounds and economic status in their home countries. Servicing communities permanently inhabited in cold climates involves different strategies compared with expeditions or enterprises that are set up for a temporary duration 3 . Expeditions are usually well funded, having provisions imported for their full duration. Participants are also screened for fitness and compatibility in order to avoid foreseeable difficulties while civilian populations consist of a large group of people of varying ages and with unique medical concerns. I have found that many of the indigenous people of Manitoba's north are afflicted with the chronic diseases that affect other impoverished peoples- Diabetes, Chronic Renal failure and Tuberculosis. In accepting a position "up North" practitioners should be knowledgeable in obstetrics, general practice, emergency, pediatrics, geriatrics, tuberculosis control, and HIV medicine among other disciplines. Situations arise that necessitate evacuations to larger centers. My experience working in Churchill Manitoba highlights some of these challenges. There are even more Northern Communities with greater extremes of weather and smaller budgets but Churchill is special for many reasons. It has a local population of 600 people and is a secondary referral center for another 8000 residents of Nunavut living in smaller communities on Hudson's Bay. Both Northern Medical Problems and the logistics of dealing with Remote Medical events are part of a practice there. Churchill is situated at the delta of the Churchill River where it empties into Hudson's bay. Historically, Trading Posts were established nearby during the Fur Trade and there were issues of conflict between the English and French Colonial Powers. More recently a military base had been established but has long since been abandoned. Today the Port of Churchill is still used for trade when the ice clears from the Bay. Railways transport grain from Southern Manitoba for shipping to Eastern Canada. Tourism remains an important industry. Churchill is best known as the Polar Bear capital of the World since the town is situated along the migratory route of the bears. Sightings of bears occur dangerously close to town. Despite colourful stories, this well-known predator of man has no in townrecorded mortalities. In the last year one woman had been attacked though. As people continue to encroach on the animals territory encounters continue. My receptionist had been out late the night before and coming home noticed that one of the new "large white rocks " the town had recently erected on her lane seemed to be moving. She realized it was a polar bear and instead of quietly backing away turned around and ran. Despite the common lack of "bear sense" she got away . As a physician working in the emergency department and Town Clinic we see interesting patients. Different waves of tourists arrive at different times from all over the world. Besides observing bears other tourist activities include: bird watching (beginning in spring), botany, whale watching in July and August, and viewing the Northern Lights in winter. The Churchill population may double or triple with International visitors from all over the world in summer and especially the fall. The permanent population is made up of Caucasians of European decent, Cree and Dene people, with southerners coming for employment during the tourist seasons. Several Inuit individuals live in Churchill, working in the hospital as translators and at the transient centre. The Inuit of Canada generally live in Nunavut and in the North West Territories. Inuit is translated to mean "the people" and is the proper term for them. The word "Eskimo or "esquimeau" should not be used as this is derived from Cree word as "eaters of raw meat." Despite its widespread adoption by Europeans and current use, this term is still considered offensive by many and should be avoided. The Churchill Health Centre , with its administrative offices, hospital ward, outpatient clinic, and long term residents are all in the Town Centre Complex-a massive building that also includes other businesses. This 21-bed hospital has basic x-ray and laboratory facilities available but extensive tests must be referred out. Inpatients include Obstetrics, Newborn, Pediatrics, Medical and extended care. Specialists such as ENT, Plastics, Obstetrics and Gynecology, Orthopedics, Urology and General Surgery visit on a rotating basis. The Transient Centre or "TC" is an important step down facility where Inuit patients stay who are in Churchill for outpatient appointments or have been discharged from hospital. They are observed here without sending them prematurely back to their community. It is also houses pregnant women from the North who are transferred down to await childbirth in Churchill, while high risk births are transferred to tertiary care centres. The clinic is open daily providing care for acute and chronic conditions - especially diabetes, hypertension, and hyperlipidemia. The clinic tries to maintain the proper periodic health examinations, regular pap tests, and follow up from recent hospitalizations, but this is often a losing battle with the lack of permanent physicians. Because of this, nurse practitioners have been brought in to assist. Physicians on call provide phone support to remote communities, which are staffed by Nurse Practioners. Nursing Stations provide primary care and are equipped to deal with simple emergencies. When a patient is assessed as either needing hospitalization or urgent referral to a physician a phone call is placed to Churchill. Equipment and medication is limited so clinicians must learn how to function with less technology and must have good clinical skills and judgment. Patients may be transferred by elective scheduled flights ("scheds") or emergency flights ("medivacs") to either Churchill or Winnipeg. An on call clerk assists with the logistics of patient transfer. Important factors include: how sick is a patient and if they can wait; where are the closest planes, can the planes fly (Weather is one factor as well as pilots who have already "maxed-out" or maximized out of their allowable flying time); and whether the patient requires a physician escort. Manitoba has an intensive care team on its "Life flight" jet and a neonatal transport team. Information must be communicated as soon as possible, so that the on call physician may work smoothly with the flight nurse coordinator. This may even require leaving Churchill to accompany an evacuation but this must be done with cross coverage from the other physicians so that another remains available for local emergencies. Case History: An on call request was made about Eric, a 47year old Inuit man who presented in the middle of the night with hemiplegia and a blown left pupil very suggestive of a hemorrhagic stroke. The community was several hours away by jet, so temporizing measures were made to start mannitol and intubations with controlled ventilation. A physician accompanied him in the evacuation. It took over 5 hours before he reached an intensive care unit. Both the remoteness of the community and the availability of planes delayed evacuation. Another case involving a middle of the night evacuation ended in tragedy with two pilots crashing after previously dropping off a patient. The Head ward nurse's husband was listed as working that shift, and it was not until later that he was confirmed to be still alive. This highlights the issue that we often order unnecessary evacuations when there are sometimes real risks with evacuations Northern Medicine Problems Indigenous Health In many areas of the developed world people of Indigenous backgrounds share many of the same health and social problems and seem to occupy similar social-political niches. Obesity, hypertension and insulin resistance affect Aboriginal people because of both genetics and our modern environment and habits. Diabetes with end stage organ involvement is more common amongst the Cree and Dene of Churchill. Tuberculosis is present in the North as well as Hepatitis A and B. Cigarettes, alcohol and drugs easily find their way up north and are directly attributable to some of the mortality. Inuit families may be large, yet the vast majority of deliveries are low risk. Osteoporosis at extreme latitude may be due to diet and decreased light exposure. Seasonal affective disorder may be noted in both natives and migrants to the North. In the summertime "Midnight sun", normal sleep can be disrupted (especially for doctors on call). People have adapted their windows with tinfoil, which conforms nicely to windows and blocks out the midnight sun. One area of concern in the North is the incidence of dental caries in aboriginal children. Milk is much more expensive than cola and this plays a contributing role. Loss of traditional foods, the welfare diet and Western junk food "addictions" are a cause of diabetes. On reviewing the local grocery store Milk was noticeably more expensive than cola. Hypothermia and Thermal injury Although common things do occur, occasionally there are unique Northern conditions that are of interest. Frostbite and Hypothermia are considerably less common than one would expect. This is due to the strong awareness of winter hazards that the Northern peoples have and due to their thorough preparation for the dangers of winter climates. All Terrain Vehicles (ATVs) Injuries are common in the North The more archaic 3-wheeled "Trikes" which use a 3-wheel support are very unstable as opposed to the 4-wheeled "quads" and notorious for accidents. A mortality occurred this year when I was in town. A young girl was injured in an accident after just previously asking her Aunt if she could wear a helmet, but was denied this. This eight year old suffered massive brain swelling and died shortly afterwards. Her last words were that she had wanted to wear a helmet. Seal Finger (aka Sealer's finger, blubber finger, and speck-finger) Seal finger is an infection of an extremity after handling marine animals (usually seal or polar bear) and begins after 3-4 days. It presents like cellulitis and lymphangiitis and may lead to a thickened and contracted joint. Causative organisms are unknown but it may be caused by a mycoplasma. This condition is resistant to many antibiotics but is very responsive to doxycycline, which is used to treat suspicion of seal finger. Rabies- Rabies is present in the wolf and fox population nearby. Many townsfolk tie up dogs outside. There is no local veterinarian but one visits annually, so not all dogs have rabies immunization. Rabid wolves are much more aggressive and often preferentially attack and kill husky dogs. The Churchill Public Health dept. does stock the rabies vaccine and immunoglobulin to treat human bites. Recently a polar bear mauling was followed for a suspected rabies case (which turned out to be negative). The Churchill Cafeteria staff had also started to feed a local arctic fox that began to hang around the hospital. Unfortunately this represented a potential source of rabies and staff had to be reminded to stop feeding the wildlife . Arctic Trichinosis- Trichinosis is acquired through the ingestion of undercooked wild game meat. Arctic trichinosis has been described in bears (polar, black, and brown), walrus and bearded seals. The Inuit prefer raw wild meat and occasionally small clusters of Trichonella occur. A young Inuit man tried some raw walrus for the first time. Days later he developed severe diarrhea and muscular pain. He was so dehydrated with cholera like facies that the receiving doctor compared his appearance with that of an end stage AIDS patient. He responded well to IV hydration, and corticosteroids for his muscle pains as well as to antihelmetic treatment. Concurrent to his admission at least 3 other confirmed cases were attributed to the same index walrus. Similar cases have been noted in Alaska. Northern Bugs - Black flies and mosquitoes are very dense in summer and are a nuisance. Luckily Churchill is windy most of the time, which decreases exposure. Black fly or horsefly bites may be painful but do not carry pathogens like onchocercosis that are carried by tropical black flies. It is unknown whether the local mosquitoes carry West Nile disease, as this is not as extensively studied as in the South. The virus does not winter. However, migrant birds congregate here so it appears plausible that this may occur here, but risk is definitively much lower than in southern North America. Global warming is feared to spread the spread of infectious diseases such as West Nile disease. Scuba Diving
Occasionally divers have planned trips to dive with the whales. Other than polar bears there are no other predators to concern divers. There has been no documented dysbarism in scuba divers in recent memory in Churchill (there is one rumor of a case in the 70s) but divers are advised to know that physicians in Churchill have no experience in hyperbaric medicine and the nearest chamber is many hours away by plane.
References
1 .A study of the Incidence of Accidents during an Artic Expedition Another important aspect for travel medicine? Fiona J Cooke; Carolina Sabin; Jane N Zuckerman Journal of Travel medicine. Jul/Aug 2000 p205-207.
2.The Circumpolar medical Society. This organization looks at Aboriginal health and Circumpolar Health. It is part of the International Union for Circumpolar Health, which includes member organizations in America, Danish/Greenland, Nordic Society, and the Siberian Branch of the Russian Academy of Medical Sciences. In addition to their published Journal sent to members, they host a meeting in one of the Union countries every 3 years. www.csch.ca .11 th International Congress on Circumpolar Health June 4-9 2000 Harstad, Norway www.detinationharstad.no/icch/index/html
3.Telemedicine: Have Technological Advances Improved Health Care to Remote Antarctic Populations? Desmond J Lugg Circumpolar Health 1996 p682-685. Travel to Churchill The website Churchill Independent Travel gives a complete list of options for those wishing to plan their own trip www.creighton.edu/~hutchens/church_travel.html
Study in Churchill-Arctic Medicine Conference A medical conference with talks in Zoonoses, Dentistry, Entomology, and Travel Medicine hosted by Wilderness Medicine in Manitoba. The next event will be scheduled in October 2005. www.skylarkmedicalclinic.com
Work in Churchill The JA Hildes Northern Medical Unit (NMU) is responsible for providing qualified physicians and Nurse Practioners to staff Northern Manitoba. For those interested please contact Michelle Vandenbroeck at 1-204--789-3711 for information in working in Churchill or other parts of the Hudson Bay Inuit communities. www.umanitoba.ca/faculties/medicine/units/northerm_medical_unit
100 things to do before you die: Travel events you just can't miss. Dave Freeman
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