back
am back.... still slightly jet lagged as i couldn't fall asleep on the plane - apart from my left arm. its good to be back in edinburgh though.

leaving (at last)
"every time we gets a good doctor, they leaves us," complained the nurse. it was my last day at the hospital, but the comment was not about me (i wish!). Word has gotten round that Dr. Y, the reliable internist, is applying for a job at the Big Teaching Hospital. With the exception of a handful of (often eccentric) old-timers, and a few who are married to locals, nearly all the doctors are trying to leave here the moment they arrive. Unsurprisingly, the better ones more often succeed. This week I also met Dr. D, a native of St. Anthony. He is a brilliant doctor - friendly, thorough, and knowledgeable. And because he is from here, is really able to connect with the patients. But they won't have him for long - he aims to set up a practice in Ontario.

Why do they all want to leave? Each must have his own reasons, but here are mine: Despite the amazing landscape and agreeable people, life in a town of 3000 is just dull. It takes about half a day to exhaust all the interesting sights, there is no cinema or theatre, and the miniscule public library is open on 3 afternoons a week - if you're lucky. Skiing and skating are fun for a while, but quickly become repetitive. And all this is assuming you aren't snowed in. Then there is the fact that everyone knows and/or is related to everyone else. Growing up as I have, I am used to being a bit of an outsider, and have come to enjoy the objectivity that this lends to my perception of people around me. But not to this extreme. Yes, I am glad to be going!

shrimp sorter's elbow
Bought a print copy of the Northern Pen yesterday. Reading it was a pretty surreal experience as every other page had mention of someone I had either seen as a patient or worked with at the hospital. In addition, it carried the obituary of the woman whose autopsy I helped with two saturdays ago (see Mar 06). But then I suppose to the regular Northern Pen reader it would be strange to open a newspaper and not know everyone featured in it.

The sealing season is nearly upon Newfoundland, and it will be followed soon after by the start of fishing. And then the shrimp and and crab plants will come to life again. Recent clinics have been full of working-aged people trying to get their aches and pains sorted out before the madness begins. Because of the quotas of seal and fish imposed, once the season opens, each fisherman basically tries to catch as much as he can as quickly as he can. This results in repetitive strain injuries of all sorts. Carpal tunnel syndrome is common among the fishermen, and tennis elbow among workers at the shrimp plant. it just seems such a misnomer as nobody plays tennis here - much bigger is broomball. but thats another story...

was walking back to my room from the hospital on wednesday evening when i noticed the northern lights dancing over the harbour. The ghostly green cascade grew until it seemed to span the entire sky, and then, minutes later, vanished as mysteriously as it had appeared.

"born to fish, forced to work"
read the decorative sign on the noticeboard at St. Lewis airport. The airport is actually little more than a storehouse divided into two - the larger part for the snowploughing equipment, and the smaller a concrete-floored room containing 5 chairs, a small, wooden Air Labrador counter and a weighing scale. "Just put your bag on here," said the red-haired, middle-aged lady. The airport is a one-woman operation. She takes your ticket, weighs and tags the bags, and you carry them out to the propeller plane yourself.

I wish I could have stayed longer in St. Lewis. It is a tiny town of about 250, and everyone works for the local crab-processing plant - or at least, they have since the cod fishery closed. I accompanied the nurse on her walk home. we were passed by several snowmobiles, Dodge trucks, uncollared dogs and unattended children. The kids just come up and talk to you. A boy of about 10 ran past me and up a 9-foot high snow bank. "Wha's your name?" he said. "My granny tol' me there was a new nurse in town." I explained that I was learning to be a doctor. "Wha?" he said, not quite hearing me from under his woolly hat. "Wha" seems to be a characteristic Newfoundland expression. It doesn't seem to be considered rude. The other phrase I've heard a lot of is "Goh aaaahn" (go on), which is an expression of disbelief, for example when i told Noel that i once scraped up an entire carpark to build a snowman.

Noel is a 30-ish man who keeps a team of racing Huskies. He is well known to the nurses because he has to go by the clinic to get to his dogs. He is large and noticeably sunburned. He took me on his snowmobile to see the dogs, which are very friendly, but so powerful that they can give you a bruise trying to lick your face. The sled is made of wooden planks, and the harnesses are simple - a soft collarpiece and straps for the forelegs, attached to a rope. The ropes are different lengths so that the dogs are one behind another as they run. To change the leader of the pack, one simply reels the lead dog in by shortening the rope. It was a bumpy ride (though i suppose as smooth as it gets on a wooden sled), with the panting dogs bounding over the snow, pairs of pointed ears bobbing up and down. They strained a bit on the uphills, and one dog, Wild, kept turning round, as if to say "is everything alright back there?" I liked him best. I've still got lots of husky fur on my mitts.

Sisters
Lucy and Susie (not their real names) sat dumpily and motionlessly side by side. The ptosis and facial muscle wekness characteristic of myotonia made them look even more alike. "Oh, you both look so fresh today!" gushed Dr. S, their family doctor. "I see you've lost weight; that's very good." I glanced back at the sisters. The paucity of facial expression gave them a markedly dull appearance, and their chubby arms rested on folds of flesh rising from generous waistbands. However, speaking to them one realises that each has a sweet, child-like disposition.

It turns out that Susie and Lucy (both in their late 20s) are 'orphans'. Their mother, who was also myotonic and mentally disabled, died unexpectedly in her sleep. Their father died of cancer a few months after. Now in the care of health and social services, the sisters were here for a check-up after receiving contraceptive injections. One wonders if they are really able to agree to birth control - but I suppose the alternative would be an enlarging tribe of increasingly severe myotonics.

Nausea
i was just about to write a 'help me i'm dying of boredom' blog entry when my beeper abruptedly crackled to life. "call 149.... call 149...." it was Dr. K, the pathologist, asking if I wanted to help with an autopsy. 4 hours ago my impression of autopsy had been gleaned almost entirely from watching Scully slice rubbery aliens open on the X-files. that, and some pathology videos in second year, where someone sawed through a cirrhotic liver to Bach's Brandenberg concerto no. 3.

The morgue was small, with bright sunlight streaming in from the high windows. A small, plump woman lay freshly dead and naked on the table. My job was to record the autopsy findings, beginning with the clothing she'd had on, and progressing in layers, literally to her very heart.
-blanket, grey (*all names and identifying details have been changed)
-nightie, pink and white
-height 150cm, build average
..... and so on
-brain 1240g
-lung, right 460g ....
-aortic valve 8cm
-no evidence of thrombus/emboli in coronary arteries
Dr. K quizzed me on the possible causes of sudden death (the lady had 'dropped dead' this morning) as we went. it was all quite fascinating, but i had to contend with a rising nausea from the moment he made the first incision. perhaps it was the smell, perhaps the sight, or the thought that she'd been alive just hours before. certainly when he sawed the skull open, the grating sound of metal on slippery bone made my sickness all the more oppressive.

after the autopsy i returned to outpatients. one of the nurses asked the name of the dead woman. "oh... Shelly...somebody," i said. "It seems she just dropped dead this morning." "Oh, she was my aunt," said the nurse, nonchalantly. Despite the fact, as last night's Canada Now put it, that "Newfoundland has a recent history of large, closely related families", i hadn't really expected her to say that. I was glad I hadn't mentioned how ill i was still feeling from watching it.

Location, location, location
GRHS looks much like a general hospital anywhere in the western world. its architecture is modern but otherwise unremarkable, the furniture is aging slightly, and the linoleum is clean but yellowing. It has a CT scanner and all the works, and patients mostly enjoy first-world standards of care. The first sign that things are slightly different is the fact that there is no radiologist. But that's ok as radiographs can be read online from St. John's. And then two patients with seemingly 'minor' problems came in on Friday:

The first was a middle-aged lady who'd had a previous retinal detachment in her right eye. She now had similar symptoms in her left. She described a bright arc 'like a windscreen wiper' sweeping clockwise over her field of vision every few minutes, along with floaters in her left eye. the eye was painless, and she was otherwise fine. now the problem was that the opthalmologist had left several months ago, and there was nobody to replace him. a snowstorm was raging outside, and this woman's retina might (or might not) be peeling right off the back of her eye. if the macula (the small patch with the most cones and rods on) came off, she'd be effectively blind in that eye. the nearest opthalmologist was 500 miles away, and no planes were flying.

The second was a man with raging sinusitis. the gruff, bearded fisherman writhed and wimpered in his chair, watched helplessly by his ample wife. he'd had it for over a week, and a skull x-ray showed a white-out in his maxillary sinus to match that going on outside the window. antibiotics and various anti-inflammatories had been tried with no success. He'd subsisted on indomethacin suppositories for the last couple of days, and the doctor reluctantly prescribed him some morphine. but it was clear he was going to need his sinus drained... i am guessing in the absence of an ENT service the general surgeon eventually did it...

so you can't get around it. even with all the wonders of modern medicine, there's just no fighting chance against the geography.