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A Vulnerable Place

A remote Alaskan village. An elderly woman with Alzheimer's disease. The son who cares for her. These are the key elements in an experience that a DMS student had during one of her clerkships. The encounter took place over a decade ago, in a singular setting, but its essentials are timeless and universal.

By Emily R. Transue, M.D.

The sky is clear and the sun is shining brightly over the small Eskimo village of Kururak. Such a day is rare, the villagers say; there are only about a dozen a year. We have brought the good weather, they tell us—the doctor, the local health aide, and me, a medical student. Indeed, it has been fair and warm ever since we flew into town this morning.

But now a cold breeze begins to blow in across the river, and a chilling mist rises from the sunwarmed grasses. I tighten my scarf around my neck as we walk quickly in single file along the narrow wooden boardwalk that runs through the village. We pass the church, the store, the large and modern- looking high school. I look up at the low, rolling tundra plain, at the hills that rise slowly but majestically to the north and south of the village. The pipe that brings drinking water down from the hills glitters softly in the sunlight. The river plain stretches to the east. The ocean lies behind us.

It is late August; summer is barely waning, but already this seems a chill and vulnerable place. I cannot begin to imagine what it must be like in February—when the tundra is covered in snow and ice and the bitter wind is blowing unhindered across the frozen waters of the Bering Sea. I shiver at the thought and draw my parka closer. Who would think, I can't help but wonder, to build a village in such a place, along a narrow, entirely unprotected spit of land between the flooding river and the Bering Sea?

We walk in silence. We are on our way to pay a home visit to the only bedridden patient in the village. She is an old woman and has not left her bed in years; she has Alzheimer's. Two sons care for her. Her husband was recently hospitalized in Anchorage with a bad infection in his leg. The doctors think he may walk again, but they doubt he'll ever be well enough to return to the village.

We approach the house—a small wooden structure perched on stilts, like all the buildings here, to protect them both from floods and from the constant freezing and thawing of the tundra. I continue to be amazed at how haphazard and insubstantial all the houses look from the outside. But appearances are deceiving. The patched plywood walls are lined with several feet of insulation and are sealed tight against the bitter winds.

The Alaskan village in this photo illustration and the people pictured on the succeeding pages are not those in the story related here—but are typical of the 49th state.

We walk up the steps and knock on a weather-beaten door. "She has a vicious little dog," whispers the health aide, who does not like dogs. The door opens, and a blast of heat engulfs us. My glasses steam up as I step across the threshold. The fog slowly clears and I see the others kneeling to take off their boots, and the old woman's son standing in front of me.

"Shut the door," he says. I realize I have been unconsciously holding it slightly ajar, clinging to the last wisps of clean, cool sea air. The house is oppressively hot and smells faintly of urine. Quickly and guiltily, I pull the door closed behind me.

The "vicious" dog is at my feet, clipped to a chain in the low entryway. She barks once or twice, then wags her tail hopefully; I kneel to pet her. She looks like a puppy at first glance, but as she clambers into my lap I realize that her feet are small. She's an old dog, though with puppyish proportions. Beside her on the floor is an old, rusty birdcage, empty, its door hanging open.

Without preamble, the son leads us into his mother's room. The bed, which fills most of the room, is huge—queen-size, I guess at a glance. It's piled high with blankets, towels, pillows, boxes of Pampers, and

folded piles of extra sheets. It takes me a second to even see the patient amidst all the piles—a small, curled form nestled in the middle of them. She lies on her side, quiet and still. Her head is resting on a pillow, her eyes are closed.

She has a classic old Eskimo face, carved with wrinkles, thick with character. The Native Alaskans in this part of the state are Yupiks; although some other tribes now consider the term "Eskimo" to be offensive, I've learned that it's how the Yupiks still identify themselves. I have been taking pictures of villagers as I travel around, elders and children mostly. I long to take one now but know that I can't ask.

On the bed at the old woman's shoulder is a small pile of dark, almost round objects that at first glance appears to be a heap of rabbit droppings. I look more closely and realize that it is a rosary made of small, dark wooden beads.

"She's awake," says her son. "She just doesn't open her eyes—she hardly ever does anymore." I wonder whether it is the honed instincts of a longterm caretaker, someone who knows her every expression, every posture, that tell him she is awake when I am able to detect no outward sign; or whether it is wishful thinking, some deep need to believe that she is still capable of waking.

Transue, a 1996 graduate of Dartmouth Medical School, is now an internist in Seattle, Wash. The incident she relates here took place when she was a third-year DMS student, during her family medicine clerkship in Bethel, Alaska. It is a true story, though identifying details have been changed to protect patient confidentiality. Transue began writing patient narratives while she was a student as a way to process the emotions of practicing medicine. Many have appeared in Dartmouth Medicine, and a collection of her pieces was published by St. Martin's Press in 2004 as a book—On Call: A Doctor's Days and Nights in Residency. She has been invited to speak about her writing at the annual meeting of the Association of American Medical Colleges in October.

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