Indian Health Services: Navajo Nation – Mara Determan, MD

Written by Mara Determan, MD (2nd year resident at  Kaiser Oakland Pediatrics Residency Program on a rotation with Indian Health Services – Navajo Nation)

 

January 12, 2014

Arrived in New Mexico yesterday afternoon, made a quick pit stop at Target, and then headed into the beautiful wilderness of the Southwest US. The views were unbelievable. Alien is too unkind of a word. Maybe another world would be a better description. The whole stretch between Albuquerque and Fort Defiance has the distinct feel that it all used to be underwater. The colors are more Martian than Midwestern. I imagine that if in the future Mars were terra-formed, this would not be such a dissimilar place.

One of my lovely roommates who is a PT student, here for her clinical rotation, took me around the hospital today. It is very new, likely less than 10 years old. From her description, it sounds like a busy place during the week, but on a Sunday afternoon, it was calm.

I have already gotten lots of reading done here. Already completed a good number of chapters from Berkowitz’s Pediatrics and Sapiro’s.

The scenery is beautiful, and the sun seems extra bright here. No bay area fog and gloom in the morning. The air is so crisp and clean seeming.

I am excited to meet my fellow pediatrics group. I am also excited to plan some hiking and day trips. There are plenty of attractions nearby, but after my day of travel yesterday and adjusting to the elevation of over 7000, as reported by the car rental gentleman, I was more than just a little wiped out. I haven’t had cell service at a time that I remembered that I wanted to look that up.

I am working on being able to say the name of the hospital. Spelled Tsehootsooi. I am trying, but I think I need to hear it a few more times. I should have paid more attention to Boris when he tried to teach me the International Phonetic Alphabet.

January 13, 2014

First day of work: orientation. I learned a little about Navajo Culture from a cultural liaison. He even brought us ‘puberty bread’! Which is the bread that is made during the ceremony, 4 days!, that symbolizes the transition of a child to a young adult. It tasted like smoke and corn.

Navajo is incredibly difficult for me to get my brain to remember it and my mouth to form it. Still working on the hospital name. I think I am getting closer. I learned that it means the something along the lines of ‘the rock and the meadow’. Apparently the meadow east of the hospital is beautiful in the spring and summer, but the rocks are impressive all year round. Beautiful red rock jutting out in stark contrast to the sandy surrounding plains.

Learned some about the some of the unique features of the hospital (including the non standard rotational doors) and about the symbolic meanings of the cardinal directions: east, life/birth/infancy/purity/thinking/white; south, toddler/planning/blue, west, yellow/puberty/adulthood; north, black/ill spirits.

Saw my first patient in the late afternoon. Very diverse patients in clinic, everything from oncology patients to rheumatology patients to colds and coughs and minor skin complaints.

I examined a patient toe to head today (Navajo culture refers to things from the ground up frequently, no head to toe here.)

Potluck tomorrow. The doctors here have been very warm and friendly. I can’t wait to spend more time in clinic.

The elevation and cold are still working me over a bit, after 7 o’clock bed is all I can think of.

January 14, 2014

Finally finished up my orientation today, and got to go to clinic all afternoon. Had a funny moment today during the CEO’s (yes the CEO spoke to the 8 new employees for about 1 hour–very nice man) talk about his motivation to make the Tsehoosooi Medical Center the best hospital in the country. He then said when people talked about great healthcare in this country to have TMC’s name up there with Kaiser Permanente!!

Seeing patients with Dr. Peterson: Good mix of not too sick kids to get my feet wet today. Hopefully tomorrow I will get a little more oriented to the clinic to figure out the work flow and get to know everyone’s name.

We had a nice potluck at Dr. Peterson house tonight. Great group of people to chat with. Very interesting to hear about everyone’s story of how they arrived at TMC.

Dr Reddy’s: many years a neonatologist, then private pediatrician, then retired and traveled the world then missed it so much that he started working again and then took a permanent position at TMC.

The family medicine and internal medicine couple: young couple right out of residency both took permanent positions less than 1 year ago, and the wife is already the interim chief of internal medicine.

Then on the way home I was able to see a nearly full moon with a ‘moon dog’ around it. I tried to take a picture to capture the beautiful ‘rainbow’ of colors around the crisp moon, but my poor phone wasn’t able to even reproduce bad copy.

January 16, 2014

Went to Hogan Hozoni (spelling?) which is a care facility that assists children while they are the foster care setting. The facility is run in part by young Mennonite women. I helped my preceptor do an intake physical on the children.

Then Dr. Peterson took me on a side trip back to TMC and showed me a beautiful canyon. I took so many pictures! I hope some of them capture even a little of the wonder. I am sad I won’t be here in the spring and summer when the rains come and add some green to the landscape.

I had my first normal day of clinic today where I could do all the computer stuff that I needed to do. Little slow going as I adjusted to a completely different EMR, but I am excited for tomorrow, but I miss my dot phrases!!

I am loving my clinic experience. I am really trying to imagine myself as an attending to move myself forward in my training to feel that full burden of patient care to come up with the complete plan, follow up, and what if’s, while still living in that lovely resident bubble of not being the end of the line. So much to read and learn still, but I am reading, reading, reading, and trying to take it back to my patients. Working on those mental templates to guide myself while interviewing my patients and presenting them.

As a medical student you can be detailed at nauseum, but as a more mid level resident it is really learning how to focus your history and exam without missing the big picture or the scary picture and being very comfortable with the management of common diagnoses once you have made them.

Dr. Malhotra from back home recommended I read Sapira’s Art and Science of Bedside Diagnosis. The first part of the book has dealt extensively on effective interview techniques. Currently I am working on is avoiding the double question, eg, how many times did he throw up AND what color was it AND was there any pattern to his vomiting AND was anyone else sick at home….That is a bit of stretch but probably closer to reality than I would like to admit. Another one is talking less!! I want to gently (but firmly) guide my patient or family to tell me the story, not interrogate them! I have found the my pediatric patients here tend to be fairly quiet in the clinic room, even with direct questioning. So I am working on getting comfortable with the pause. Eventually the patient starts talking, and it is often so helpful for them to tell me the story in their own order and words. I have even used the technique of just moving my fingers in a ‘go on’ way, and had great success.

January 18, 2014

This morning I woke up and had internet on my phone for a brief moment, so I searched for nearby things to do (which I should have done before I got out here!) and found the Petrified Forest, so I headed out.

The forest was an amazing park that included some of the southwest Badlands, the Painted Desert, ancient Native American villages and structures. The weather was mercifully mild, and I was able to do all but one of the hikes before it started to get chilly as the sun was setting. Some of my favorite parts were the petroglyphs. One petroglyph, used to demarcate the summer solstice, was particularly impressive. I am still working out my thought experiment of how I would do this, but I might cave and look it up on Wikipedia soon.

The petrified wood was surprisingly colorful, almost like a petrified rainbow. The absolute vastness of the landscape is starting to settle in my mind. Today at one of the look out points, an sign pointed in a direction and said, if you see this mountain, you can see 120 miles away. I could see it. It was the San Francisco Peaks, which are just north of Flagstaff, AZ and considered sacred by the Navajo tribe, in their language called Dook’o’oosłííd. It represents the West and is associated with the color yellow, and if I remember correctly, is also associated with adulthood.

At the end of the day I got a phone call from a very good friend, who had sad news about her father-in-law. He was recently diagnosed with multiple myeloma. She wanted my thoughts on few of the medical and hospital aspects of things. Because multiple myeloma is a very rare disease in pediatrics, the last time I had heard much about it was in medical school. When I looked things up, I was so shocked to see how much things had changed in just 3 years. The speed of medical advancements is amazing, and a bit nerve racking. I feel sometimes like I could read all day and still be behind the times.

At the end of the day instead of heading home, I decided to just go on to the Grand Canyon because I have a three day weekend to recover from the trip.

January 19, 2014

It turns out the Grand Canyon is so big it blew a few circuits in my brain. I would look at a small region and think to myself, “Wow this is the biggest thing I can imagine.” Then I would look a little in any direction, AND IT GOT BIGGER!

On my way home I stopped at the Meteor Crater, AZ. Which was apparently the first meteor crater to be definitively proven to be of extraterrestrial origin. It was impressive, but I think my ‘impressed scale’ was slightly mis-calibrated since I had seen the Grand Canyon only a few hours before, so on any other day it would have been downright breathtaking.

January 20, 2014

My lovely roommate took me to Gallup, NM today (Adventure Capital of NM as the radio informs me) to get internet to work on projects.

The coffee shop seems to be the hub of lots of activity for the older adolescents of the area. There are beautiful pictures of filming of a movie called “Monster Slayer” which is a modern retelling of a Navajo Legend, but I haven’t quite found a super reliable source for the story yet. But this is the best I could do in a quick search. Oh, maybe this is a better one. I plan on going to the Quality Inn soon because Dr. Peterson told me there is a great little bookstore there with several good books on Navajo history.

I purchased a lot of books on my tablet, so I can have lots to read at home as well. I started The Emperor of All Maladies: a Biography of Cancer; it is a fascinating read so far, and I suppose this is about the best time possible to read it as I start my Oncology & Hematology rotation after this.

The history of pediatric Acute Lymphoblastic Leukemia was shocking. I hadn’t really appreciated before how closely the successful treatments of ALL were to the time when we first understood the structure of DNA, quite how many of the agents we use to treat ALL were quite serendipitous discoveries, and the pivotal role of groups like what ACOG is now was to the advancement of therapy for this rare disease.

January 21, 2014

Spent the day on the ward and in the nursery today. A few big differences from back home, because the pediatric population isn’t large in the inpatient service the floor is mixed with all ages and all services–medicine, surgery, pediatrics–are on the same floor. There is no NICU so most babies besides hyperbilirubinemia and dehydration, need to go to UNM or UA, which are both hours and hours away. Even TMC can be a huge distance from the home of the patient give the size of the catchment area.

I am starting to appreciate how different the practice of medicine is here. For example, at home, you can send a phototherapy blanket home with a family and have them come back to the lab the next day. Here a significant number of families don’t have electricity so that wouldn’t even be an option. Additionally, if you sent them home and asked them to come back the next day, that might be a >100 mile round trip with a newborn and mom who just gave birth.

Interestingly, there is a lot more serious Strep pneumo infections here than I am used to. Dr. Peterson tells me that is one of the reasons Johns Hopkins is here doing their vaccine research. Will have to follow up with their research doc.

January 22, 2014

I spent the day with the PT folks. My roommate is a PT doctoral student doing a clinical here at TMC and today she and her preceptor put on a whole day seminar on advances in sports PT and several pediatric related areas. I think the one that I liked the most was about neuromuscular training to help children with chronic pain. I was very interested to see some of the techniques that the physical therapists use. I wasn’t familiar with manipulations prior to this. Then I learned about how physical therapists have different privileges based on their location.  Also interesting was hearing about many of the issues that they face at this particular hospital. They have a very wide span of practice from the NICU grad to the post concussion adolescent clinic to the geriatric stroke victim with multiple comorbidities including depression after death of a spouse.

January 23, 2014

Today was an exceptionally busy clinic day. At home we use lots of amoxicillin for Strep throat, here families really prefer the penicillin G shot. The shot has lots of advantages to it, excellent antibiotic for the organism, great and consistent blood levels of the drug, single time dosing, verification that the child has received the drug, no wait at the pharmacy, no need to worry about the proper storing and administration of amoxicillin for 7-10 days at home, but I had never used it before. I don’t know if my clinic just doesn’t have it on hand, or if families are historically not interested in an IM injection. I will have to investigate when I get home.

January 25, 2014

Helped my roommate get to Gallup today after she discovered a flaw in the side of her tire. These cold country roads are not where you want to get a flat! On the way we stopped in the Navajo Nation Capital where there is a museum on Navajo art and history. I was shocked at the recent collection of young Navajo women’s art. The pieces were hauntingly beautiful, and from local women, some younger than me, and most without formal training, but full of passion and talent! Also interesting was the exhibit on the Long Walk, which is a pivotal point in Navajo modern history about their forcible relocation and destruction of their farms and pillage of their traditional homeland in the 1860’s.

We visited the Flea Market in Gallup, which is extensive with an amazing assortment of crafts and Navajo jewelry. When we made it back home to Fort Defiance, we had a mini party for no reason at all. Several friends came over including two Army Medics here for a brief rotation. We hiked into the hills behind the hospital and star gazed. The night skies here are so clear. Most of us had never seen so many stars in our lives. We even had a good go at identifying the stars and constellations after we found and properly oriented our star map.

The Army medics leave soon. They have been a friendly duo around the hospital visiting every clinic and service they could manage. It is amazing how quickly you can care about people. I think it is magnified down here because there are fewer distractions and everyone is a bit out of their routine. As shameful as it is as just a person, much less as a pediatrician, I have been fairly distracted from current events recently, and the ongoing world conflicts haven’t felt too ‘real’ to me. In college I had many friends in the military or recently out, and deployments and repeat tours were never far from people’s mind.

January 26, 2014

Visited Canyon de Chelly (pronounced dey SHAY–an amazing corruption of a Navajo word into Spanish then to English with a bizarre pseudo-French spelling) which is sort of a manageable, mini Grand Canyon with pre Navajo indigenous people’s ruins.

Stopped by a local restaurant to have my first traditional Navajo cooking. Lots of lamb and stew, which is totally hitting the spot given how cold gets after the sun sets here.

January 27, 2014

Back to a busy clinic this morning. I had an ex 25 week infant come in. I get nervous when I have this type of baby back home during RSV season, but now here at this elevation, it makes me downright skittish! Mom was doing a great job, but baby was falling off of the weight growth curve. After talking it out, we realized that mom was having a huge difficulty getting all his feeds fortified because she can only get 2 cans of formula at a time which lasts only a few days before she has to go back to the local WIC office which is far from her home. And the cost of this special formula (baby had unfortunate GI problems in NICU) is prohibitive as well as difficult to find at regular stores. I wrote a note to the WIC office so hopefully the family will be able to get some respite from their frequent trips. Also, so happy that the clinic just hired another full time pediatrician, so now this little one can have a regular pediatrician. The lunch ladies know my name!! Starting to feel right at home here.

January 28, 2014

Went to the OR this afternoon with my patient that surgery consulted me on and was the first assist. This morning when I worked on the initial consult, it was the first time in I have really felt like a ‘specialist’ as a pediatrician. Here the general surgeon was asking my opinion on antibiotic treatment, course, and developmentally appropriate pain management for a young adolescent with post surgical complications. I loved researching the topic (thank goodness for some really great recent papers with recommendations on intra abdominal infections in adolescents) and then coming up with a comprehensive and individualized plan for my patient. Clinic was hopping in the morning with some interesting cases: pre septal cellulitis and bowel cleanouts action plans!

January 29, 2014

After clinic in the morning, I worked on a presentation I will be giving to the other pediatricians and updating myself on new influenza recommendations as the flu has finally made its way to the Navajo Nation and it brought its friends RSV and Human Metapneumovirus!

I stopped by the ward this morning to see if my consult patient was feeling any better. Poor guy was bored out of his mind, but his pain seemed to be better. Talked with the floor nurses, but they have very few art supplies or books for his age. I made a trip to nearby town to pick up some colored pencils and some playing cards for him, which went fine, but then I saw the produce section. I was a little disheartened to see vast and elaborate snack/chip/cookie aisles and displays and then when I tried to get an apple, having to pick through the pile to find an apple that is only moderately bruised. There are huge pushes in the community and at the hospital and across the Navajo Nation in general to help reduce the undue burden that DMII plays here, but I think it would be difficult to put many of those dietary recommendations into place at this store and unfortunately, stores this big and well stocked are few and far between, so many are dealing with even fewer pickings at small gas stations with a few aisles of groceries.

January 30, 2014

Hand-foot-and-mouth disease–all day. I don’t ever remember having it as a kid, so here’s hoping that good hand hygiene will keep me free of it.

Had a little potluck tonight at one of the PT’s home for my roommate who will be leaving soon. She has been here since October and has made lots of friends. I still can’t get over how welcoming and social people are. It’s potluck mania–I feel like I could go to a different one every night if I wanted.

January 31, 2014

Diagnosed my first surgically treatable case of gallstones with gallstone colic today. The story at first was not very compelling for much because the young woman was very vague in describing her symptoms. I think she was a bit shy with me (and probably most everyone else who has seen her in this months long course of recurrent abdominal pain). But I pulled out one of my new techniques, and really just stayed quiet for an uncomfortable amount of time, and she eventually started telling me a detailed story in her own words rather than the bits and pieces I had been pulling from her initially.

 I scribbled some thoughts down in my notebook today, but I can’t quite remember my philosophical thoughts from the moment. I wrote “Healthcare is not a person, it is a system.” I can’t quite figure out what I meant by that. Hmmm. I think I was pondering all the parts of the healthcare system that patient comes in contact with from the trip to the hospital to the reception area to the clinic room and beyond, and no matter how good any one individual does in any of those roles, if the effort isn’t coordinated or well oiled, the patient might not feel like they are being well taken care of. Also, I think I might have thinking about how important it is to have systems in place to make best practices easy to do. I really should write more down in my ramblings.

February 1, 2014

Happy White Rabbit Day! I won for the month with my fiancé

Made the trip to Gallup again with friends to get the much discussed Sushi. Not bad at all. And on the way there, was treated to an amazing desert sunset and moonrise.

February 3, 2014

I had my first direct interaction with the busy dental clinic today. I had an older teen with facial swelling, and on exam I thought I felt a bulge along the maxillary jaw near the site of where the wisdom tooth should be. Turned out to be a dental abscess at the wisdom tooth. It was amazing to just walk the patient down the hall to the dental clinic and get the dentist’s opinion. I haven’t had similar experiences with the podiatry, PT, and optometry clinics. We’re all just down the hall from each other so interdisciplinary discussions are incredibly easy. And it’s nice to see people rather than solely talk on the phone with me.

February 4, 2014

Had normal clinic in the morning. Busy, busy, busy as always. Then I made a referral to the traditional healing services for a family with a young man with pain that we couldn’t identify a source. So Dr. Peterson then took me over to meet with some of the traditional healers. I spent the afternoon speaking with one of the hospital’s traditional medicine men who works primarily in the Adolescent Care Unit, which is an inpatient ward for adolescents who are having psychiatric or substance abuse issues. They have counselors, a psychiatrist, teachers, gardens, a huge outdoor recreation center, and while I was there they were preparing for graduation. The programs lasts, I think 12 weeks, before the kids return to their communities. Dr. Peterson said it is remarkable when you do intake physicals how down many of the children are, but by the middle of the cycle they are laughing and smiling and have the energy to do school and play and do crafts. The medicine man filled me in on some of the basic Navajo principles that they teach the adolescents while they are there to help them connect with their heritage and find a meaningful place in the community.

February 5, 2014

Getting sad that my time is running out here. Clinic was excellent as always, then this afternoon I spent time with another medicine man for a healing ceremony in the hospital’s hogan. The patient didn’t make it, so instead he sang lots of different songs for me and discussed what his practice is like. He does work with both the hospital and privately. Apparently there is a huge demand amongst Native Americans in many tribes across the country and very few traditional healers. He travels everywhere from the Dakota’s to Florida to do ceremonies–from home blessings and weddings to births and treating depression. He also spoke of how some Navajo people have fused Christian beliefs and Navajo beliefs into new form Navajo belief system.

 I learned some too about the taboos surrounding death in the Navajo culture. The traditional healers don’t tend to do any ceremonies around death and death is spoken very little about. Funerals tend not be public and off all the possessions of the dead are burned or given away. Sometimes families will even burn the person’s hogan down as part of the ceremony. Ceremonies are variable and often times distinct based on the family or clan of the decedent.