Volume 11 Issue 3 2017
After fifteen years in Emergency Medicine, I knew that I was suffering from “compassion fatigue.” My emotional response to patients and nurses was increasingly negative, and I needed to reconnect with what I loved about being a physician. I de- cided to use two weeks of vacation and work for the Indian Health Service. I signed up for a locums deal in New Mexico.
One of my first patients was dressed in layers— white petticoats, floor-length full skirt, long-sleeved, high-necked blouse—and more turquoise than any trading post had to offer. A traditional Navajo elder, she considered a trip to the Indian Health Service Hospital to be a ceremonial occasion, and her trouble breathing would not allow her to disrespect me by not dressing appropriately.
“Grandmother,” I said, using the preferred term of address, “that is the most spectacular necklace I have ever seen.” Her daughter translated as the woman showed me several other necklaces under her outer blouse, four pure silver bracelets on her arms, and finely inlaid earrings.
“I have to wear all my jewelry when I leave the house, or my lazy grandchildren will steal it to sell for drugs.”
Welcome to Navajoland, where two worlds collide.
the new hospital in fort defiance, Arizona, was situated on a plateau not far from the Navajo capital of Window rock. It was a fortified government installation on the outside, a bunkered and razor-wired bastion of the u.S.A. in the middle of a foreign nation. It could be locked down in a few minutes, sheltering the non-Navajo doctors from natural or man-made threats. Out here in the middle of nowhere, the fortifications seemed both excessive and insulting; only the proximity to los Alamos and NOrAd indicated some strategic importance to the site. despite this, the Navajo Nation was scheduled to take over control and management of this hospital within five years, and was intensely proud of that. Inside, it was the cleanest hospital I’ve ever seen. All day long, Navajo were sweeping floors, cleaning windows, even shining door handles. the high desert dust never had a chance to settle anywhere.
there were few Navajo doctors at the hospital; most physicians were caucasian and fresh out of residency, paying off student loans through public service. there was a single Emergency physician in town; others, like me, rotated through on a locums tenens contract. the nurses were mainly Navajo and approached their job quite seriously, since they never knew what quality of physician would appear on shift.
Grandmother’s family undressed her and got her settled in bed. I had never seen anything like that. the nurses here did nursing—medications, vital signs—and nothing else. families (who always accompanied their loved ones) were expected to undress the patient, bring them food, transport them to X-ray, and pick up their meds at the pharmacy. they knew better than to bother the nurses for non-medical concerns.
A Navajo elder in the Ed was always seriously ill, and Grandmother was no exception. She needed emergent kidney dialysis—she was smothering in her own fluids—and would have to be transported to tucson, the closest facility that had a full-time dialysis center.
chronic renal failure requiring dialysis is a common problem on the reservation, probably a result of genetic factors. We had a protocol for treating these patients. traditional Navajo medicine was considered an essential adjunct to Western practice, and Grandmother’s other healer arrived and hung fetishes and sang the Blessing Way right in the Emergency department while I arranged transfer. I was included as an equal partner in the search for a cure; the people were open to what modern medicine could do for them when religion faltered. the delay in treatment would be put to good use, as I gave her medications and her culture provided spiritual support.
Narrative was central to Navajo culture. the doctor-patient encounter took time, because there were stories to tell about the illness, the family, and the clan. traditional Navajo could not be
rushed, and would often be insulted if the formalities were ignored at the start of an evaluation. the time required for translation often gave room for this process. I had to adopt a new approach to my patients here. I had to sit and listen and learn, almost a reverse interview. there was only this simple interaction; no demands, no entitlements, only the expectation of respect, an expectation that worked both ways. I had listened to Grandmother’s story about her grandchildren; now she agreed to my treatment and I participated in her sing, a Navajo healing ritual.
Within that culture of mutual respect, my professional self felt at home for the first time. the practice of medicine here was fundamentally different from that in the world outside; we were creating a joint narrative.
A few days after Grandmother left for tucson, because I had demonstrated respect for the Navajo culture, the rugs appeared. Women brought museum quality pieces, made on a traditional loom from the wool of local churro sheep and colored with plant dyes, for sale at a fraction of retail cost. A rug was a woven story and the weaver gladly explained the pattern and its symbolism. Every rug had a deliberate flaw; one did not tempt the gods by being perfect. there was also a thin thread that ran off the edge of the rug. this was the Spirit line, an escape route for the soul caught in the weaving. I did not see the relevance to my own life until years later.
there was another story, too, of the weaver’s family: how the children raised the sheep for 4-H,
the men sheared them, the mothers and grandmothers dyed the wool and spun the yarn, then wove the rugs over a period of months. the families saved part of the money so their children could attend college.
the contrast between old and new was always in play. One afternoon, I walked into a room where a young woman was garishly painted like a nightmare clown. Her face was smeared with red and white paint and she was dressed in baggy old pants and a threadbare checked shirt. I immediately thought she was drunk or drugged. She laughed at the expression on my face and spent ten minutes teaching me about the symbolic meaning of Navajo clowns and their role in ritual narrative. there had been another type of ceremony that day, one designed to bring rain to these high, dry plains, and the Watersprinkler was an essential component of that sing. My clown had fallen off her horse and twisted her knee. I quickly got her set up with a splint so she could return to her essential role.
Alcohol abuse remained a serious problem, but on the reservation, it was primarily considered a family issue, not a medical one. the Navajo had a genetic abnormality that made them both sensitive to alcohol and very tolerant of it, and most people had a close friend or relative trapped in alcoholism. Intoxicated Navajo tended to be very peaceful and non-violent, and so had little negative contact with the tribal or county police. If the tribal police brought an unconscious person to the Ed, the nurses quickly instituted a protocol
with sugar, fluids, and vitamins that had them walking and talking in about an hour. they called the family to pick the patient up; if they were unable to do so, the tribal police took them home. Intoxicated patients didn’t stay long in the department: the goal was safe, not sober, and the community took responsibility for that safety.
the rez had other significant problems, of course. Methamphetamine use had decimated an entire generation. the addicts were not culturally embraced like the alcoholics; most eventually left the reservation for the city because their relatives had zero tolerance for their behavior. theft in particular was a huge issue, primarily because of the disrespect it involved.
this wave of addiction had a profound effect on the Navajo, and threatened their traditions, but the people responded unexpectedly. Grandmothers raised their grandchildren when parents disappeared to Gallup and Albuquerque. Weaving, once dominated by women, is now often done by men who were brought up sitting by their grandmothers’ looms. the Navajo language is being spoken again, and the traditional ceremonies are being performed more frequently. children are back to being part of extended clans.
At the same time, the Nation has built its own college, so that Navajo seeking higher education do not have to travel to Albuquerque. the already established nursing school thrives, and the first wave of Navajo doctors are returning to fort defiance.
the hospital had a robust clinic system, and continuing care usually meant a walk down the
hall. the pharmacy filled all prescriptions on site; as a doctor, you wrote for what was on hand in the formulary. the single-payer system worked smoothly here because everyone had similar goals. the patients were invested in the hospital; they were active participants in its creation, maintenance, and function. the doctors were self- selected in their desire to provide care while immersed in a different culture. In fort defiance, I saw how doctors, hospitals, and the community can work together.
Medical care was adequate, sometimes excellent, rarely poor, but often limited by available resources. Advanced treatment—chemotherapy, heart surgery, complex fractures—required travel off the reservation. Not all medications were carried by the pharmacy. And yet, I never heard a complaint from a patient or a family.
the integrated healthcare system at fort defiance gave me something that I never had in
my career: time, which is an essential component of narrative. the number of patients was never overwhelming. I didn’t have to call outpatient doctors or make follow-up appointments. I knew exactly what was available at any given time, and the transport protocols were solidly in place. the nurses proudly did their job; there was no intrigue or gossip, at least outside of the community. they only cared that you were competent and respectful. Since I didn’t have to bird-dog their actions, nor spend time arguing with and cajoling consultants to do the right thing, or tracking down family, my stress level plummeted. I could focus on the
Maureen Hirthler is director of clinical Examination at the lake Erie college
of Osteopathic Medicine in Bradenton, fl. She received her MfA in creative Writing from the university of Missouri-Kansas city in 2015. Email: email@example.com
patients, who forced me to learn to engage them in that space between cultures shared by stories. I didn’t tell them what to do; they rarely disregarded my advice. I never felt like an adversary; no one cursed at me for not prescribing narcotics. I began to see that there could be a different way to provide health care, one that worked better for both doctors and patients.