The first entry from home and last entry of my great adventure

So how did this happen? Seems like I was just kicking myself for purchasing a used RV for a trip that had not yet materialized and here I am back at home again. In the intervening 4 months my son has graduated college, moved to Tulsa, OK, and become the teacher he has dreamed of since 7th grade...with a few bumps along the road. I have driven close to 4000 miles, from OR to WA to OK to NM and back to OR. I have fulfilled a life long dream to return to the Navajo Nation and provide health care on the reservation. I have lost a chicken and gained a cat. Yes, that makes 7. And now, here I sit, on the deck, with a glass of wine, a cat next to me and another trying to get in my lap, as if nothing ever happened.

Jonny is having a pretty rough start. Let's see, what has TFA done to help him? Well, he spent the summer teaching first grade and is now on his own with 250 9th graders. He signed on to teach 4th grade bilingual students, then was told he would be teaching MS social studies, then 9th grade OK history. And he is really teaching US Govt and Politics. But he is doing it Jonny style. Gets frustrated,  questions why he is there, but gets up every morning, puts on his teacher clothes and hits it again. He has recruited almost a full lineup for the baseball team he will be coaching. And it sounds like he is making friends and has some good support systems. But he is in Tulsa, OK. Which is a very far distance from Eugene. Today I changed our message machine to leave him out. That was hard.

I am having some difficulty getting used to the Eugene scene again. I am surprised. All I could think about when I was in NM was how much nicer it was in the Pacific NW. And I arrive to arid conditions and temps much higher that Gallup had all summer. And the noise. White folk are so loud. Everyone wants to announce to everyone else just how great whatever they are doing is. Facebook on steroids. And the smells. What is it that makes white kids with dreads think that body odor and lack of hygiene is so wonderful and natural? I just spent the summer with folks whose ancestors were here a long time ago, many of whom do not have indoor plumbing or running water, but they bathe regularly and don't take pride in showing off. I guess I didn't really get it till I got home. And went to Saturday Market. That was probably not the best thing to do this early. I went to 3 powwows while I was in NM. Dancers in regalia that was heavy and probably really warm in the desert heat. They danced for hours on end. And they did not call attention to themselves or how wonderful they were or how much smarter they were than anyone else. They just danced. And they shook each others' hands. And they danced and they drummed. Not to make a point or a statement or support some cause. It was to maintain their culture. Young children, teenagers, young adults and elders. All dancing together.

Okay, so those of you who have been reading regularly know that it was not all sunshine and lollipops while I was away. There was the redundant policies that made no sense and took up too much time and took away from providing good patient care. And there were a few too many drunk and dependent Natives on the street. But, all in all, I learned probably as much as I taught. Not everything needs to be fixed now, immediately, or yesterday. It's okay to not be busy constantly, all day, every day. Take pride in what you do, but that also means not announcing it to everyone. I have always been a little skeptical of those who wear their beliefs, concerns, etc on their shirt sleeves. This experience has reinforced that.

The bats are out and flying around now. That means the mosquitoes are out too. I miss my friend Andrew. It was particularly hard to say good bye to him. I miss my quiet little apartment with just me and Otis. I miss going to the dog park where rescue dogs are really rescue dogs: the dog with no front legs that someone truly rescued after witnessing it getting hit by a car. I miss the smell of mutton and fry bread and kneel down bread. But I am glad to be home. Who knows what next summer holds in store????

the last entry from gallup

Well, I have done it. Made it through 3 months of the working in the most dysfunctional clinic I have ever worked in. But I am left feeling very grateful that I was able to have this experience. And now that it is almost time to leave I wish I could stay a little longer. I am making headway and seeing positive change and would like to see it happen for real. But that would require another 5 years, and, although I could live here that long if I had to, I would much rather be home.

Reflecting back this has been a little bit like pregnancy, only backwards. What? you ask. Well for most women the first and third trimesters are much tougher than the middle one. For me, here, the first and last thirds were good, bordering on great, but that middle part really sucked. I do feel, just a little bit, like I was eventually being used by some of the permanent docs to stir things up that they didn't feel comfortable stirring up, and this actually served to make things less pleasant for me because I was constantly being reminded how bad things were there. On the other hand, I can definitely leave Tohatchi Health Clinic knowing that I had a big role in improving things for both the patients and the staff, and that is ultimately satisfying.

Yesterday, the clinic staff gave me a little ovation and had a nice breakfast, complete with Spam, before we started seeing patients. I presented the stained glass piece I have been working on, and it was well received. Of course, I forgot to take a picture of the final piece, but it did turn out nice if I do say so myself. I saw a few final patients and was then sent to Gallup for my final paperwork and sign outs. It was such a typical example of excessive paper work to no obvious purpose I had to laugh. I was sent hither and yon to be told I didn't need to be there, or that I had the wrong paperwork, and eventually the consensus was that I didn't really need to do anything at all except give back my name badge. For that I could have charged 4 hours work, but I didn't, of course.

I did have a few nice conversations with some of the docs there who expressed how happy they were that I had had the guts to stand up to the powers that be and not put policy in front of patient care. They encouraged me to come back and I just might take them up on it. Maybe. After I get a chance to clear my head.

Rich came out to visit last week and we had a great time. He got to do his personal tour of Canyon de Chelly on Friday, then we went to the Totah Festival in Farmington, NM, which was a great combination of Powwow and crafts. We toured the Aztec Ruins (not really Aztec, of course, they just happened to be in Aztec, NM. We got to actually walk through ruins that people lived in over 1000 years ago. Then we took a short walk through the NM badlands, Bista something, which is eerily like a moon scape. We did some work on Bertha too. This is a really nice part of the country to visit and check out. Blue, red, white, and black rocks, ruins from the earliest organized settlements, mountains, of sorts, and some really nice people. But I don't think I would want to live here. I would miss being able to garden and having nice big trees to sit in the shade of.

Tonight we went to the Navajo Nation Fair in Window Rock, AZ. About 30 miles from here. Had my last mutton on fry bread for a good long while. That's probably a good thing. And went to my last powwow for a while. I am still in awe that on a Saturday night there were all these folks, from 3-83, dressed in traditional regalia, dancing for hours on end together. What a beautiful sight. And not one I can share. I decided to put away the camera and soak in the emotion all for myself.

Tomorrow me and Nancy will finish loading up Bertha. We will take Otis to the dog park one last time. And we will begin our journey home.

the upside of my experience

I have been so down on all things Gallup these days, I have decided to purposefully write about some positives. I have Otis with me. But wait, is that a positive? Well, I have learned to do more stuff around the house and have made some good friends at Home Depot. And just having a Home Depot is a positive. Last time I was here, there wasn't so much as a Safeway. My apartment is growing on me. We are close to the kid's athletics fields so we get to absorb that energy when we hear them out there practicing. I have a grand view for sunsets and sunrises. Okay, one little positive/negative about the complex. I have befriended a Navajo gent by the name of Andrew (well, Richard was his given name, but somehow it got changed recently). Andrew is about 50ish, clearly either developmentally delayed or the victim of severe head injuries, or likely both. We have been talking everyday as he waits for the bus to take him to his activity center. He taught me how to do needlepoint. His sister hates me. Because I am white. She has never spoken to me, but throws me looks that could kill, and when she is around, Andrew ignores me. He tells me she gets really mad if he talks to me. Or the Bolivian pediatrician that was here for awhile. But he is obviously so lonely.  Well, 4 days ago I showed him my finished needlepoint masterpiece from a pattern he gave me that is meant to frame a picture. I framed a picture of Andrew in it. I haven't seen him since. I think his sister is locking him in the apartment because he was talking to me, that evil white woman who gave up her entire summer at home to come care for the Navajo, whose ancestors were happily drinking beer in Bavaria whilst other European settlers were doing awful things things to Native Americans. I don't understand why it is okay for some people to be racist.

On the medical side of things, the clinic seems to be settling down. I am still that doctor that doesn't follow rules that make no sense, but there are more docs suddenly around and all are questioning the same things I have, and some change is in the air. We still see anyone who walks in, but we aren't being pushed to get them out the door at 4:30 or else. And today, when we had a young girl brought in unresponsive from the middle school, it was me they asked to see the patient first. We have a new Navajo NP and a locums from the DR that just finished residency. Ha, we now have 3 of us to do what I have been doing all by my lonesome!!

I went to my first Pow wow during the recent inter tribal Indian Ceremonial last weekend. Uh, it was actually the weekend before. My how time flies. What struck me about this was that here were tribes from NM, AZ, SD, and other places. They all have their own take on creation and God and other things. But here they were, all in beautiful regalia, dancing with and for each other, for the sheer joy of expressing themselves via dance and drums. Well, okay, there was a small cash prize given to those judged by Native peers to be the best dancers, but lots of folks were just dancing to dance. And I thought to myself, so many people right now are dying because of their interpretation of religion and God and creation. Maybe we should all eat some fry bread, smoke a pipe, and dance a little. Just  a thought.

today I learned how to run coaxial cable

As with most blogs, after a while folks stop reading, but I am also using this as a diary of my thoughts whilst here, so if you happen to read this post it may be a little disconnected a la free form thinking but it helps me remember what happened here in the land of the Navajo.

Today I came home to the curtains I hung to keep otis from destroying more Venetian blinds on the floor. An umbrella was ripped up in the living room. He tried to scratch thru the door to my bedroom. And he pulled the cable for the tv clean out of the wall. So we made our weekly trip to home depot to get the fix ins for cable repair and I jerry rigged something that will get us thru the final 3 wks here and it seems to be working! Today's Otis antics were brought to me by the handymen that were working next door on a flooded apt. They think it's cute to say hi to him thru the closed window, not realizing that it drives him nuts.

Earlier this week, after a particularly interesting day where I was referred to as a Godsend (now that's a first), more on that later, I was driving home and saw a cute Golden running down the road. I said to myself, gee that dog looks a lot like Otis, which is good, because it was Otis. As I drove past the apartment complex to pick him I saw my curtains blowing out the window, and a mangled screen laying in the bushes. And Otis running down the street. I think it was the thunder that day that sent him on his journey. So I have learned to repair screens and cable tv this week.

Work. Ah work. My last post was rather depressing. But unfortunately it was also realistic. It turns out that Tohatchi Health Clinic has had a great deal of difficulty recruiting and keeping docs. I can see why. While I enjoy so many aspects of caring for the Navajo, there is so much I don't understand. Like, why do they expect me to understand their idea of time, but they don't understand that I can't see 10 patients all at once? And how do a few women with a chip on their shoulders gain so much power in the organization? Okay, I know the answer to that. It's the government. When someone fails at one job, promote them to get them out of there.

Let me cite some examples to illustrate why this is a hard place to work. Reader beware, this is clinical.

We are supposed to see anyone and everyone who walks in the door. Graeat in theory. But a lot of folks walk thru the door w/complaints that most of us would not even think of going to the doctor for, thereby utilizing time that could be spent on the other folks who stay at home until they can't breathe before coming in. Case in point: I was recently busily trying to convince a nice Navajo woman that a stuffy nose for 12 hours probably doesn't warrant antibiotics whilst another patient was sitting in the waiting room with a trimalleolar ankle fracture (3 breaks in 1 ankle). And then, whilst trying to fashion a splint out of available material for said ankle fracture, I was being harassed by the receptionist of sorts to get up off the floor covered with plaster dust I had created during the creation of a wonderful if i do say so myself splint. Why? not to protect my clothes from plaster, you silly. She  wanted to go home (it was 4:30 after all), but I needed to stop taking care of the patient, go to a computer and complete my note before she could leave. So can you just take care of the important stuff doc???

On the day before I left to come home for a week, which was wonderful I might add, I was seeing the last patient of the day. She was put in the room at 4;20. Somehow I was supposed to see her and get done and out of there in 10 minutes. How do you do that? Especially when her main concern was that she had slept with someone 3 months ago, without the benefit of a condom, who clearly had syphillis by her description. And they weren't just sleeping. When I examined her she had a problem that I wont describe in detail, but suffice it to say she had number 2 coming out of the wrong place. She had been wondering why it was so hard to stay clean. So you don't just see that and walk out of the room. After a little bit of discussion, I come out of the room, at 4:45, and all the clinic lights are off and everyone is gone. I am still seeing a patient that someone decided needed to be seen, but she is not important enough for anyone to stay until she is adequately cared for. Even the med student shadowing me that day said " really?"

When I returned I was determined to put that behind me and carry on without pissing anyone off (by, ummmmm, taking care of patients???). Foiled again. On day 2 after my return a man in his early 50s came in looking like, as we say in medicine, shit. He was having a heart attack before our very eyes. I called the local er and explained what was going on, whilst resuscitating this poor man, and we both agreed the best course of action would be to fly him directly to albuquerque to the heart hospital. I called the cardiologist there and he agreed. So I asked the paramedics to direct the helicopter to the nearest landing site. They did, the patient flew to ABQ, and he survived. the feedback I got? I broke policy. I didn't waste time by sending him via land ambulance to Gallup, who would then have sent him to ABQ. I am a bad girl.

POLICY. FUCKING GODDAM POLICY. Does no one here care about the patients???????? We are supposed to open the flood gates at 8 am, but if that lazy ass white girl doctor isn't done by 4:30 she has probably been sitting on her ass eating bonbons all day. But now I must rest. More later.

the down side of my adventure

Sitting here is SFO(just got the usual we are delayed and we don't know for how long) and can’t get wi fi connection. Just like my apartment in Gallup. So I am going to have an Irish coffee at the Buena Vista and try creating this blog in Word and put in on my blog later.This trip home couldn’t come at a better time. I have been in the Navajo Nation in general and the IHS in particular long enough to be bothered by the many warts I see now. The honeymoon is definitely over. Although I still am glad to have had this experience, I doubt that I will be back. Much to Dr. Mock’s disappointment. He says he likes how I stir things up and wants me to stay forever.

The negatives of the Navajo Nation. The main thing that bothers me is the trash. A people that supposedly takes pride in Mother Earth certainly doesn’t take care of her very well. There is trash everywhere. Broken bottles, mainly of vodka, plastic cups from the many Sonics and McDonalds, and empty beer cans decorate the landscape in as much abundance as the cacti and wildflowers.

Yes, there are stumbling drunks, in great abundance at the first of the month, but they are benign. Sad, but benign. They talk and laugh with you, occasionally hit you up for money, but are not aggressive and don’t litter the street corners with cardboard signs and themselves. I am amazed at how much they move. Walking everywhere. Up to the plasma center, across to the liquor store, back to town, and often end up at the hospital where they can get a meal and a bed while waiting to be seen in the ER for their daily visit.

And that is my segue into the Indian Health Service. This is Medicaid gone really, terribly wrong. Not in that services are not available. To the contrary.  Everyone comes to the doctor or dentist as often as possible. 20 yr olds have charts as thick as most octogenarians in the private world. Wake up with a stuffy nose? Go the clinic. Don’t like what they say(usually that antibiotics are not needed), go to a different clinic in another town. Still don’t get what you want , go to the ER, where they are so busy seeing non-emergent patients that they are likely to cave in and give you the antibiotics you are demanding. And guess what? You get better in a few days. So take a trip back to the original clinic to complain that the white lady doctor doesn’t like Navajo people and wouldn’t give you the antibiotics that the Navajo PA in the ER did and see how much better you are already. Of course, you would have been better by now anyhow, but now you get to make the rounds again to get treatment for the yeast infection caused by the unnecessary antibiotics. And all this unnecessary care is totally free of charge.

Make an appointment to see the doctor? Never. That, too , is seen as the white man not understanding the Navajo culture. Time isn’t a big thing. Unless you can’t see all at once the 10 patients that all walk in at 8:30, demanding to be seen for either inconsequential or very complex problems that really require a lot of thought and maybe some time, and someone has to wait an hour. Then you get the stern glance at the watch, the “ how long are you here” question, and the shake of the head cuz no doctors stay here longer than 30 days. Kind of reminds me of the days when Chrissy was looking for a husband. 

I am considered the walk in doctor. Which means I don’t have any scheduled appointments. At all. Some days I see 24 patients and some days I see 5. Great use of my time. The IPC (stands for improved patient care, haha) docs are the full time, permanent docs. While I am running around handling lacerations, chest pain, fractures, and a lot of nothing wrong, but while I’m here visits, they are leisurely walking from room to room, seeing only scheduled patients, half of whom don’t show up.  Anyone who walks in, with any complaint, gets to sit in the waiting room until I can get to them. Even if their own doctor is in that day. Even if they just saw said patient the day before and made changes in their meds. I get to jump in the middle of the stream and try to figure out what happened during the 2 hospitalizations they have had in the last 2 weeks, one of which was at another IHS hospital. (Oh, did I mention that none of the medical record systems in the IHS talk to each other? They all use the same EHR but they don’t communicate with each other.)

BUT, here’s the killer. I have to see anyone and everyone AND be absolutely done by the bewitching hour of 4:30. Then everyone, and I do mean everyone, leaves or at least clocks out. Yesterday, I got in to see my last patient at 4:20. She had issues that happened a year ago, but she was in the eye clinic anyway so thought she’d check in for a medical appointment. I came out of the room at 4:35 to find the clinic empty. Looked like the morning after. Lights off, nurses gone. I needed to do a pregnancy test and some blood work to evaluate the inevitable “oh, by the way” complaint, so I went to the lab. The lab tech was there, but clearly informed me that it was “10 to 5” clearly implicating that  the lab was closed. So I did the tests and drew the blood and got it ready for them to process all while she sat there and watched.  And when I turn in my time sheet, they will give me grief for having put in “overtime.”

During our morning “huddle” I have tried to make suggestions that maybe patients could be triaged by one of the 3 RNs we have floating around everyday (in addition to 3- 4 assistants and a few health techs to walk patients to the rooms), and the less urgent folks could be asked to make appointments, but I am told it basically that it is a treaty right for native americans to get health care when and where they want. It doesn’t seem to matter that this is less quality health care than it could be as I really can’t take the time to go over everything with one patient when I know there are 10 more waiting. Then I get the eye roll, there goes the white girl again look. And you should see the looks I get when I say that I am fine staying late to make sure patients are cared for, but it would be nice if a few of the support staff stayed as well, since I don’t know the system………

Yep, I am ready for a trip to the chicken coop and some hugs from my son and hubbie.

getting lost on the rez

At times I feel I am really out of place here, and at times I really am. I have this thing about putting patient care in front of policy. I have never seen an organization with more policies than the IHS. I suppose it's a governmental thing. I mean, how would they spend all our tax dollars if they didn't have 10 policies, written by 20 people to cover 1 thing. Last week I did battle with the pharmacy. In the rest of the world a physician sees a patient, comes up with a diagnosis, and writes for medication, if needed, on a prescription that the patient takes to a pharmacy and waits for the pharmacist to fill the prescription and educate the patient about the medication. (except for if you pick it up through the drive through, as I discovered when I treated a bus full of puking, and other things, baseball players).

In this system, we not only have to provide the diagnosis to the dispensing pharmacist, we have to complete our chart note so he can review it before he will dispense the medication. No big deal, you say. Well, I counted mouse clicks and waiting time whilst trying to create a note on a patient in this ridiculous EHR system the IHS uses. Between 60-70 mouse clicks and 2 minutes watching the circle go round before you can enter a note into the system. An average of 7-10 minutes all together. Per patient. If I see 15 patients, I have spent about 2 hours looking at my computer. So I see a patient, type for 10 minutes, see a patient, type for 10 minutes, and get further and further behind. And at 4 I have 3 more patients to see, but the problem is, the clinic staff walk out, literally, at 4:30. I am supposed to be done. If I'm not, I should be. After all, the government contract says so. Unfortunately the patients have not read the contract and don't know that they can't show up septic (really, badly infected) and withdrawing from alcohol at the end of the day. So I stay until all patients are cared for, AND notes are written, and then get called to task for being here too late. There must be a separate Hippocratic oath for docs who choose to do this full time. And what, may I ask, does a friggin' pharmacist need my note for to give a drug I have ordered????

There, I got that out. On to fun stuff. Kind of.

On Saturday I decided to find an out of the way trading post that is supposed to have an incredible Navajo rug museum. The reviews say it is great, but expect to have some loose teeth after traveling over the bumpy, unpaved road to get there.  So I head north, past the community where my clinic is located, and see the sign to Toadlena about 50 miles north. Then my phone dies. No problem, I will follow the signs. Except there are no more. I am bouncing over roads that make NW logging roads seem paved and see nothing nor nobody. But maybe around the next turn....Well after 30 minutes of this I decide the further I go the further I will have to walk when I pop a tire on one of the many rocks  I have been trying to avoid, so I turn around. Then I have to pee. But I am afraid to turn off the engine for fear it won't start and I literally have seen no signs of life in a very long while. (altho the scenery is pretty). I stop the car, put it in park and brake, and step behind the car to take care of my bladder and then realize that I am in rattle snake country. I am envisioning the head lines: local doctor run over by own car after getting bitten in the butt by a rattler, when the only car I have seen in 45 minutes drives by. Timing is not my strong point. Turns out the place I was looking for was 5 minutes from the highway.

Sunday I toured the beautiful Canyon de Chelly with an old residency friend that is working in Chinle, my favorite place in the Navajo Nation. I will try to post pics on Facebook, but internet connection is slooooowwww tonight. This place is magical. Ruins and pictograms from the 13th century. Red rocks and green trees. And homes placed 50 feet up a solid rock cliff. And I complain about the 3 steps into our house from the garage!!

Speaking of my garage, I will be home for a week soon. Can't wait. This is a long time to be away from my chickens!!

Rugs and royalty

On Friday I attended the monthly Crown Point Rug Auction. On the second Friday of every month Navajo weavers from all over the SW convene in this little town out in the middle of nowhere to auction off beautiful works of art that they may have spents months working on, especially if you count the raising and shearing of the sheep, the spinning and dying of the wool, and the hand weaving on the loom. Some of the rugs were no bigger that coasters and some were 4x6 feet. All were exquisite.

By the end of the night they had submitted for sale (not all sold) probably 200 rugs. Some sold for $40, some for $2000. All were worth every penny. I managed to keep myself from buying the big ones, knowing I had nowhere to display them, but did walk away with 6 smaller rugs to use as gifts and remembrances. To know that the weavers that created these pieces were sitting at tables in the back of the room was pretty special. So much better than going to some "trading post" knowing that the artists were paid so much less than the sellers would make.

 As I was standing in line to complete my purchases a man walked up and said he had won the bid on 6 rugs, but only got 5. The clerk found the last rug and said she thought he had bid $75 for it. He had really won it at $140.  She was going to take $75, but he said he couldn't do that. It was worth so much more. He paid $140. Just like NYC, right Rich??

I experienced my first road check point that night. As I rounded a curve on the very dark and isolated road I saw a bunch of police lights. I thought there had been an accident. But it was a random check point, where they stop all cars going in both directions to screen for DUIs.  This is a good thing, I thought. The car in front of me was being questioned for a particularly long time. Eventually the driver got out and literally stumbled around to the passenger side and the woman that had been a passenger became the driver. 3 miles down the road I saw them by the side of road exchanging seats again. This is why you have to be very careful driving after dark here.

Yesterday was the weekly Flea Market again. I decided to make a quick trip to see if there was anything new and different. Still lots of used tires, socket sets galore, and food and jewelry. And DVDs. Lots of them. As I was passing by a picnic table in the glaring sun I saw this regal elder Navajo woman, scarf on head, traditional skirt and jewelry,  sitting there eating an ice cone. I smiled at her, wishing I had the guts to ask to take her picture. After mustering up my courage (yes, this is one thing I have a hard time attacking) I went back and asked if I could take her picture. She obviously spoke no English, but I think she understood my hand gestures. As her ice cone dripped in the mid day sun I took one quick pic of her with the usual stern face that you often see on Navajo elders. When I returned with a few napkins for her, she busted out the most beautiful toothless grin. OH, thank you!! she said. The extent of her English I am sure, and I got to hear it.