Posted by • October 6th, 2015


Credit: Indian Health Service

Over the past few weeks I experienced many firsts on the frontline in the Tuba City emergency department. Among many firsts are my first Diné words including yá’át’ééh (yah-tah-hey) which means hello in Diné Bizaad, and, in case you forgot, boozhoo (hello) in Anishinabemowin. So far simple greetings and polite courtesies are all I can muster, but I do look forward to learning more. It is a beautiful language, which carries such power and meaning in its rich timbre and tone. At times it can be melodic and soft, and other times abrupt and to the point, the words sounding like the cracking of a hard walnut in your hand.

These new experiences would not be possible without the subtle mix of luck, the support of family and friends, and the scholarship program offered through the Indian Health Service (IHS). Founded in 1955, the IHS is an operational division of the United States Department of Health and Human Services. It was originally formed as a part of the War Department in the late 1800s with an ulterior motive: to stem the spread of infectious diseases to Western expansion populations and U.S. soldiers via vaccinations and quarantined care of Native people. Its structure and mission have thankfully changed significantly since then, and now provides comprehensive health care services, scholarships, and jobs to roughly 2 million patients from over 560 federally recognized tribes through a network of tribal and federal facilities, health and dental clinics, and urban health programs. There is wide variation in the services each facility is able to provide. Despite improvements in the state of health of many Native communities, many challenges still impact the quality of care delivered to Native people. Even with my nascent experience in the ED, I now see these plainly and they have led to some other firsts for my career.

For example, last week was the first time I treated seven patients from the same family all together in the same exam room. Just recently, a close family contact had been diagnosed with meningitis and one member of the family presented now with seizures and fever. The other family members were evaluated, thankfully asymptomatic, and received chemoprophylaxis. Despite some of the most successful vaccination programs in the country, living conditions on the reservation promote the spread of harmful disease like invasive, gram negative meningitis. On the “rez,” the unemployment rate can be greater than 50%. Unchecked poverty and scant economic opportunity leads to a considerable amount of cohabitation, with multiple generations living under one roof or “hogan.” Roughly 30% of homes do not have access to adequate plumbing and the same proportion have earthen floors. Close quarters and living standards below what other Americans have come to expect create a near perfect environment for the spread of communicable disease.

I also transferred my first critically ill patient to another care facility — an act unheard of where I trained in Boston with five Level 1 trauma centers and the best tertiary and quaternary specialty care in the world. But for Tuba City Regional Health Care on the Navajo Nation reservation in Northern Arizona, access to critical care is about 30 minutes away by helicopter or 2 hours by ambulance and can come at a cost of more than $20,000. And in a rationed health care system like the IHS, the economic impact of these transfers can delay or preclude necessary care for non-critical patients. At times it can feel like we are caught in a zero-sum situation. For some to gain others must lose. Beyond the practice liability and cost is the burden to patients’ families. Many have already delayed care due to lack of adequate transportation, some traveling over an hour on unpaved roads. And if the patient happens to be the primary wage earner for the household, in an area where the unemployment rates can be as high as 50%, the result is even more financial devastation.

Despite these obstacles, most of my initial interactions have been enlightening, educational, inspirational, and, quite frankly, touching. Like the first time I called an elderly woman “shimá” or grandmother and saw a surprised smile come over her face, melting away her apprehensions of being in the ED. Or the first pregnancy diagnosed at bedside with ultrasound, with the tears of an elated mother-to-be who had all but given up hope of having children. And finally, my interactions with my dedicated and experienced co-workers, many from the community they serve and eager to have a new physician to teach and learn from, have been welcoming and comforting to myself and my family.

With that said, I have a lot to learn and a lot more experience to gain, not to mention Diné vocabulary. And I cannot wait. Challenges aside, this place has made quite a positive impression on me and I look forward to the days, months and years to come.  This is a place for great medicine, great friends, and great potential.

2 Responses to “Commencement”

  1. Michael Buscher says:

    Great post! Happy to hear that your first few weeks have been rewarding. Looking forward to updates.

  2. Chris says:

    Hi Ken,
    We miss you in Boston but sounds like your doing some fascinating work. Your coworkers are very fortunate to have you such a kind and compassionate MD on board . Your postings really help to educate us as to what is happening in your emergency department. Thank you for sharing ! Take care and keep up your great work ! And please continue to share .