Sunday, November 12, 2017

bedside ultrasound in the Southwest

In the Hopi Emergency Department, and many emergency departments across the country, when it is outside of business hours, our laboratory and radiology technicians (the people that can run the blood tests and take the x-rays or CT scans) are on call and 40-minutes away.

What if there was a tool that would allow us as providers to look inside your body right there in the room with you, 'at the bedside', and find out what is wrong without calling anyone in from home and without exposing you to any radiation?

We are realizing more and more that we already have this tool -- ultrasound -- and if we learn how to use it properly it can be incredibly powerful. Ultrasound uses sound waves to look inside the body. Most people are familiar with the use of ultrasound for pregnant women to look at their babies and how they are developing, but it has many many other uses.

I was fortunate to have had some amazing mentors in my residency program who trained us all in bedside ultrasound right at the beginning of our 3-year residency program and allowed interested residents, myself included, to do an elective in our third year to get much more hands-on experience with ultrasound. 

I love ultrasound for many reasons. First, it is quality time spent with a patient. I love to show someone their kidney, or gallbladder, or liver, or pregnancy, or veins, and either reassure them that they are OK or show them what is causing their problem, and patients to look at the pictures with me. Second, it is very cost effective. Ultrasound machines are a bit pricey, but once you have the machine it can be used over and over, so in the end it is cheap, easy, portable, and sometimes saves unnecessary expensive tests, radiation, or transfers to another hospital.  Third, it s so fun to teach. I have had the opportunity to help teach courses at my own residency, at a Global Health conference for family physicians, and most recently at a nearby Indian Health Service facility at Zuni.

This last weekend, after running in the middle of the night and again early morning in the Ragnar race in Phoenix, I drove out to Zuni, New Mexico and had a wonderful Contra Costa Family Medicine reunion with a couple of former co-residents and a couple of our ultrasound mentors in the setting of a two day course they were putting on for bedside ultrasound for Indian Health Service providers.

IHS-Contra Costa bedside ultrasound champions
I had been doing quite a bit of bedside ultrasound before, but after these recent courses my excitement and awe of the potential of ultrasound has been elevated even more, and I'm working on mentoring other providers at Hopi to be able to answer some simple questions with a bedside ultrasound: Is your leg swelling from a blood clot in your veins? Is your stomach pain coming from your gallbladder? Has a pocket of pus formed in your skin infection that I need to drain?

Sometimes, the answer to one of these questions can make all the difference for a patient's care. 


Friday, October 6, 2017

Running the mesas, the deserts, the mountains

Since moving to the Hopi Reservation last fall, I feel a sense of coming full circle on my path to running.

I hated running as a child, and only came to it as an adult, around 10 years ago on Pine Ridge Reservation in South Dakota when I started running simply because I felt cooped up from physical inactivity. So I started running on the gorgeous rolling plains of South Dakota. It took several weeks for me to build up the ability to run a mile or two, and then, for the first time, it actually felt good and I was hooked.

Rolling grassland of Pine Ridge reservation. I learned to run on this gravel road.  
Since then, I've kept running a part of my life, at least in some way, and it has become a sanctuary to get outside, to move, to clear my thoughts, to feel my heart pounding and my lungs burning. I've received some puzzled glances from local communities as I ran on the beaches of a Garifuna village in Honduras and the dirt paths of the Rainforest in Peru.

And then, one year ago, I moved to the Hopi Reservation in Northern Arizona, and incidentally found myself in a place where not only do I not receive any puzzled glances when I run, but where I am completely amazed and humbled by the running tradition and culture of the Hopi people.

The Hopi have a long tradition of running, and maintain that tradition to this day, through ceremony, sports, and everyday life. In 1912, a Hopi runner named Louis Tewanima won a silver medal in 10,000 meter race, setting a US record that would stand for 52 years. There is now an annual 5K and 10k race in his honor, which I had the honor of participating in earlier this month. http://www.tewanimafootrace.org/about.html

At this, and many other races I have attended, Hopi people of all skill levels and all ages, from elementary school children to grandmothers and grandfathers, come out to run together, and cheer eachother on: "nahongvita" or 'stay strong'. There are running trails all over the reservation, looping around all the villages, up and down the mesas. The Hopi Wellness Center runs an annual "100 mile Club" which encourages participants to run or walk a total of 100 miles over the course of the summer.
Running trails behind the Wellness Center
In one other impressive example of the ongoing culture of running, the Hopi High School boy's cross country team has won the state championship in their division for the last 27 years in a row. Here's a New York Times Article and an ESPN SC featured video about the team and its legacy if you are interested.

It has been truly amazing to be a runner and be surrounded by such a deep, rich, running culture.


This fall, I've joined an eight-member team of mostly Hopi staff members of the hospital for a 2-day trail relay run in November 3-4 at McDowell Mountain Regional Park outside of Phoenix. We'll each be doing three legs spanning day and night for a total of 15.4 miles each or 123 miles total. It'll be a fun time and a good challenge for all of us, but we are also doing it as a fundraiser for the Unite to End Violence Native Women's Empowerment, a small grass-roots organization that organizes a run on the 25th of every month to raise awareness about domestic violence and works to support survivors.

Example care package for survivors of domestic violence
We're collecting donations to Unite to End Violence via this gofundme page if anyone would like to contribute.

Saturday, July 29, 2017

a new understanding of water

“How could a place defined by the absence of water be defined by the presence of it?” --Craig Childs, the Secret Knowledge of water.

When I chose to move to Arizona, I gave little thought to fact that I was moving to the desert or how radically different this would be to any other climate in which I have lived. In the last nine months, I have become so much more aware of water: when and how I drink it, when and how and how much falls from the sky, how it defines the landscape and living creature’s relationship to it. I'm including a few quotes from a book "The Secret Knowledge of Water" by Craig Childs which express much more eloquently than I could some essential concepts around water in the desert. 

Each time I go into town for groceries, I also load up the back of my car with empty gallon water jugs, which I fill with tapwater in Flagstaff and bring back. This is a choice I make because the water that comes out of my tap comes from local groundwater that naturally contains arsenic, at slightly above EPA recommended levels. I then watch the water jugs empty themselves, about one per day, for my cooking and drinking water, until I get a chance to replenish them.

And this is only at home – when I go hiking or backpacking in this area, planning water sources is much more critically important. In the desert, there are a few types water sources: springs, streams/rivers, and potholes: natural depression in rock which fill with water and, depending on the size, remain filled for a matter of days or up to weeks to months if they are large enough. 

Pothole water in the Grand Canyon
Spring in the Grand Canyon
All of these but the largest of rivers and potholes are seasonal, and can be found completely dry in the summertime, making careful research, planning, and budgeting of water essential. I recently went on an overnight backpacking trip in the Grand Canyon where none of these water sources would be available, so we each carried 11-12 liters of water (around 25 lbs). That is a heavy load!

Colorado River at the bottom of the Grand Canyon -- always has water, but hope it to be clear like this not muddy after a rain!
Much more dramatic than my own personal relationship with water, is the way in which water defines the natural environment here. Surely the natural springs on the mesas at Hopi played a role in their settlement here over one thousand years ago. In some of the villages, you can still see the natural potholes dug deeper by ancestral Hopi to store water on top of the mesas. And to this day, the Hopi perform ceremonies and dances to bring the rain their crops need to survive and thrive. When the rains come, they seem to be another entity altogether from the rain I am used to anywhere else. The open landscape allows you to see for miles in any direction, and see storm clouds dumping rain and lightning in a patchwork of places with some areas left bone-dry in between.

It's raining on the buttes in the distance, but not on the road i'm walking


Which brings me to the flipside of water in the desert: its momentary abrupt abundance and resulting floods. In the space of a few minutes, flash floods can turn a dry rock channel into a living, seething, roaring river with water and rock defining one another: “the shape of the canyon is the shape of moving water, and the shape of water, like the canyon, will amend to the slightest bias. While resisting and accommodating each other, water and canyon both become patterns of the same intelligence.” --Craig Childs, the Secret Knowledge of Water.

Dark Canyon in Utah, carved by water
Closer to home is the sandier version of canyons: the numerous ‘washes’ that meander across the Hopi and Navajo reservations. They appear as dry creek bottoms, lined with cottonwood trees, and fill with water only for short bursts of time, but enough to define their physical paths and resulting ecosystem. Paved roads have bridges with signs marking the wash as if it were stream or river (which is sometimes); unpaved roads simply go through the washes, sometimes heralded by a “do not enter when flooded” sign.  Families that live off of some of these dirt roads not infrequently find themselves trapped, unable to venture out from their homes to town, work, or appointments at the health center due to mud or a flood.

Mud cracks as it dries the day after a rain

To say that the desert has no water is a tantalizing misstatement. It is believable. But to look over this raven land and know the truth – that there is immeasurable water tucked and hidden and cared for by bowls of rock, by sudden storms, by artwork chiseled hundreds and thousands of years ago – is by far a greater pleasure and mystery than to think of it as dry and senseless as wadded newspaper. It is not only drought that makes this a desert; it is all the water that cannot be seen.” --Craig Childs, the Secret Knowledge of Water. 


Tuesday, January 17, 2017

New year and new life on the Hopi Reservation

It is hard to believe it has been more than three months now that I moved out here and started work as a family doctor on the Hopi Reservation. I haven't written before now partially because I have been busy and partially because I have been struggling with how much I feel is appropriate to write publicly about my experiences here. The Hopi people are very open and welcoming to non-native guests such as myself in the community, but also clearly and understandably request respect for their privacy. There are many signs throughout the reservation requesting no photographs, audio recordings, or notebooks.

So I'm going to focus on my own experiences and share photos of the natural environment, but will not be sharing any (even de-identified) patient stories or recount any of my experiences with Hopi cultural dances or ceremonies. If you are Hopi and are reading this and would prefer I remove any part of it, please let me know and I'll be happy to do so.

My goal in these posts is to update friends and family about my life as well as to share some of the experience of working here with others who might consider coming to work at Hopi or a similar IHS site. This first one is a general overview and as such may be a little on the long and dry side but there is so much to say to give you a picture of my life.
A double rainbow behind first mesa, taken from my backyard
I continue to truly love both work and life, more than I could have possibly imagined when I made the decision to come. On my interview, I fell in love with the mesas, the desert, the sky, and the people. And while I knew that I was signing up to work at one of the more remote sites, with a much smaller medical staff than any of the others and therefore potentially much less support and mentorship, I followed my heart to come here because I felt the experience at Hopi would be most in line with what I was looking for with IHS -- cross-cultural medicine and meaningful connection with a compelling and underserved community.

My work at the Hopi Health Care Center feels similar in a lot of ways to global health experiences I have had (ie Santa Clotilde, Peru for those who have been there). It is a critical access rural hospital with a 24-7 emergency department which receives patients from the tribal EMS system as well as walk-ins, a small 4-bed inpatient unit, a 2-bed labor & delivery unit, an outpatient clinic, behavioral health, physical therapy, lab, pharmacy, radiology with x-ray, CT, and ultrasound (and a mobile MRI van 2x per month), and a private dialysis clinic all housed in the same beautiful one-story building with doors coming off a large common lobby / waiting area filled with natural light and Hopi-inspired architecture.
That same rainbow continued its arc through the sky to end at the Hopi Health Care Center

When I'm on I work in every aspect of the hospital -- covering hospitalized patients and obstetrical patients then seeing patients in clinic and helping out in the emergency department on weekends. Its really beautiful to work in such a small, tight-knit hospital, because it never feels bureaucratic or impersonal -- I almost always know and have a personal relationship with the staff in other departments that I work with regularly, and everyone is willing to pitch in to make things happen for patients. Sometimes that means going out to the parking lot with a social worker and public health nurse to have a family meeting in a patient's car. Sometimes that means a pharmacist getting to do the med rec and suggesting which medications to continue on a hospitalized patient because I got pulled elsewhere before I had time to do it. While there is always more to be done, Hopi is in the process of developing a really wonderful medical home model in clinic. I work closely with a nurse "care coordinator" who makes phone calls and follows up with patients when i'm gone, and I work with the same medical assistant every single day I'm in clinic(!!) which makes everything so much smoother for me and for patients. When I'm not in clinic she is preparing charts, calling patients, ordering labs, processing medication refills, and getting ready for the next day in clinic.

Some days at work can get a bit hectic when i'm pulled in multiple directions at once (which isn't so uncommon in the medical world) and other days are much more smooth. I am grateful every day for the strong training I got in residency at Contra Costa -- we do have very friendly specialists in Tuba City and Flagstaff to help us out and who will take our patients as transfers when they require a service we do not offer at Hopi, but sometimes there is a snowstorm and there is no safe way to transport a patient and we have to turn the Hopi ED into a mini-intensive care unit for 18 hours with patients on breathing machines until the storm clears.

My first backpacking adventure out here in Dark Canyon, Utah

After the intense schedule of residency, I am luxuriating in my schedule here. We work ten hour days for eight days out of every two week pay period. This means sometimes I work four days and have a three-day weekend, and sometimes I work longer stretches (up to 8 days straight) and then have a four, five, or six-day weekend. The result is that I don't need to use vacation days to take frequent five and six day trips, including a roadtrip to california for a friend's wedding in yosemite, multiple trips to see family, and a few backpacking trips. I also really enjoy having time off at home here at Hopi when I go for runs on the trails behind the housing complex, go hiking at some of the nearby canyons and mesas, and participate in some of the community events here at Hopi including lots of organized 5K/10K/half marathon runs when the weather is warm, and when I'm invited, observe some very special dances  or a baby naming ceremony.

This trail run was amazing -- so many people of all ages running together to celebrate the Hopi running tradition

Within the tribal housing complex where I live, there is a great community of hospital staff and other tribal employees. We get together frequently for potlucks, movie nights, or book group, loan eachother tools and supplies, and bring each other groceries from town. I love that I have close friends of all ages who do all kinds of different work.  I've also adopted a grey cat named Blue who previously wandered from house to house through any open door. I shut the door on him a few times at first, but he was persistent and has won me over. He is very playful, a bit rambunctious at times, but very loving and is sleeping on my chest right now as I type this. In addition to keeping me company, he's also been a great way to meet many of my neighbors as he wanders into their homes and most take him in and play with him until I get off work to pick him up!

Blue and I watching the sunrise through my window and enjoying breakfast before work
Where do I buy groceries? many people ask. There are a few general stores on the Hopi Reservation with basics to get me through, but then every 1-2 weeks I make the 2-hour drive to Flagstaff, a small but beautiful mountain and university town. "Flag" as it is known in the area has everything I need in a city -- multiple natural food stores, a farmers market in the summer, an amazing public library, numerous outdoor gear stores, several thrift stores, a craft store, a used book store, and a pretty good selection of ethnic restaurants. And the San Francisco Peaks lay just to the north of Flag, giving beautiful mountain views, great places to hike, and attracting a lot of down-to-earth outdoorsy sorts of people. And then the Grand Canyon is just an hour an half north of Flag. I'll close with some pictures from hikes I've taken there. I had previously visited the canyon as most tourists do -- driving along the rim and looking down into a giant hole -- and just felt overwhelmed by it.  But since moving here, I've gotten to hike down and around and through the canyon and realized what an incredibly complex, intricate, and truly gorgeous maze of a canyon network is here as a regional park for me to explore.

At the top Battleship, a peak within the Grand Canyon

A cottonwood grove seen while winter backpacking in the Grand Canyon
Sorry once again for the length of this post -- I've never been very good at brevity and even less when attempting an overall portrait of my life out here, so different from my former life in the SF Bay Area. Hopefully I'll get some shorter, snazzier posts up sometime soon.