2020

It's been quite the year -- personally, professionally, and for the entire world. 

December: snow in the canyon - For me, the changes of 2020 started on a snowy day in December 2019 when I stuffed a thrift store dress into a backpack and hiked with Wade and a few dedicated friends to the top of a butte in the Grand Canyon ...

....and got married. 

It was a beautiful, special day, and I highly recommend the outdoor micro wedding approach -- even outside of a pandemic. 

January: transition - Then came figuring out how to be able to live in the same place together. I struggled for months with the idea of leaving my job and my life at Hopi. I felt so connected to my patients, my colleagues, and the whole community. I knew I would be hard pressed to match that level of meaning in another job. Yet I also was ready to live in the same place as my partner, and we ultimately decided that meant living and working together in Flagstaff, about two hours away. I accepted a job at a hospital in Flagstaff, which serves as a receiving hospital for many of the clinics and hospitals on the Hopi and Navajo reservations.

February/March: a novel virus - As I was starting this whole transition process, we started hearing more about this novel coronavirus that emerged in China. Like so many of us, I went through the motions of preparing for its potential arrival to northern Arizona, but didn't truly worry too much about it, remembering all the preparedness for Ebola in 2014 which never really came to the United States. I focused on transitions for my patients, my projects, and a re-centering of my life in Flagstaff.

March/April: quarantine - And then it came. The first cases on Navajo Nation came just before my last day at Hopi in mid-March. Then I was off for four weeks between jobs. My travel plans canceled, I quarantined at home with the rest of the country as Wade began caring for coronavirus patients as a nurse. It was a surreal time -- I felt like a player sitting on the bench while my team was playing the hardest and most important game of the season. I had four weeks of anticipation as cases surged in New York and New Jersey, and surged even harder on Navajo Nation, with a higher per capita case count than either of those states during the first wave. I heard heartbreaking stories from Wade as our hospital repurposed other units to make more intensive care units to handle all the coronavirus patients, the vast majority transferred in from the hard-hit Navajo reservation. 

I waited at home. I unpacked. I bought rainboots to wear to work in the closed coronavirus units. I watched the news, read the medical journals, and tried to prepare myself to take care of patients with this novel disease. 

April/May: on the frontlines - I started my new job mid-April, and as I learned my way around the hospital, I realized that nothing was normal. All the new faces I was trying to match with new names were covered with the same blue medical masks. Many of the usual ways to get around the hospital were blocked off to make closed coronavirus units. With all the uncertainty of how the virus was spread -- if we were at risk in our jobs, if we could spread it to loved ones at home, it did feel like we were on the 'frontlines'. 

I won't ever forget the first time I was called to admit a patient known to have the coronavirus. Gown, gloves, face shield, mask. My heart raced as I slid open the glass door, and then slid it closed behind me. I walked up to her, introduced myself, and started my interview. My heart calmed to its normal rate. I was a doctor, caring for a patient. I knew how to do this. She told me her story, I asked her questions, examined her, and told her our plan. I made eye contact, touched her hand with my gloved hand, and tried to be as human and reassuring as I could through all the layers of protective gear. 

A partner of one of Wade's fellow nurses took these photographs during this time, which were later published in a beautiful Washington Post Magazine piece, and they certainly resonate with me in terms of the gravity and intensity of those months. 

I also won't ever forget the first death certificate I entered for a coronavirus patient. Completing death certificates is part of our job as physicians -- certifying the cause of death of patients who died while under our care. I have done it many times before and will many times again. As I submitted this one, though, I felt like I was watching a single drop fall into a large and ever growing bucket. I had added one more number to the rising death toll of this virus, which now as of September 2020 has surpassed one million in the world. One thousand thousands. I knew this one person--I knew what she had gone through in the last weeks of her life, I knew her husband and her children, and what they went through as she worsened and began to struggle to breathe, video chat the closest they could get to saying goodbye. I know this one story, but each of those 1,000,000 people has a story, a family grieving for a loved one who is no longer with them, many with other deaths or critical illness within the same family. It is hard to wrap our minds around the magnitude of the tragedy these deaths represent, let alone the tragedy of jobs lost, economic hardships, evictions, mental health consequences of this pandemic. 

June/July/August: a new normal  -- over the summer, we settled in to a 'new normal'. I stopped thinking twice about walking into a room with a patient with coronavirus, because I do it so frequently and trust the protective equipment to keep me safe. Still, the 'new normal' was not a comfortable one -- Arizona surged in cases over the summer, like Texas and Florida, with hospitals starting to near capacity in many parts of our state. The demonstrations for racial justice sparked by George Floyd's death stirred much needed conversations about police violence and the deep roots of racism in this country that persist to this day, but also disturbing counter-protests rooted in hate and fear. I do see some rays of hope in the conversations they have sparked within medicine. Like so many institutions, our medical system and our medical education system perpetuate bias and racism, and more mainstream voices within medicine are acknowledging this fact and starting conversations about what can be done about it. 

September: gratitude - as summer turned to fall, Arizona managed to contain a large surge in coronavirus cases that caused much anxiety for all of us in July and August. For this I am tremendously grateful. Right now, I have to say that I don't feel that I am on the 'frontline' any more of dealing with this pandemic. I have it easy -- I leave my house regularly and get to interact with people in meaningful ways at work. Aside from extra protective equipment and headaches due to slow turn-around on coronavirus testing (wouldn't you think we would have adequate supply of rapid tests in this country by now?), I mostly get to do the same kind of job in a relatively similar way as before the pandemic. I got it easy. 

Instead, I feel those bearing the brunt of this pandemic right now are many -- all the parents out there trying to work from home and provide childcare and keep their kids on their zoom classes. All the teachers trying to do the impossible task of virtual distance education for children of all ages. All the administrators in schools and universities trying to pick some kind of a path through a no-win situation. All the governors and mayors who have suddenly become public health officials. All of the people who have gotten sick or died from the virus and their friends and family that are grieving. All those who have lost jobs or whose businesses are suffering or closing. It brings me tremendous sadness to observe this economic recession that is amplifying pre-existing disparities between the wealthiest and the lowest wage earners, between men and women, between white people and minority groups in this country.

October: a few requests -- and now it is October. We are finally 3/4 of the way through this crazy year. With elections coming up and the prospect of a combined coronavirus/flu season this winter, it seems the last months of this year are unlikely to be any smoother a ride. Indeed, in a first curveball of this last quarter, President Trump has just tested positive for the coronavirus. I wish him a mild course and speedy recovery as I do for all those affected by this virus. I'll close with a few requests for all of us to get through this time together:

#1 - Get your Flu Vaccine -- its not a perfect vaccine, but it does reduce your chance of a severe flu illness. If we all get vaccinated, we'll have fewer cases serious flu illness, fewer hospitalizations and deaths from flu, and more room in hospitals for coronavirus patients this winter. 

#2 - Be safe when visiting with friends and family. It may not be realistic to all quarantine at home at all times until a vaccine is here, but the risk of getting/giving coronavirus is real if you spend indoor un-masked time with other people. Spend your time together outside if at all possible, and if you do spend time inside together, wear masks! Here's one table that helps show levels of risk of different contact situations: 

#3 - Vote. As a doctor in this pandemic, I have felt abandoned by our current president, who has systematically downplayed the risk of the virus, encouraged an attitude of recklessness that facilitates its spread, and has not ensured adequate testing and protective equipment in this country to this day. Electing Joe Biden and Kamala Harris would be an incredible breath of fresh air to have strong, logical, science-based leadership for pandemic management. 

Creativity

I spend a lot of time using the analytical side of my brain. Reconciling medication lists. Keeping track of orders. Looking up algorithms and applying them to my patients. Keeping task lists and grocery lists. Staying up on my email.

I sneak opportunities to apply my creative side at work -- leading team-building activities, designing recruitment materials, developing interactive community outreach booths. But it is in my free time that I get to really let it out, and this is an amazing place to create and appreciate art.

I recently picked up oil painting, in addition to pastel painting. It has been challenging but fun to add this new medium.

my first oil painting

photo reference -- my housing complex in the winter time

This was my second oil painting, and actually one of my favorites, mostly because the subject matter was so beautiful. Like many of my favorite photos and paintings, it was taken from my backyard...

photo reference - rain clouds over first mesa from my backyard

my second oil painting

my oil painting setup

yes this is a real photo and I have no idea what made the blue searchlights appear in the sky, but they were amazing

and so fun to paint a reverse sunset with searchlights over a cornfield

I have my mother to thank for getting me back into art 3 years ago and for sharing an amazing art retreat with me each summer at The Clearing!

red ribbon run

I had one of those beautiful days today at Hopi and just wanted to share it.

It started with an early rise at 7am with my father and stepmother who were visiting to get ready to help out at the Red Ribbon Run -- a community event that I've been involved with for the last 2 years to raise awareness for Substance Abuse Prevention.

From 8am-9am I helped out with one of the Health Center booths for education about opioids along with two really amazing students who are rotating with us right now at Hopi. We talked to dozens of people about opioids and played a game sorting pain medications as opioids vs non-opioids and talked about safe use, storage, and disposal of opioids and all the non-opioid ways to treat pain to reduce the risk of addiction and overdose.

This is part of a larger, very successful community initiative for opioid abuse prevention. The students were so fantastic at running the booth that I got to do a fair amount of mingling and visiting the other booths and socializing with friends, colleagues, and acquaintances and nourishing connections. The atmosphere was light despite the heavy topic as it was also a Halloween Fun-Run and everyone was in some pretty amazing Halloween costumes!

After the runners took off, I went in to the hospital for a few hours and took care of our hospitalized patients for the day -- all wonderful people with caring, supportive families. I got to flex my brain on some interesting medical issues, do some teaching, and then made it home for lunch with my father and stepmother.

The afternoon was spent in the desert with my parents and overly energetic dog Talus, who finally got to burn off his energy playing fetch with my dad on the dirt road.

 I mistakenly left the house without water, and thought we'd be ok with it being a cool fall day, but 75 degrees in the sun got to be rather hot and we all got rather thirsty by the end. I showed off the wash and its crispy crunchy dried mud flakes, and we journeyed back in the heat with Talus soaking up all the shade he could find.

photo not from today -- but an example of the crispy crunchy dried mud surface of the wash

Walking back through the neighborhood, we weren't the only ones enjoying the beautiful Saturday and stopped and chatted with friends and neighbors a few different times before making it back and chugging some serious water together.

I went back into the hospital for a bit to catch up on charting and exchange some friendly banter with nurses and providers, and now am enjoying a quiet evening at home with Talus passed out on the couch (finally!).

One of those days that makes you stop and appreciate every facet of life and work here -- community, medicine, teaching, colleagues, the desert, the sun, and the stars.

reflections and a new year

In the Hopi traditional calendar, December or Kyaamuya, is a time of quiet, reflections and stories. It is a time to reflect on the past year and what you want to improve upon in the coming year.

I like this idea of a reflective, peaceful time. A time to slow down and do less and think more.

What has 2018 meant to me? It was a good year with much to be thankful for. A job that is invigorating, challenging, ever changing, and meaningful. Smart, fun, kind, supportive colleagues. Time with family and to explore the Southwest. And an incredible partner in life, love, and outdoor adventure.

In December, Wade and I took a quick 2-night backpacking trip in our 'backyard park' of the Grand Canyon. We hiked down South Canyon to the Colorado River and spent two nights on the beach. Such are the short winter days at the bottom of the canyon that sunlight only hit the beach for around 4 hours that day, which Wade spent fishing and I spent writing. It was a bit chilly but such a beautiful route down and pleasant area to explore -- including a waterfall, a cave, and ruins.

The view from 'Stanton Cave', one of the many places we explored from our beach camp at the mouth of South Canyon

Mid-day sun lighting up the Canyon

December also brought some of the biggest snowfalls I've seen here at Hopi. Yes, it does snow in Arizona. How much depends entirely on the elevation. In Flagstaff at around 7,000 feet, it snows quite frequently, and even more in the mountains, enough to operate a ski resort. At Hopi around 6,000 feet we usually just get dustings that melt within a day or two at the most. But in December we got a few snowfalls that accumulated and stayed and it was beautiful.

My neighborhood of adobe homes after a winter snowstorm

Hiking through the desert snow

Sunset colors peak and sparkle on the snow

And then January came, a new year with new beginnings, and a new outdoor destination. Wade and I venture often to the Grand Canyon as it is close enough to be our 'backyard park' and offers a lifetime of new places to explore. When we had a little longer stretch of time off together in January, we decided to take the plunge and do something different and instead ventured to a National Park in our neighboring state of California -- Death Valley. I imagined Death Valley as an big, flat, hot desert -- but discovered that couldn't be farther from the truth. It does indeed have valleys below sea level which are exceedingly hot in the summertime, but these same valleys are actually quite cool in the winter. It is also the largest National Park in the lower 48 states and includes multiple mountain ranges with some mountains over 10,000 feet tall, dozens of canyons, Joshua tree forests, and moving rocks! We spent a week there and saw all of these and more in a tiny fraction of the park.

We spent most of our trip in the vicinity of Racetrack Valley, an expansive mudflat with a few rocks scattered on its surface, some of which have tracks stretching into the distance, a record of their movement across the mudflat over time. For a longtime the mechanism of their movement was a mystery -- wind? water? aliens? The, in the winter of 2013-2014, scientists set up an experiment and observed how rocks move rocks move when sheets of ice form over a shallow water pond and are blown by the wind and push the rocks and the mystery was solved. 

an example of a few of the rocks with their tracks extending hundreds of feet towards the horizon

The view from a saddle on our approach to Racetrack Valley on our backpacking trip

fun with shadow pictures in Racetrack Valley

 The other highlight of the trip was soaking in the natural Saline Valley hot springs. It is a true desert oasis with palm trees, outdoor showers, and many soaking tubs with views of the surrounding mountains during the day and stars at night. The place is truly remote, gorgeous, free, and exquisitely maintained by the communal efforts of volunteers. We made our way there at the beginning of our trip, and had to make time to go back again after our backpacking trip before leaving the park.

 And lastly, both Wade and I got to see Joshua trees for the first time. The Joshua tree forests appear almost like something from a Dr. Seuss book, they are so different from other trees and each one is so unique in shape.

January and since come and gone, and now February is here, bringing me to Phoenix for an acupuncture training, another new beginning for me for this year. I've always been interested in traditional medicine modalities of all sorts, and this form of Traditional Chinese Medicine has started to get more mainstream recognition, especially in its role for pain treatment in the era of realization of the risks and harms of opioids for chronic pain. I'm now midway through a 6-month course for medical providers to learn acupuncture therapy and it has been quite thought-provoking for me around concepts of health, medicine, healing, evidence, and patient-provider relationships.  More on that to come...

Monsoons

"There are two easy ways to die in the desert : thirst and drowning"  - Craig Childs, The Secret Knowledge of Water

This winter was exceptionally dry in Northern Arizona . Forest fires raged in many forests in the area throughout the summer. Most towns and cities canceled their 4th of July fireworks due to danger of starting more forest fires. The majority of the National Forest around Flagstaff where I and so many others regularly go hiking was closed off to the public for the last several months. And it has been a terrible year for the Hopi dry farmed corn which depends on winter moisture deep in the soil to sustain the plants until the monsoons. Many plants have not come up at all.

And now, at long last, the monsoons are here. The forest is open around Flagstaff.

view of the 'peaks' from national forest trail as the mountains near Flagstaff are affectionately known

 While the rest of the country has four seasons, here in Arizona there are really five: fall, winter, spring, summer, and monsoon season. The monsoons peak mid-July through mid-August and are very different from the thunderstorms I am used to in the Midwest. Storms roll through and drop large amounts of rain in just a few minutes, and may completely miss an area just a mile away.

The arrival of the monsoon means many things. My garden that has been limping along is about to take off, along with weeds that will soon outnumber my plants. Roads will be washed out or muddy and make transportation difficult or impossible for many of my patients. There will be flash floods in towns, canyons, and washes, like the one in Flagstaff today. The mosquitoes will be here in a few weeks, just for a few short weeks.

But for now, I am thoroughly appreciating the first storms to come through Hopi this year:

The washes are flowing 

the storm clouds are incredible to watch in the open desert

and the monsoon sunsets are unlike any other

with the vibrant colors in the sky lighting up the puddles behind my house

Second mesa sunsets

Last night I walked into my spare bedroom, and this is what I saw through the window:

Clouds aglow behind the Walpi housing complex

 I grabbed my family who was visiting and we walked across the housing complex and watched the end of the sunset over the San Francisco Peaks:

I have never seen sunsets anywhere else like the ones I have seen in the last year since moving to the Hopi Reservation. Every day that I am able, I like to take a walk in the desert around sunset because it never disappoints. I thought I'd take this chance to share some of the photos I've taken of sunsets here, all of them from within a mile of my house. 

Sometimes there are no clouds and the sky lights up the silhouette of the mountains

Sometimes there are wispy clouds

Sometimes the clouds are thicker.
In the summer, the sun sets behind Second Mesa instead of the San Francisco Peaks. 

Did you know that if you turn around and face East, in the opposite direction of the sunset, is another display of color?

It is like a reverse sunset. Yellow on top, then orange, then red, then blue.

Sometimes these colors make me want to paint them!

Sometimes my sunset walks take me on the other side of the health center.

And sometimes a photographer friend happens to be there to make a picture of me making sunset pictures!
Photo credit: Christina Gomez-Mira

This has been rather more of a photo-album than a blog post, but I think the sunsets speak for themselves. I am ever so grateful to be here in this place enjoying these colors, taking in this space, and breathing this air.

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.