Of Two Minds

These days, I seem unable to think about much other than the challenges of Kayenta and my lack of comfort and confidence while taking them on. Thus, as I looked back at my tracks in the snow, coming and going, “of two minds” seemed an obvious title for the image.

At another time, or maybe as another person, a solitary stroll to the highest point in Mesa Verde National Park would not give rise to thoughts of struggles at work, but to paraphrase Rumsfeld, apparently you live with the brain you’ve got, not the one you might want.

For the weekend, I took a short road trip up to Cortez, CO and nearby Mesa Verde. Getting out of Kayenta has a funny effect, but I like it. The balance between determination to succeed and anxiety, which leans to the latter in Kayenta, shifts to the former when I hit the road. Perhaps this isn’t desirable or healthy, but it’s welcome. I spend much time in Kayenta wondering what the heck I’m doing, and it’s reassuring to every now and then feel more fully the value of the effort, and to see the big picture.

The next week should be an important one. Due to the difficulty of recruiting permanent employees to Kayenta, the physician staffing (other than me) in the emergency department (ED) is contracted out to a staffing company which provides the physicians. Needless to say, neither the contract bidding process nor our site attracts the crème de la crème of emergency physicians. This week I meet with the contracting company to try and convince them to send some upgrades.

We also officially start the acquisition attempt to implement the electronic health record in the ED. We have worked hard to get the necessary blessings to go forward, but it is a big ticket item (for those of you who remember the old Disneyland, it’s an E ticket, for sure), and there are many spots where it could get derailed. As a solidly 20th century physician, why would this 21st century item matter to me, you wonder? In my view, typically the electronic record process is geared toward the goals of the administration: billing, data tabulation, compliance with various regulations, etc. The real power of the electronic record to directly improve patient care and provider satisfaction ends up a secondary concern. We need, badly, to reverse those priorities here, and have selected a system which we believe will actually help the providers make good and prompt decisions, thus improving care.

We are attempting to be the first ED in the IHS to implement a system of this sort. Other IHS EDs either have no electronic record, or have gone with one that is difficult to use and impossible to implement in a place like ours. It will be quite a coup if we succeed. Stay tuned, miles to go before we sleep..

Success in either of these major efforts would go a long way toward making me feel like I'm actually doing something here, and that would be nice.

At the end of the week, home to Portland, the chance to hug family, then in mid January off to Mali for two weeks to hug more family. A good end to 2011 and a great start to 2012.

Write what you know

Neighbors

It's been quite a week here on the rez, but it may be years (or more) before I can make any sense of it, so please don't expect any wise distillation of meaning here. I finally put on the stethoscope and went to work in the ED, although even that unfolded in a now-expectedly unexpected way. A calm re-entry was planned for Wednesday, at which time there would be another doc on duty, allowing some back-up and orientation help. Instead, I learned Tuesday morning that the doc scheduled for the day had been stricken with an evil GI bug and there was no other back-up, so it was a surprise solo day for me. Despite waves of very unpleasant anxiety, the day went well (at least as far as I could tell), although much of what took place was bizarre and left me shaking my head and wondering what it was that just took place. The nurses were great and kept things functioning until my replacement arrived.

The neighbors drinking spot

Happily the doc who recruited me to Kayenta returned from a lengthy leave, so there was some welcome but belated context, advice, and support which is much appreciated.

My shadow reflecting on the shadows and reflections

Much of the rest of the week, I think I'll omit from this post. I made a vow (not really, but that sounds pleasantly dramatic) that I would shift the balance of work-related posts from anxiety, confusion, and futility to instead a focus on progress, successes, and inspirational moments. Surely, after this much time a few would begin to appear, no? Well, no.

The view to the west

It is said that one should write what one knows, no? So, loyal readers will need to wait a bit more for those reports, but please know that the frustrations of the week have served to fuel my determination to produce some (any) blog-worthy forward step soon. Fear not.

Absent any tales of work success, let me just sprinkle this with some shots from my Saturday morning walk behind the Toes. It was, again, wonderful to breathe hard in the cool air, concentrate on choices of photo images, and plan a weekend of relaxation. All the sweeter, knowing that Angela and Beth will be here for Thanksgiving. One never knows - perhaps both the Super Committee and I can pull off a miracle or two before then...

Huh?

One of the benefits, maybe the only benefit, of having an endless list of difficult-if-not-impossible workplace problems is that there is much to write about. And, if you're unimpressed by the challenges that you might have anticipated, I can always find one that will mess with your mind. Say, for example...

Today we had a disaster planning meeting in anticipation of an upcoming statewide disaster "exercise" that will bring a very large number of complex casualties to Kayenta. I know it involves both natural and man-made badness and many, many victims. So, among the many considerations is what to do with the dead. No problem, you say, just implement the pre-existing mass casualty plan for handling many dead: temporary morgue, some cold storage, you know, the usual...

Well, no plan here. The traditional Navajo have a very different view of death, and the dead, than exists in the world outside. It's a long story, but included in the belief system is that there should be minimal contact with the dead, and that structures previously occupied by the dead should be abandoned (a challenge for a health care facility where people do die). Furthermore, it is believed that there is great power in the spoken word and that, regardless of the intent, speaking about death is likely to bring it on.

Planning ahead to handle a disaster as well as possible, even with the intent of saving lives and enhancing harmonious well-being, is viewed by some as a bewitching likely to cause great harm.

So, it's an ideal setting for disaster planning. Sometimes because of the individuals involved, but perhaps more because the individuals involved wish to respect the views of the community, there has been no in-depth discussion of this topic, and certainly no resolution. So, at the meeting, the Incident Commander was happy to see a white guy in my seat and said, "we'll see what the ER comes up with". No problem, good as done...

He's actually a delightful, sharp, and funny guy who, rumor has it, is also a medicine man. I spent almost an hour after the meeting getting some private cultural schooling from him. He is very committed to traditional ideals, but has as his job the coordination of disaster response. My sense is that he finds it pretty hurtful to be considered an instrument of death by some.

I asked about using the abandoned, derelict BIA school buildings as a temporary morgue, but apparently one of the reasons they are abandoned is that the lead paint lead abatement program was too expensive, so lead toxicity may rule that option out. Just another day at the office...

We had the biggest laugh over his description of some of the plans previously suggested by white people. These included storing bodies in the refrigeration units of local restaurants and schools. Out here, I'm thinking this would be a poor marketing strategy for the restaurants and would be unlikely to help with school attendance.

The death plan was only one of several new adventures today, but it's a hard to top that, so I'll sign off.

Just a pleasant quickie

Well, back in Kayenta again for a 2 week stint. Have spent day 1 and day 2 of the week mostly in new employee orientation, a mostly soporific and tedious ordeal, created with good intention, but clearly executed primarily to fulfill the requirements of the Policies and Procedures manual and the Joint Commission. Could the time be better spent? Well, off the top of my head, I can only think of about a gazillion things that would be more useful....

Not all time was spent listening to the presentations by every conceivable department, and then some - I was called out many times to address different whack-a-mole manifestations of a physician staffing problem that came up in the ED, but I'm still sorting that out. I'm confident that it will still be popping up tomorrow - yes, there is another half day of orientation also...

So, I did the only reasonable thing - returned to my modular home, grabbed the camera, and headed out for a quick sundownish scamper. Since both past and future posts are, and will be, often filled with stress and challenges, I decided to just send a few images from a warm, late afternoon near the Toes.

The way I see it, this is orientation. One of the few really helpful presentations today was about Navajo culture. Included was an overview of the direction, location, and spiritual importance of the sacred mountains that define the nation. Can't quite see them from here, but still very nice to climb up and try.

Also remarkable to go only a short distance from the Health Center, with all of its challenges and evidence of the ways in which the lives of people have gone wrong, to find immediately why they believe in the spiritual power of the land and why they draw strength from it.

Be well.

Homecomings

Well, it was the 50th Kayenta Monument Valley High School homecoming week this week, culminating in a 44-6 Mustang ass-whoopin' over the Tuba City Warriors in football. The highlight of the week was the annual parade which, much to the dismay of tourists en route to Monument Valley, resulted in the complete closure of the only highway through town for the 1 1/2 to 2 hours of the parade (followed by a lengthy bumper-to-bumper traffic jam of the delayed tourist cars, campers, and motor homes).

Candy-laden kids awaiting the next toss

The locals lined the entire 2 1/2 mile parade route and were treated to a fine show, including a small marching band, several groups on horseback, high school class royalty couples, and many floats ($1000 prize for best float) and other conglomerations. In a non-nod to the current obesity and diabetes epidemic in Native Americans, most parade participants threw handfuls of candy to the kids lining the street. I note that the parade entry instructions included proper technique for throwing candy (throw high with the wind, low against it) and safety instructions. In a community where many still ride around the rez unrestrained in the back of pick up trucks and kids very often sit on parents' laps without seat belts, it's no surprise that the rules were a bit more lax than one might find elsewhere.

Anti-diabetes banana trails the float

Among my favorites were the FFA float (KMVHS has the nation's largest Native American FFA program), and the diabetes prevention float (complete with banana costumes adorned with Navajo decoration). As another indicator of my tight department control, I was surprised to find that there was an Emergency Department float. Who knew? This small community managed to come up with enough participants to keep 'em coming for almost 2 hours...

The night before this Friday spectacle, I enjoyed the varsity volleyball match against the Chinle Wildcats. The Mustangs also put a hurt on that opponent, sweeping them easily in three straight. Volleyball is huge in Kayenta with, I believe, 17 girls on varsity as well as large JV and Freshman teams. Big community support with hundreds in the stands and everyone's small children running about and playing on the areas of the gym surface not used for the match. It was a refreshing sports experience; people playing as hard as they could throughout the whole match without any coaches screaming at them, lots of effort, lots of smiles. It was all about the game; just the excitement and pleasure of being the ones on the court and making the most of it.

Following that homecoming, I returned to Portland for another, spending a couple of weeks home to work on many administrative projects before returning to Kayenta later this month. A great pleasure to be home, but a great challenge to get things done from afar. We'll see how it goes.

At this point you're no doubt wondering if this tale is truly blogworthy and I share your concern... Here's as much profundity as I can muster -

When lucky enough to go someplace far outside my usual world, the first impression is always how wildly different it is from home. Then as people are met, ideas exchanged, life and families are observed, and the story unfolds, it becomes no less wildly different but one starts to understand how much is the same. Conclusion: People want life, liberty, the pursuit of happiness (hopefully aided by food, clothing, shelter, security, education, health, and the rule of law), and a good parade.

Stockdale on the Rez

Good news and bad news. The good news: After 3 days, I have a much better idea of the challenges that need to be addressed, and the job is beginning to take form. The bad news: I have no idea where or how to start. Thus, the above title (for background, see http://www.hulu.com/watch/4123/saturday-night-live-joyride-with-perot ).

In summary, a small but badly overburdened, underfunded, chronically understaffed health care facility that, within a few months, has lost a longterm very gifted and dedicated internist (married and moved down the rez to Tuba City), its very gifted and dedicated clinical director family doc (family medical leave), and a 20-year family doc. Those 3 constitute half of the permanent physician staff. Thus the entire continuing care system is under extraordinary stress. The ED is staffed by a mish-mash of contract docs who range widely in both their giftedness and dedication (several appear to have both, some neither), and many of whom are not here long enough or often enough to really learn and mesh with the rest of the clinic system to help relieve the stress.

Throw in the need to convert a paper record ED to electronic (a huge and frightening essential task), a few important accreditation issues to resolve, the need to create a good CQI system, the possibility of adding ED ultrasound and possible (one can dream) portable CT scanner, and several other priorities on top of the large-enough challenge of simply improving daily ED operations - and you've got a good-sized mountain o' trouble. Just for grins, take out of the picture the only person who really knows what's been going on and could explain (6 more weeks of leave) and you've got Admiral Stockdale at the vice-presidential debate all over again, in form of yours truly.

Just when one reaches the point of wanting to run screaming to the car to make a fast getaway (a frequent occurrence), one sees the full waiting room, the people out front, the many more sitting in their cars and trucks in the parking lots, the additional cars and trucks rolling in, and one talks with the exhausted, burned-out long-timer providers and the bright-eyed idealistic newcomers who have made the sacrifice to be here, and one must just shake one's head and get back to taking small steps in the right direction. As of today, that's the plan.

Lest anyone get the wrong impression, there have also been some very, very nice moments. I've now met and spoken with many of the staff and even lunched with another human today for the first time. Colin is a brand-spankin' new nurse practitioner (career span 5 weeks) who has made this his first job. He's a former Peace Corps volunteer (Kenya) with great dedication. His girlfriend is a nurse-midwife elsewhere on the rez, so he, too is missing his loved one(s). After work today, he, Charles (a medicine resident from San Diego), and I, scampered up The Toes (see earlier blog or Google) for a beautiful hike. I planned to take a few pics for this blog, but was sad to find the camera battery needing recharge. Yesterday, I drove 20 miles to the turnoff to the Navajo National Monument and had a very, very nice bike ride from the turnoff up the hill to the monument and back. Just what the doctor ordered. Internet (still pirated from my head nurse Keith) allows me to listen to NPR news, Skype with the fam, email, and blog (lucky you). Tomorrow eve, I hope to attend the Kayenta HS vs Chinle HS volleyball match, and tomorrow at noon is the annual homecoming parade, which passes the Health Center, so should get a glimpse ($1000 for the first place float). So, there!!

I think I have a plan for work tomorrow (one day at a time...), and then will head to Flagstaff Friday PM to fly home early Saturday. More later...

What's best?

In a happy coincidence, I happened to pick up a copy of "Zen and the Art of Motorcycle Maintenance" before leaving Claremont and heading to my new gig. 

Sitting alone on the floor of my new home-away-from-home in Kayenta, Arizona, the night of my arrival, after unloading the car, buying some basic groceries and supplies, and assembling my Ikea table, I had the free time to fully appreciate the lump of panic in my chest. A good time to distract oneself from the fear of having made a great mistake, I tried to focus on the question, "what's best", the fundamental question addressed in the above-mentioned book. (Note to readers: I'm only 4 chapters in, so it may not turn out to be the question addressed, at all, but it fits my blog plan so you're stuck with it. This sort of literary license is a genetic predisposition in my family. Sorry)

On paper, my choice to work with the Indian Health Service (IHS) has enough check marks in the “plus” column to justify overlooking some important (very) marks in the “minus” column.  Hopefully still true, but I must say that on night #1, fatigue, anxiety, and loneliness seemed to be trumping any of the noble intentions that got me here. The challenge of splitting time between Kayenta and Portland, attempting to do well at work, marriage, health, and happiness, all while doing no harm to the attempts of others to do the same is daunting. As much as I want to succeed in this, anxiety delivered an initial ass-whoopin' to confidence.

Past experiences suggest that this will all work out – lordy, I hope so. Until then, I spent my first weekend here replaying all of the “wise” advice that I’ve given my daughters to help them face significant challenges of their own. Time to walk-the-walk. If I can handle this with the grace and courage that they have shown, this should pan out. Thus spake myself to myself.

Happy to report now, after my first day at work, that I have been panic-free almost the entire day, and now that I am pirating internet access from my neighbor/co-worker, all is good. With temporary calm restored and the ability to focus on something fun, decided to drop this brief blog and introduce all to the 'hood.

To the right is the view out of my kitchen window, north,  showing my fence, a driveway, the 'hood playstructure, a few of my neighbors' homes, and "The Toes" rock formation. This area is open for hiking and mountain biking, and is likely to be the best chance of regular exercise. Not a feral dog in sight, and a really beautiful day.

Out the front door, looking south, is Sven, the road to the Health Center (3 minute walk), and the boarded-up remnants of some long-abandoned BIA structures. A fine 'hood, surrounded mostly by co-workers, many I've now met. 

I am occupying only a small part of this 3 BR house, and things are still a bit "under development". My giant inflato-bed has been great, satellite radio a blessing, and my Ikea lamp most excellent for reading. There are still patches of un-put-away stuff scattered around. It's really a fine home, although temporary, until my smaller home is refurbished.

Work day #1 was largely spent with orientation and paperwork, but got enough time to discuss things with others that I have a good start on understanding what the job will really entail. More on that as things develop, but for now I'm feeling that it will be about what was expected: big challenges, not a lot of resources, very worthy objectives. 

So, after almost 72 hours here, what's best? Even I'm not foolish enough to hazard a guess, but at 5:52 PM, Mountain Time, I'm feeling much better about being here. That said, can't wait to be in touch with y'all and to see Angela this weekend back in PDX. Meanwhile, I'll keeping reading, wondering "what's best?", and trying to sort out what in the world I’m doing here.