Saturday, May 9, 2015

Part 1: Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM)

My first week at Indian Health Service (IHS) in Gallup, New Mexico was incredibly diverse. I spent the first couple days in clinic, where I learned about the detection and management of the most common diseases in the community--namely, diabetes, obesity, rheumatologic illnesses, alcohol dependence, and depression. Unfortunately, nearly all the patients I met had an underlying diagnosis of diabetes and obesity, likely due to a combination of genetics, an increasingly sedentary lifestyle, and lack of access to healthy food (more on this in my next blog post). I also learned how the PCP diagnoses and treats rheumatoid arthritis (including how to differentiate between general non-active RA and a flare) and ankylosing spondylitis. Since there is no local rheumatology specialist, the PCP is responsible for managing this on his/her own. The PCP I worked with also taught me about the use of Naltrexone in alcohol dependence, which I had previously never prescribed during my residency training in Boston. I also met several patients who were successfully treated with Naltrexone and were doing a lot better. Finally, regarding depression, there were a number of patients I met who had undergone physical and/or verbal abuse from their family members as children and as adults, usually in the context of alcohol abuse. I learned about the stigma of getting therapy in the community, which made me realize how important and needed it is to integrate behavioral health with primary care.  

I spent the second half of the week doing a mixture of inpatient medicine and ID/tuberculosis clinic. On the inpatient side, I took care of a young man who was admitted overnight for fever, headache, jerking movements and diarrhea. He had a history of coccidio-meningitis and resultant syringomyelia status post VP shunt and so meningitis was on the differential and he was initially treated for both bacterial and recurrent coccidio-meningitis. Serotonin syndrome was also on the differential since he was on a number of pain medications for his neuropathic pain (including a high dose SSRI and SNRI), so we discontinued these potentially exacerbating medications. Ultimately however, his CSF studies from the lumbar puncture were benign and his stool study came back as c.diff positive so he was treated for c.diff and sent home. I am glad that ultimately the patient had an identifiable and treatable source of his fevers and it was fascinating to think through his case as it progressed in the hospital. It was fun to present his case during ICU and infectious disease rounds at Gallup Indian Medical Center and get the input from the team of physicians and other healthcare providers.

In tuberculosis clinic I learned the nuances of how to treat latent TB infection as well as active TB and how to monitor for drug side effects. I took care of patients who had been recently hospitalized for extrapulmonary TB and were undergoing treatment, and I also initiated treatment in a patient who is a healthcare worker who had a positive ppd. It was interesting to learn about how common TB is in the population and about the process of contact investigation once someone is diagnosed. We also learned about TB reactivation in immunocompromised patients, namely in rheumatoid arthritis and diabetes, which are very common on the reservation. Finally, we learned about the history of Hantavirus, which was first recognized by Bruce Tempest in 1993 at Gallup Indian Medical Center.

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