Late Presentations to Care on the Navajo Reservation in Shiprock

Akash Gupta, MD

Resident in Medicine/Pediatrics at Massachusetts General Hospital

PGY-4

March 21, 2019

I just completed a 4-week immersive clinical elective at Northern Navajo Medical Center, a small community hospital run by the Indian Health Service in Shiprock, New Mexico. Shiprock is a small town on the Navajo Reservation, named for the nearby beautiful rock formation with sacred significance for the Navajo. I was able to visit the rock formation at sunset early in my rotation, pictured below

The facility serves about 53,000 members of the Navajo Nation. It has 55 inpatient beds, a small 5-bed ICU, and attached outpatient clinics. Represented specialties include Internal Medicine, Pediatrics, Family Medicine, General Surgery, Orthopedics, Ob/Gyn, Podiatry, Audiology, PT/OT, and Radiology.

As a Medicine/Pediatrics resident, I was able to rotate on both the internal medicine and pediatrics services. Internal medicine had a very interesting practice, where providers saw patients in continuity clinics, walk-in clinics, and specialty clinics through the day. However, they also admitted and followed any of their primary care patients, even if they were in the ICU. This meant that they were able to practice across the spectrum of their training, which is very fulfilling. One morning for me consisted of rounding and presenting two ICU patients in the morning to hospital-wide ICU rounds, then going to HIV clinic in the morning. I would be bouncing back and forth between counseling patients on HIV Pre-exposure Prophylaxis, and having a family meeting with an ICU patient. In the afternoon I did walk-in clinic, from which I admitted a patient and continued to round on him the next day. It very much suited my personality, as I enjoy variations!

A lot of the morbidity I encountered was similar to what I would find in Boston: diabetes, hypertension, COPD, pneumonias, cirrhosis, skin infections. However, some of the patients presented significantly later in the course of their illness than I was accustomed to. For instance, one middle-aged man came to a walk-in clinic complaining that his toe was red. What he actually had on exam was an ulcerated, necrotic, gangrenous large toe that had developed over about 10 days. He had been on a work job in Utah, and had been trying to manage at home with topical creams and bandages. He had gone to an urgent care about a week earlier and started on oral antibiotics, but when the toe started ulcerating he had not re-presented to care for several days. He ultimately required emergent debridement, and will likely require amputation. I encountered other stories similar to his, where late presentations appeared to be related to long-distance travel for work, as occupational opportunities were minimal in the immediate surrounding area. It’s interesting to think about how to optimize a health system to meet this issue!

All in all, it was a highly educational 4-weeks at Shiprock!