By James (Jim) Martin, BSN, RN, CCRN, CSC, CMC
Cardiac Surgery ICU
It was after dark when my small commuter plane landed in Durango, Colo. As I stepped out of the cabin and onto the tarmac, a warm, arid wind rattled the turbines of slumbering jets nearby. The energy of the desert surrounded me, its magic palpable under the starlit sky. In that moment, I knew that the trip of service on which I was about to embark would be an unforgettable part of my earthly journey and exactly what my spirit called for in the wake of the first wave of the coronavirus.
Geography, Resources and Health Outcomes
It was immediately obvious that geographical proximity to resources played a much different role in everyday life in Shiprock than it does in Longwood, where several of the world’s best hospitals are nestled together within a few square miles.
Patients at NNMC who require advanced support modalities are stabilized and transferred to larger facilities in the area, the closest of which is a 45-minute drive away and offers the only cardiac catheterization lab and mechanical circulatory support in the region. Advanced cardiovascular life support (ACLS) ground transport off the reservation is not reliably available due to a shortage of cardiac EMTs and paramedics in the vicinity, so escort by two hospital nurses is frequently needed. The arid desert winds that welcomed me on arrival often prevent air transport.
To make the situation even more complex, the COVID surge exacerbated a nursing shortage. With permanent nurse staffing vacancies of more than 50 percent in the ICU and 75 percent in the ED, traveling nurses and volunteers have been critical to continuing operations. It seemed that, across the board, all health care professionals were in short supply in the rural Southwest.
Additionally, the very flow of bedside practice was different in this community setting than in our Boston academic medical center. Nurses in this setting demonstrated a high degree of flexibility as they float to any number of units and often need to function with few support services. I also observed less hierarchy than accompanies our large departments and a more relaxed style of interdisciplinary communication.
While all communities and health care workers who have endured a COVID surge continue to recover, it was apparent to me that this small community felt it differently than we had in Boston. March brought a surge and, like ours, it made providers acutely aware of their own vulnerability to this disease and drove barriers between devastated families in a way that has come to define the year 2020. But when NNMC abruptly developed a critical gown shortage, workers from around the hospital held all-night sewing sessions to protect their own from succumbing to the same fate as their patients. As I donned the same gowns they crafted, a nurse shared heartbreaking stories of intubating her colleagues. I was reminded of my own deployment in one of the Brigham’s Special Pathogens Units and felt grateful for having been sheltered from some of the harsher realities that were felt in communities like this one.
Beyond the walls of NNMC, the breathtaking desert terrain of the Navajo Nation has been home to the Navajo people for generations. Legend says that the tribe will be protected as long as its people remain on their land between the four nearby mountains. Apart from main highways, much of this territory is without formal roads such that hospital forms include a blank space next to “address” for the GPS coordinates or descriptive directions based on landmarks. Deeper in the reservation, families tend to live in small groups of homes, the majority of which are without electricity and running water. The necessities for living are made or grown, purchased at trading posts, or obtained on longer ventures off the reservation to stores in nearby towns. Talking with Navajo health care workers about tribal lifestyle and day-to-day life in combination with the constraints of the health care access shed some light on the stark disparities that affect the Navajo tribe.
Navajo culture holds elders in high esteem. Tribal history is an oral tradition that is imparted to each member of the tribe from older generations. This respect is evident at the bedside, where I was encouraged to call elder patients “Grandma” and “Grandpa.”
Too often, I think that modern American culture at large views elders through a lens of disability and fragility, filtering out their wisdom and leaving behind the hues of feebleness and senility. Caring for the elders who “paved the way” for us is an honor, and receiving the wisdom in their stories is a privilege that holds the key to a life well-lived for the attentive listener. As each of us goes about our days providing world-class care to the individuals and families who come to the Brigham, we teach them about their expected journey through the health care system. But are we listening for what are they teach us? How do we honor them and the path that brought them to us? How do we engage in open dialogue to honor them when they move toward death and subsequent transition into another dimension? What do we do to allow them to share the wisdom of their experience before they depart?
Being a valuable member of a health care team isn’t just about the ABCs of clinical care; it’s also about empathetic connection with people. It’s about seeing, hearing and respecting the individuals and families you care for as well as your colleagues. It’s about meeting your charges in the context and the reality of their experience and using your education, clinical expertise and authentic self to illuminate the rocky path ahead, spotting them when they reach unsteady ground. It’s about supporting your peers as you share the tragedy and triumph of health care, highs and lows understood uniquely by those who have left their loved ones to care for a stranger at the bedside.
About Me / The Author’s Lens
A crucial component of this trip for me was openness to my own ignorance. To summarize a Zen proverb: You cannot pour tea into a full cup and, likewise, one who assumes they know everything is not open to learning anything.
Observing the challenges of providing care and living in the desert, combined with the disproportionate hardships that have affected indigenous people, has solidified for me the importance of reflecting upon the formative privileges and opportunities (or lack thereof) that shaped the lenses through which I observe myself, others and all aspects of this world. With the first wave of COVID, the Black Lives Matter movement and now the Navajo at Shiprock fresh in my mind, I am overwhelmed with awareness and gratitude for the life I’ve lived. How would my life experience have varied if I had been born a different sex, race, height or nationality? What if I practiced a religion different from peers, lost a sibling to drug overdose, or were wrongly imprisoned? Every part of my daily life is touched by privilege granted to me simply by “accident of birth,” good fortune and some prudent decision-making.
I am a queer, cis-gendered, gay, white man who works as a medical professional in the Northeast, where I was born and raised by educated, middle-class parents. As I was taught from childhood, and as I know to be right, I treat others with respect and kindness and advocate for the sick, the dying and the underprivileged. With the help and guidance of a supportive family, I attended in-state university on academic scholarship and started my career as a nurse near home. I learned more about health as part of my professional development and enthusiastically pursue my growth despite being part of a community affected by significant health disparities and barriers to culturally competent care. As I grew in my professional practice, I sought opportunities to mirror this growth in all facets of my life, relocated to Boston and joined a team that provides some of the best health care available anywhere in the world. Along the way, I have tried to heal past wounds and treat others as I would like to be treated — investments I hope will mature into a better tomorrow for both myself and those with whom I connect.
After nine years of nursing practice and over 30 years in the University of the Universe, it seems apparent to me that we all want essentially the same things, including: to have our basic needs met, to love and to be loved, to care for others and to be cared for in return, to be heard and seen, to meaningfully contribute to the well-being of others and to pursue what fills us with passion, free of persecution.
I am sure this is not an original sentiment, so I lend my voice to harmonize with others who have already said that now, more than ever, the world needs more kindness and respect shown by all people for all people; openness to sharing our own experiences and learning about those of others; humility to admit error and to make amends; advocacy in the face of inequity; hard work toward common goals; selfless giving to others in need; self-care as a foundational component of lifestyle; and a shared love of humanity.