by Dr.
Andrew D. Saal '87
"Are you sure you're a doctor?" The young woman smiled at me
as I sat on the floor, a cup of coffee in my hand. Her family
rested uneasily in the few chairs crammed into the tiny waiting
room of the intensive care unit. They watched me with a suspicion
reserved for outsiders. "Aren't you supposed to stand over us
and speak with authority or something?" The woman asked this in
a hesitant but humorous way, as if she were worried about overstepping
some cultural boundary. In a way she had. She was Navajo, and
I was yet another Anglo doctor in the hospital. "I thought all
you doctors wore white coats," she teased.
We had spoken several times that weekend at her father's bedside.
She herself was studying nursing down in Phoenix. In her own way,
she was an intermediary between the hospital and the traditional
members of her extended family. Her humor helped to defuse the
tense situation. But still, there was an awkward silent stress.
The family conference was an impromptu update on their father,
brother, uncle. The 54-year-old Navajo man was sick and getting
sicker. He had battled two months of a slowly worsening pneumonia.
Despite multiple rounds of antibiotics and numerous hospital visits
all over northern Arizona, no one had been able to cure him. He
had come to our office for the first time only five days earlier.
When one of my partners had seen him that day, he was nearly
blue with respiratory distress. He had profound dehydration and
a soaring fever. Within an hour he was admitted directly to the
intensive care unit. His hospital course began like so many thousands
of others. We gave him IV fluids, ordered a slew of tests and
opened fire with antibiotics. In the words of the police chief
from Casablanca, we tried to "round up the usual suspects."
But something was different about this man and this illness.
Something just didn't fit in the usual patterns. More history
was gathered. More specialists were consulted. More tests were
ordered. More diagnoses were guessed. Yet the man still lay dying
in the ICU. Our best efforts were not good enough.
I leaned back against the wall of the waiting room and sighed.
Frustration had been the predominant emotion among the involved
staff that morning. Nothing was working and nothing made sense.
I could explain the details of what was wrong, but so far no one
could explain why. With my cup of black coffee as emotional support,
I launched into the family update and fielded their questions.
But in truth, I had no answers. The young nursing student translated
for the traditional elders present. Her presence helped me bridge
the language as well as the cultural gap.
That day did not go well. For some unknown reason, he rapidly
deteriorated. He was floridly delusional, seeing animals and hearing
voices. When I returned to see him that evening, his daughter
was visibly shaken by his abrupt decline. My concern was a bleeding
stroke, hers was something else. I sensed that something must
have happened earlier that afternoon. She didn't want to discuss
the matter.
While we prepared him for an emergency CT scan of his brain,
another visitor arrived. He carried a modest bundle in plain fabric
-- a medicine pouch. I recognized
him as another consultant of sorts. With respectful nods we traded
places at the bed. I stepped quietly to the back of the room and
silently observed the Navajo healer practice his art. He asked
the daughter several questions, and listened patiently.
Although I had been permitted to
observe, the conversation was held in Navajo. Some ideas just
can't be conveyed in English. Abruptly they both fell silent.
The elder began examining the skin of the patient. He observed
the patient's hands and a small blemish on his neck. Suddenly
the healer hissed air between his teeth and shook his head silently
at his own conclusion. Several members of the family squirmed
uncomfortably.
The medicine bundle was opened
at the eastern edge of the bed. The healer sang prayers and burned
a very small amount of an herb. After several more prayers, he
extracted a tuft of white sage. With gentle yet precise sweeps,
he passed over the patient as if he were washing him with the
sage. Purification. Cleansing. But why? The answer eluded me.
The other Navajos in the room were uncomfortable with the diagnosis.
They weren't discussing it either. Something remained unspoken.
"You feel like a fifth wheel? How
about a sixth or seventh?" the pulmonologist on the case asked.
He was a friendly middle-aged intensive care specialist. With
a humorous twist, he spun my lament back at me with a smile. Like
an uncanny percentage of doctors in Flagstaff, he drove a pickup
truck and spent his free time hiking the back country of the Grand
Canyon. He also seemed to enjoy mentoring the rookie. "You may
not be writing all the orders, but your presence on this case
is as important as anyone."
I thanked him with a humble smile.
That night had been a long one. Our patient had slowly but deteriorated.
He had become more restless as his ability to breathe declined.
Finally, just before dawn, we had to intubate him. He was on life
support, completely dependent on the ventilator to keep him alive.
Several IV medicines were being infused to maintain his heart
rate and cardiovascular tone. From my chair at the nursing station,
I could see several new colored lines dancing on the monitor over
his bed. Nearly every possible vital sign that could be measured
was now quantified, computerized and animated on a screen. Two
of the specialists on the case debated the intricacies of the
man's unknown disease. I listened for awhile, then graciously
bowed out of the conversation. Even with all the tests and machines,
we still had no idea what was happening. We knew how to stabilize
him but not how to heal him.
I wandered out to the waiting room
to meet again with the family. I knew my limitations in the intensive
care unit, but perhaps I could gather more history to illuminate
his diagnosis. Not surprisingly, a more family members had arrived
in the night. I was not prepared for their sheer number. Crammed
into the tiny waiting room, almost 20 people had set up a base
camp. My friend the nursing student introduced me to the matriarch
of the clan, a Navajo grandma dressed in a green velveteen blouse
and a dark skirt. The elder had worn her best turquoise necklace
for the journey into town. I greeted her with my poor Navajo phrases,
but formal respect. She shook my hand loosely in Navajo fashion.
Until someone trusts you, a Navajo handshake is usually a loose
brushing of hands at best. The handshake was a social form introduced
by the Anglo settlers. For a traditional Navajo, an enemy could
poison or curse you by simply touching you. Hence, the cautious
handshake with a stranger.
I ended up on the floor again,
coffee in hand, while the family gathered in the room. I updated
them on the recent change of events: the tests, his respiratory
failure and what to expect when they saw him on life support.
Discussing his overall prognosis, however, was a cultural hurdle
in itself. To even mention death as a possibility would invoke
fate itself. Speaking of death was taboo. Even mentioning the
name of a deceased loved one could bring about horrible things.
So I spoke in vague metaphors and
a few facts. I stumbled at times, but the grandmother quickly
realized what I was trying to communicate. Their medicine man
was also welcome to assist in any way he could. Several people
minutely nodded their heads in agreement.
After a few more questions and
answers, I gently began to hint at questions of my own. I needed
to know more details of the preceding months. Something had happened
over the summer, but the details were foggy. Several animals on
his farm had died rather abruptly in the weeks before he first
fell ill. With that vague piece of history, the infectious disease
specialist had already modified the antibiotics. A dozen tests
for rare illnesses had been ordered: plague, hantavirus, brucellosis,
tularemia and a slew of other unpronounceable diseases. But even
with appropriate antibiotics, the man had been slowly slipping
away.
Two of the young adults looked
at the grandmother, then back at me. Slowly they recounted the
details of the animal deaths. Two goats had died within the first
few days. Then one of the horses began acting odd. It was warm
to touch and sweated profusely. The horse soon broke out in blisters
all over its flanks. In the end, it could only lean against the
stall. When the horse finally died three days later, the patient
had taken the carcass out to bury it.
A man and woman in the back of
the room shook their heads and gestured as if purifying themselves.
Clearly the animals had something to do with his illness in the
Navajo belief system as well as mine. I took a leap of logic,
and prayed that I would not break a cultural taboo. "What do you
think is going on? Did someone cause this illness to happen?"
I could hear electronic chirps
from the ICU and people shuffling about far down the hall. But
hardly a sound came from the 20 people gathered in the tiny waiting
room. During that infinite pause, I could only wonder if I had
made a severe blunder. Had I honored them or offended them by
asking such questions? After all, we were the gods in white coats.
Didn't we know everything? Would I undo the prayers of the medicine
man by mentioning such a thing openly?
The silence lasted only a few heartbeats,
but its duration seemed a lifetime. The silence was broken by
the grandmother herself. Slowly and deliberately she told me all
she wanted to share. "A man . . . with a tatoo." Five succinct
words, and she was again silent. The others in the room seemed
split over the matriarch's decision to allow an outsider into
their family crisis.
The nursing student silenced the
dissension with a simple remark. "He asked for our help. They
need to know." The waiting room again fell silent. The student
looked at the grandmother, then back at me. She swallowed dryly
then spoke. "Yesterday morning I was alone with him in the room."
The patient had been fairly lucid and even able to sit up. "He
was happy and seemed to be getting better." She closed her eyes
and shook her head. From inside she gathered her strength to finish
the story. "Then that man arrived . . ." Her voice trailed off
faintly.
After a considerable pause, I whispered,
"The man with the tattoo?" The room fell deathly silent. I suddenly
understood just what had happened that previous day, just an hour
before the patient had spiraled downwards.
For a traditional Navajo, there
is no separation between religion and life. The Navajo Way is
a philosophy that is ingrained into every minute of every day.
Generosity for one's family and respect for life are just a few
of its elements. Harmony with the world around you is its center.
Disease is often a spiritual matter. A person can become ill through
his own actions or by the actions of others.
Most people follow the Navajo Way
to some degree. Even those on the Jesus Way still respect the
traditional philosophy. But in the Navajo world, a few persons
actively reject the Navajo Way and hence all that is good. For
their own gain and personal power they corrupt the natural order.
The most unspeakable of any Navajo taboo is a person who rejects
the values of family, community and life. He or she represents
corruption and real evil. Rumored to be shape-shifters, they can
change into animals to further their malicious desires. Although
they can jinx a person with a simple glare, their worst curses
are placed by touching the victim. The name of such an evil person
should never be mentioned, because surely he or she will hear
your voice and come after you as well. So a certain word is whispered
but generally not spoken if at all possible: Skinwalker. A Navajo
witch.
A skinwalker is far from the European
concept of a witch. They are not like benevolent television characters
or even the earth-loving Wiccans of the Celtic tradition. They
are pure selfishness and hate. I surmised by the family's silence
that the tattooed man was rumored to be one. He had unexpectedly
visited the intensive care unit that previous day. And before
the daughter could stop him, he had touched her father. Now our
patient was on life support and near death. Our machines had managed
to save him, if only for the time being.
Anglo physicians likewise have
several taboos and unspoken fears. To discuss our actual powerlessness
over death is to confront our own deepest insecurities. We fear
not knowing the answer. We fear failure.
I still remember a question from
my medical school interview. "Are we in the golden age of medicine?"
I had replied "no" to the two professors. We'll never know everything.
One has to remain a student their entire life. There will always
be new illnesses to unravel and new facets to the ones that we
thought we understood.
We as doctors are essentially powerless
over the unknown, just as we are powerless over everyday events.
No gods walk in white coats. For physicians, the deepest unspeakable
fear is inadequacy. Despite our best efforts, we may not be good
enough.
Our patient remains in the intensive
care unit on life support. The medicine man has conducted several
healing ceremonies to restore harmony. The medical team continues
to pour antibiotics, steroids and other chemicals into his body.
And finally, much to our relief, something finally seems to be
helping. In the past few days we have weaned him from the drugs
supporting his blood pressure. We've even turned down the ventilator
a few notches.
Yes, we are powerless over death.
But far beyond the realm of antibiotics and technology, both the
family and the medical staff are trying to grasp the most potent
medicine of all -- hope. Because
if disease may occur on the spiritual plane as well as the physical,
then so must healing.
