It was early summer—monsoon season—when I began my first job as a family practice doctor in Cuba, New Mexico, in 1986. Thunder and lightning and a dark sky greeted me on the day of my arrival. A sudden cloud burst released a dark curtain of rain that poured down at an angle, driven by gusts of wind. Within minutes, the red clay road turned into slick mud. My two-wheel drive Honda slid from one side of the road to another as I struggled up the long incline to my new home in the foothills. A four-wheel drive pickup truck sailed past me. The driver peered through the side window at me, no doubt wondering about the newcomer sliding around in the mud.

After reaching the two-room adobe house I had rented in the foothills of the Jemez Mountains, I spent the next few hours hauling my belongings into the musty, mice-infested house and figuring out where to put everything. By the afternoon, I decided to take a break and drive back down the road to town and introduce myself to the doctor and other staff members at the clinic.

The steep, slippery road meandered through spectacular scenery with otherworldly rock formations and towering ponderosa pine trees. The invigorating, crisp mountain air smelled delicious.

As the road rapidly descended, the landscape became more like high desert, dotted with sagebrush, interspersed with piñon and juniper trees. Rabbits darted in and out of my peripheral vision as I concentrated on keeping my wheels outside the deeply carved ruts in the road.

Once I finally reached the pavement, I spotted the series of long, low, ramshackle buildings made of partially rotted wood with tin roofs. The sign in front said “The Cuba Health Center.” The Health Center housed a nine-bed hospital with a busy emergency room and outpatient clinic. I tried to enter what looked like the font door but found it locked. I knocked on the door. No answer. I knocked louder. An emergency medical technician (EMT) in blue scrubs opened the door a crack, stuck his head out and said with impatience, “What do you want?”

Taken aback, I responded warily, “I’m the new doctor.” He looked me over briefly and then opened the door wide to let me in and said with a mischievous smile, “We’ve been waiting for you.”

The EMT led me to a small room where the medical practitioners wrote in their charts at the end of the day. The doctor sitting at the desk looked me over from head to toe—a friendly, flirtatious fellow trained in emergency room medicine. He said, “Hi, Erica. My name is Bill. You have no idea how glad we are to see you. I’m ready for a break.” Bill had been hired on a temporary basis to work at the clinic until a permanent doctor could be found—someone willing to serve time in this isolated stretch of the Southwest.

It was a few minutes past five o’clock. I asked Bill, “When do you get to go home and get some rest?” His answer stunned me. “I’m going home right now. You’re on call tonight. We’ll be alternating nights on duty. It’s just you and me, Doc. Tommy here will show you around. He’s one of our best EMTs. Good luck.” I noted that more than one person had ominously ended their sentences with “good luck.”

I could never have imagined what awaited me that night.

 

Cuba, New Mexico

Cuba is located at the base of the Jemez Mountains, not far from magnificent wilderness country, full of bears, elk, mountain lions, and wild turkeys. The town itself has been described on more than one occasion as “god-forsaken” by travelers passing through on their way to somewhere else. Shops, gas stations, and restaurants lined the road that runs through town, at that time a poorly maintained two-lane highway connecting Albuquerque to Farmington.

In those days the town had only 2,500 inhabitants, but the clinic and little hospital also served thousands of people within a seventy-five mile radius. Tucked away in the surrounding high desert and mesas lived clusters of Navajo families, hard scrabble Anglo and Hispanic ranchers, and the many employees who worked at the Cuba Health Center—along with a sprinkling of Anglo artists and writers, renegades, and other eccentrics who had left mainstream America behind.

I came to Cuba in 1986, fresh out of my residency in family practice at Mercy Medical Center in Denver, Colorado. The University of Colorado gave me a scholarship to cover the first two years of medical school. The other two years were paid for by a loan from the National Health Service Corps. The government expected me to repay the loan by working for two years in an underserved area after I graduated—an obligation I welcomed.

Throughout my medical training, I had an idealized image of myself spending the rest of my life as a rural doctor. After working as a school teacher for two years on the Navajo Reservation near the mouth of Canyon de Chelly, and then working as a sheepherder for a Navajo family in Red Rock, Arizona, in the early seventies, I knew I wanted to serve a Native American population in a rural area.

During my last year of training, I visited various sites throughout the country, looking for a suitable place that would qualify as an underserved area. Cuba, New Mexico, seemed like the ideal place.

On my site visit, I met the Health Center’s staff of doctors, physician assistants (PAs), emergency medical technicians (EMTs), and nurses. The staff seemed bright, youthful, and energetic. I could easily envision myself working with this team of dedicated and congenial healthcare providers. I enthusiastically signed the two-year contract to fulfill my National Health Service obligation. I returned to Denver barely containing my excitement, imagining my new life as a rural doctor after completing my residency program in family medicine. 

A month before leaving Colorado to begin my highly anticipated first job, one of the doctors from the Cuba Health Center, Leonard Cain, phoned me with some startling news.

Dr. Cain said, “Erica, I feel compelled to let you know what you’re getting yourself into by coming to the Cuba Health Center. It’s not what it used to be when you came for the site visit last fall. Every single member of the crew of physicians you met during your visit quit their jobs last month in protest over the policies of Presbyterian Medical Services, the governing organization in Santa Fe.”

He said that PMS had drastically cut back funding in the name of cost-containment. Vitally important health programs had been either eliminated or scaled way back; the satellite clinics were in danger of closing—all in the name of cost-containment and improved efficiency. The medical staff had been frustrated with PMS policies for years. The latest change was the last straw.

In closing, he said, “I’m really sorry to bring you this bad news. But it didn’t seem fair that no one had told you what you’d be facing when you came here. To put it bluntly, you’ll be on your own. But at least you’ll have help from the highly competent nurse practitioners, the PAs and the EMTs. They’ll be a big help to you and a source of valuable information. Often they have more experience than the new doctors. I’m sorry, Erica. All of us doctors had been looking forward to working side by side with you. Good luck.”

The news that I would be working on my own, without the team of colleagues I had initially expected and looked forward to, left me feeling terribly disappointed and apprehensive about being the only full-time doctor on staff for the entire Cuba Health Center. How would I know what to do with no one around to help me—no supervising physicians to guide me? Could I handle all the work by myself? This was going to be a much greater challenge than I had ever imagined.

 

Trial By Fire

Before Tommy, the EMT, went off duty for the evening, he offered me a tour of the facility. We walked down the dark hallways, stopping intermittently for cursory introductions to the various personnel as they were leaving for the day. After the brief tour, he turned to me and said matter-of-factly, “You’ll be on night duty, starting now, until tomorrow morning. Then you’ll be seeing patients in the clinic all day. Good luck.”

This casually dispensed news hit me like a Mohammed Ali uppercut and made my mouth go dry and my heart race.

Before my senses could register what was happening, the clinic began to pulse with action.

On his way out the door, Tommy added that a drunken Navajo medicine man had been run over repeatedly, with a vengeance, by an acquaintance in a truck. It had happened about thirty miles away in front of a bar. The driver had been charged with attempted murder.

“Oh, I forgot to mention that the two EMTs we sent out to get him are stuck in the mud. One of them just radioed in and wants to know what he should do?”

Not having a clue what the stuck EMT should do, I asked him what he would normally do in this situation. “Well, we usually send out our other ambulance, but the battery is dead.”

After managing to recharge the dead battery, a third EMT sped off into the last light of the sun. I bolted to the trauma room to make a quick study of where everything was located while I waited anxiously for their return. A kind nurse practitioner, fairly new to Cuba, stayed and helped me get set up. As we were running back and forth from the supply room to the trauma room, I noticed something odd at the end of the long, unlit hall. Water trickled in under the same door I had entered an hour earlier. The stream of advancing water looked like a snake slithering sideways toward us, ever expanding in its width.

The nurse noticed my mouth agape. She said in a tone of annoyance, “The maintenance man was supposed to fix that problem today but didn’t get around to it. Whenever there’s a big downpour lately, the water gets funneled into the clinic.” By the time she finished speaking, the water had reached my shoes and stopped short of covering the tops.

 

My First Procedure

The ambulance finally arrived back to the clinic. The EMTs carried the lifeless medicine man on a gurney into the tiny emergency room. He had no detectable blood pressure and was not breathing. Having only intubated anaesthetized dogs and plastic mannequins in my medical training, I took a few seconds to say a short, silent prayer (“God help me”), took a deep breath and charged forward. Upon opening the patient’s mouth to suction out the blood and vomit, I could see that the pharynx—the back of the throat—was crushed. Intubation by the normal route would not be possible. So I took another deep breath, grabbed a scalpel and punctured a hole in the patient’s neck below the thyroid gland in order to insert a breathing tube.

But there was no tube available to insert. “Where are the tubes? The intubation tubes. Someone find me a tube. I need it now. Don’t you guys have an intubation tube around here?” My voice rose in pitch. No tube was forthcoming.

“Does anyone have a ball point pen?” I addressed the EMT standing next to me, “Can you take out the inside of your pen and give it to me? Hurry. I need the outside of your pen.”

The technique was something I had heard about from medics who had fought in Vietnam. I pushed the empty barrel into the hole and blew into the makeshift tube until a proper one could be located and oxygen attached. Those five minutes felt like an eternity.

At that moment I realized, allowing myself a nanosecond of amazement, that I had just successfully performed my first crycothyroidotomy on a real human being.

But the procedure would not do any good given that the heart had stopped beating. One of the EMTs performed chest compressions with little success. It was time to use the electric paddles on the chest to jolt the heart’s electrical system into action.

With our feet in ever-rising water, it seemed like a good idea to move to another room to avoid electrocuting ourselves. We raced the gurney down the hall, looking for a room with a dry floor. We swung the gurney through the door into the supply room. After a couple of tries with the defibrillator, the Navajo medicine man’s heart began to beat erratically, without enough force to create a detectable blood pressure.

The same EMT who had driven the second ambulance out to pick up the medicine man did a chest x-ray with the patient supine on the gurney. The x-ray revealed that the medicine man’s chest had been crushed with all the ribs fractured and blood pooled in the lungs and chest cavity.

The medicine man needed to have a chest tube inserted into him to clear out the pooled blood. I wondered how the procedure would compare with the ones the residents were forced to do on the helpless anaesthetized dogs during our training.

Most family practice residency programs do not train doctors for emergency room medicine. I had little choice but to do whatever I could to save this man’s life, even though he was technically DOA—dead on arrival. I wondered how many other doctors had experienced trial by fire on their first day of doctoring after graduation.

The nurse practitioner rummaged around and found the primitive, jerry-rigged glass jar with two tubes coming out of the stopper that the doctors at the Cuba Health Center used for draining blood and other secretions from the chest. With another wordless prayer, I plunged the scalpel into the designated spot between the ribs and inserted a tube that immediately reddened with escaping blood.

Once the EMT placed a catheter in the man’s urethra to monitor urine output, there was a tube in almost every orifice. I could now stand back, breathe and assess the situation.

The medicine man barely clung to life. I was in way over my head and needed help. Fortunately, I had the support of experienced EMTs and nurses during that unforgettable evening.

At my request, one of the EMTs placed a call to the emergency department at the University of New Mexico in Albuquerque and relayed the dire situation to the doctor on duty. A trauma surgeon and crew were immediately dispatched by helicopter. Their estimated time of arrival: one hour.

By the time the helicopter landed, resuscitation efforts ended after a two-hours of futile attempts. The EMTs notified the medicine man’s family members of his death. Word spread rapidly throughout the community. His people had already started arriving at the clinic and were gathering in the waiting room even before we had pronounced the patient dead.

The trauma surgeon jumped out of the helicopter just as it landed on the little pad behind the clinic. He dashed toward the clinic ready to jump into action. I hung my head and said that the patient was dead, and related the whole story to the eager and caffeinated young doctor while choking back my tears.

He put his hand on my shoulder and congratulated me for being able to get even a few heartbeats. He tried to comfort me by saying that only one percent of victims found “in the field” with a non-detectable blood pressure can be resuscitated. He took a brief look at the dead man then shook my hand and said, with a sincere look on his face, “Good job. Keep up the good work.”

He dashed back to the helicopter and took off. I darted into the bathroom and felt bowled over by all the feelings I had suppressed. I cried into a towel, muffling the sound of the sobs. After a few minutes, I reined in my feelings, rinsed my face with cold water and snapped back into action. The night was young.

On my way to the waiting room to talk with the grieving family, one of the EMTs announced, “There’s a pregnant Navajo woman with seizures on her way to the clinic.”

In the meantime, all the seats and standing areas in the waiting room were filled with friends and relatives of the medicine man. At first, the Navajo people seemed angry that the medicine man had not been saved, probably without realizing the condition he had been in when the EMTs transported him to the hospital. I assured them that everything possible had been done to save his shattered body. I handed one of the relatives a paper bag with the medicine man’s turquoise necklace, silver bracelet, old turquoise earrings, and his headband, along with a few dollar bills I found in his pockets.

I spoke from the heart, barely holding back the tears, in a combination of English and Navajo. Hearing the new doctor speak Navajo disarmed them. Their hostility dissipated before my eyes. I expressed to them my heartfelt sorrow. When the Navajo people had no more questions for me to answer, I shook each person’s hand and excused myself.

By then it was well past midnight. The next couple of hours I spent monitoring the pregnant Navajo woman with the potentially life-threatening seizures related to extremely high blood pressure—known as eclampsia. I placed an IV in her arm and added magnesium sulfate to the intravenous solution. Magnesium is vital for stopping the seizures. This important mineral works by relaxing the smooth muscles that line the blood vessels.

I sat with the stoic young Navajo woman until her blood pressure stabilized and the seizures stopped. An EMT wheeled the pregnant woman into the little nine-bed hospital where the nurse on duty could monitor her.

The night was still young. A steady trickle of people came in with problems less likely to raise my adrenaline levels, like sick babies with ear infections, a woman in false labor, a man with acute alcohol intoxication, and other more routine ailments. I felt a sigh of relief facing problems I had been well trained to deal with.

Finally, when the Health Center quieted down that night, I decided to drive home to try to get a couple of hours of sleep. But before I could get to the end of the hall, a young Hispanic woman came in moaning in labor. Her two sisters, mother, and grandmother accompanied her. I turned around and headed for the delivery room. The woman had received no prenatal care, not uncommon in isolated, rural areas. Fortunately, the delivery went smoothly and my first, tumultuous night shift as a doctor, ended on a joyous note.

The joy dissipated when I looked up at the clock and saw that it was already daytime. The patients would be streaming into the clinic in less than an hour. There would be no time to go home and rest. No time even to shower or eat a real breakfast.

And thus began my two-years of service at The Cuba Health Center.