Team Rubicon: Navajo Nation COVID-19 Medical Response

The novel coronavirus 2019 (COVID-19) pandemic has disproportionately affected various regions in the United States.  One area, New York City, dominated the press with dramatic stories of death and heroism.  Another, the Navajo Nation, spanning 3 states in the southwest, received minimal national attention until recently, despite having higher per capita cases than any state. With approximately 350,000 inhabitants living within 27,000 square miles, the Navajo Nation has seen a dramatic increase since March to 3,740 positive COVID-19 cases and 127 deaths as of May 14.¹ The Navajo Nation rate of infection has been 10 times higher than that of the state of Arizona.²

The reasons for this devastation are myriad and include a historic lack of resources and sufficient medical care, a high number of medical comorbidities amongst this susceptible population, a widespread lack of running water making frequent hand washing and proper hygiene difficult, and distributed governance.  But also, the Navajo tend to live communally with multigenerational families in single room homes.  At the intersection of culture, governance, and health, COVID wreaked havoc.

Team Rubicon is a non-governmental non-profit disaster relief organization founded in 2010 that provides domestic disaster and international humanitarian response using the skills and experience of veterans.  Team Rubicon volunteers have deployed across the country in response to the COVID-19 pandemic to assist with both medical and non-medical services. In April 2020 Team Rubicon deployed to Kayenta, Arizona in an area of the Navajo Nation especially hard hit by COVID-19. Our mission was to provide assistance with medical and incident command personnel and supplies for the Kayenta Health Center and the surrounding region. Greyshirts (Team Rubicon volunteers) deployed to the area included incident command (IC) support staff as well as physicians, physician assistants, nurses, paramedics and EMTs.  These volunteers helped in the health center’s command center as well as the Kayenta Emergency Department and the Navajo EMS service, augmenting local staff stressed by the effects of the COVID-19 pandemic.

The Kayenta Health Center, a part of the Indian Health Service, built in 2016 has a 24 hour/7 day/week emergency department with 10 rooms including a trauma room, negative pressure room as well as pharmacy, lab and radiology including CT scan.  There are no inpatient facilities necessitating transfers by ground, helicopter, or fixed wing aircraft.  Similar to other areas, COVID-19 has resulted in a decrease in total volume but a dramatic increase in the acuity of patient’s seen.  Since the start of the pandemic the facility has shifted to disaster mode and stood up an incident command center to monitor and control the response.  Access and movement within the facility is controlled to decrease the chance of spreading infection and temperature checks are performed daily on everyone entering the building. Team Rubicon IC staff helps monitor and assure availability of PPE and tracks staff exposures.

Both of us typically work in urban academic medical centers.  Working in Kayenta, a rural critical access emergency department, provided clinical, operational, and cultural challenges.  But the experience also provided ample opportunities for humility.

Many elderly patients only spoke Navajo requiring staff to help with language translation. Most of the COVID patients were extremely ill when they presented.  It was not uncommon to see multiple patients from the same family, especially since those who were infected with coronavirus but not sick enough for admission would be discharged back to their communal homes as there were no facilities for them to self-quarantine.  Patients who might be managed at home with prone positioning and high flow nasal oxygen would require intubation to assure a safe airway during flight to accepting facilities, often as far away as Phoenix.  Sometimes flights would be delayed, resulting in a need to manage a critically ill patient on a ventilator for a prolonged period, sometimes with limited equipment and medication supply.

This deployment helped attempt to relieve the burden of chronically undersupplied medical care on the Navajo Nation. The Navajo Nation has been under-resourced and medically underserved long before this pandemic struck. After the COVID-19 virus began to afflict the Navajo Nation, the already stressed medical system was strained far beyond its capabilities. Team Rubicon recognized the need for outside medical support early and asked for volunteers to deploy to the hardest hit region of the Navajo Nation at Kayenta. This region in the center of the Nation has been leading the number of positive COVID cases with only an emergency department to care for their patients. Team Rubicon has been able to assist the medical mission as well as provide acutely needed personal protective equipment (PPE).  The Indian Health Service staff has been grateful for the support as well as the critical care expertise and education Team Rubicon was able to provide.

The COVID-19 pandemic produced Team Rubicon’s first domestic medical responses, to Navajo Nation as well as a Federal Medical Station in Santa Clara, California and a drive-through testing center in Charlotte, North Carolina.  These missions illustrate how an NGO can work with governmental and private organizations to meet the needs during a pandemic disaster.

Personal Experiences:
Keegan Bradley MD- An experience that I will always remember from this deployment was the night one of our own emergency department staff came in as a patient. The day had been very typical with plenty presenting for COVID-19 related symptoms or mainly minor complaints. We were all able to relax and enjoy each other’s company while I continued to interrogate the nurses about their trick to making a perfect Navajo taco like we had the day before. I sat there wondering when we would get our sick patient that day, as we had seemed to reach the point of averaging at least one COVID-19 infected patient per day who was critically ill enough to require intubation and transport. It wasn’t soon after that we were notified there was a critical patient being brought back with hypoxia and tachypnea and concern for COVID-19. Next thing we noticed was this was not one of our typical patients, but one of our own emergency department team-mates. There was quiet and concern that I noticed swept over the rest of the department. The teammate was brought back and immediately evaluated. It didn’t take long for the team in the emergency department to recognize the same signs they had seen in so many critically ill COVID patients before. I could see on their faces they quickly knew that intubation and air transport were in the near future. One of the regular physicians at the sight volunteered to be the one to primarily care for the patient and intubate her. The procedure went well and then the team member was transported without complication to a higher level of care. Typically, after these procedures everyone is high-fiving and moving on to the next patient feeling like heroes. Today did not seem to be the same. I noticed a department team that had been severely shaken for not just worry that it could have been anyone of them getting intubated and flown out, but just as important that it was one of their team and family that they had just treated. I saw tears, I saw silence, I saw encouragement, and I saw comforting. This was not the typical COVID patient stabilization we had done countless times every day…this was different.

Emergency Department staff witnessing their own teammates being brought in for an emergency is thankfully not a common occurrence. COVID-19 has been a unique and deadly virus and taken many lives all over the world. Medical providers have not been immune from this. I saw how hard this impacted the emergency department staff, and I will never forget what it means to take care of a sick team member and not know what the outcome may be.

A month after I returned home, one of the EM docs from Indian Health Services contacted me with news that their colleague died after a month on the ventilator, fighting COVID in the ICU. During the funeral, the entire hospital staff lined the highway to honor their teammate and show how much love they had for them. Even after this tragedy, everyone working at the Kayenta Health Center continues to fight with even greater resolve and determination against the COVID pandemic in their community.

Stanley Chartoff, MD, MPH – The experience that struck me most involved the first death of a COVID-19 patient I personally witnessed.  Even though I had taken care of very ill COVID-19 for the past month in my emergency department in Hartford, Connecticut, none had died prior to transfer to the Intensive Care Unit.  I was on duty my first evening shift in the Kayenta emergency department when a patient I heard from the nurses had previously tested positive for the novel coronavirus and was short of breath was being brought back in a wheelchair.  I saw on the tracking board that she was 28 years old. One of the other physicians started donning his PPE in anticipation of treating her when she suddenly slid out of the wheelchair and collapsed on the floor in front of the nurse’s station.  The physician who was in his PPE and several Team Rubicon volunteers who were not jumped in to assess her, found she was apneic and pulseless and began CPR.  I quickly donned my PPE and we were able to lift her to a stretcher and move her to the trauma room to continue the resuscitation with the Kayenta staff and Team Rubicon volunteers working as a team.  She had copious secretions from her mouth and needed an airway.  My colleague attempted twice without success and handed me the laryngoscope and I was able to secure her airway with direct laryngoscopy.  I learned quickly how resource limited the Kayenta facility was with limited equipment (no adequate video laryngoscope), personnel (no respiratory therapist) and supplies, including medications. Our team continued the resuscitation for over two hours.  She would intermittently regain pulses and then lose them.  The air medical transport team was called in anticipation of transfer to a medical center, but they had delays getting out of Gallup, New Mexico.  As I looked around the room during the code, I observed a mix of emotions on the faces of the nurses and technicians. There was determination in saving such a young life as well as despair as her condition did not improve.  There was also concern and likely fear about exposure to COVID-19, especially those who jumped in to help at the beginning.  Eventually, when it was obvious the resuscitation would not be successful, her significant other was brought into the room to be with her.  That is when I learned that he had been infected first with COVID-19, likely from his job in a prison, and that the patient and the couple’s infant child only recently tested positive. The baby was being cared for by the women’s family while she stayed home to care for him while he was ill.   A moment of silence was held and the grief of witnessing the death of such a young individual was apparent. What I didn’t notice was that staff that were Navajo shied away from the room after her death. Later one of the nurses explained the Navajo’s belief and fear of the spirit of the dead that lingers around the body. My physician colleague and I only had a short period to debrief the staff before ambulances brought in several trauma patients needing our care.  Later I learned more about the life of the young woman, a former Miss Navajo, from multiple news stories celebrating her life.  Although I have witnessed innumerable deaths during my career, including those of young people and children, the cultural aspects and fear of exposure during a pandemic made this experience different.  I developed a new respect for how devastating the effects of COVID-19 can be.

1. Dikos Ntsaaígíí-19 (COVID-19)

By Keegan Bradley, MD
(Atrium Health-Carolinas Medical Center)

Stanley Chartoff, MD, MPH, FACEP
(University of Connecticut – Hartford Hospital, Team Rubicon Northeast Territory Medical Director)