My name is Brandon Pagni, MD, and I am a third-year emergency medicine resident at the University of Wisconsin Hospitals and Clinics.
Where did you complete your global health elective? How long were you there?
I had the pleasure of spending four weeks in the emergency department (ED) at the Gallup Indian Medical Center (GIMC) in New Mexico, on the border of the Navajo Reservation. The 99-bed hospital is a Level III trauma center run by the Indian Health Service, the federal health program for American Indians and Alaska Natives.
The workload at Gallup is one of the largest in the Indian Health Service with 250,000 outpatient encounters and 5,800 inpatient admissions annually. GIMC has the largest staff of all Navajo Area IHS facilities. The ED has 25 care spaces, including 19 rooms where patients who need to be “horizontal” can be cared for and a fast-track area for lower acuity (or “vertical”) patients.
What drew you to Gallup and to working with the Native American population there?
I have participated in global health work in the past and wanted to continue to take steps to make it a regular commitment. I knew I wanted to move West after graduation and several of the positions I was looking into served local Native American populations. Luckily, we have a great Global Health program at UW, and we already had an established relationship with Gallup where several students and residents have gone before me.
I was eager to learn more about the local population and understand the limited resources available for their health care. I also knew that the experience would help me to grow and make an impact during my first job after residency.
How did the clinical experience at GIMC differ from your training at the UW?
First, GIMC is a critical access center with limited resources, which is different in many ways from a large academic medical center or even a community hospital. From a clinician perspective, I was able to see more nuanced management to common pathologies at GIMC that are less frequent at UW Health’s University Hospital. I also learned about some of the unique challenges that the local Native American population faces, in terms of medical care.
I really valued the insight and experience I gained from getting to run the emergency department and deliver optimal care to patients with limited resources. For instance, the robust trauma resources at the UW are not available at GIMC, so with the ED team, I had to manage several blunt and penetrating trauma cases with no immediate surgical support. This experience helped to refine my resuscitation and procedural skills necessary to be an emergency physician.
What are some of the challenges patients in the Gallup region face that most impacted you?
In my time at GIMC, I cared for many patients experiencing alcohol withdrawal, gastrointestinal bleeding and interpersonal violence. Working with a great team in the ED offered me an opportunity to learn from these cases, especially how to use every available resource in my toolkit to provide holistic care and support for my patients. For example, I discovered how to safely and optimally manage alcohol withdrawal with phenobarbital and prevent further withdrawal and safety of discharge.
Did health system capacity and access affect your clinical decision-making and care delivery?
A critical piece of caring for patients was understanding their ability to follow up with an outpatient provider or be admitted to the hospital. In Gallup, nearly every other admission requires several conversations to optimize and find a potential transfer. Patients frequently had to be transferred by flight several hundred miles — sometimes across several states — to see a specialist. Some patients were unwilling or unable to travel such a distance, which meant it was up to us to set them up with the best chance of success without the usual resources we would use at University Hospital.
This also required more nuanced thought of how to safely dose medication. For example, GI bleed cases had to be transferred out along with any emergent MRI requirements. As the UW is a big satellite hospital, I have had very little experience with this.
In addition to navigating challenges within the health care system, did you have to think about the unique situations of patients living in very rural areas?
Yes, some of the individuals I cared for live without power and with limited ability to travel to Gallup for medical care. These patients required special thought prior to discharge because it was less likely they would be able to follow up within our recommended timeframe. We also had to ensure therapies would be accessible to them at home.
How did you stay busy outside of your clinical shifts? Do you have any favorite places or memories from your trip?
I brought my mountain bike and explored several great trails in the Zuni mountains, Flagstaff and Moab. I also enjoyed some beautiful hiking trails at Red Rock Park and found a local Brazilian jiu-jitsu academy so I could keep up with my practice. Gallup, and the Southwest in general, has great food. Cocina De Dominguez, a locally owned and operated Mexican restaurant in Gallup, was amazing; I visited several times during my stay!
What’s next for you after you graduate in June? Will you carry Gallup with you after residency?
As I begin my attending career in northern Arizona this summer, I will carry many of my experiences in Gallup with me as I continue to provide medical care to the local Native American population.
I am grateful that UW–Madison and UW Health have afforded me the opportunity to help advance my skills as a physician, expand my understanding of emergency care delivery in low resource settings, and meet many wonderful members of Gallup’s local and Native populations. I’m also very much looking forward to continuing to explore the Southwest as I start my attending career there!