The first patient of the evening balks when physician Steve Brown asks to drain his infected finger. Hunched on the edge of the exam bed, a matted cowlick rising from his head, the 38-year-old man cradles his painful left hand in his right. He yelps when the doctor gently squeezes the middle finger, which is plump, stiff and glossy.
The man says the throbbing of his finger woke him in the middle of the night and there was nothing to do at that hour except watch Judge Judy on TV. Discomfort and Brown’s coaxing eventually overcome his reluctance to have it lanced. Brown and a nurse try to get the patient to lie down. He’s had too much to drink, he won’t let go of the windbreaker tucked under his arm, and he has a bottle of Coke jammed into the front left pocket of his jeans.
Brown, ’94, has tapped infections in the pad of the finger before, but not recently, and he spends a few minutes studying a textbook of emergency medicine. After injecting a local anesthetic, he makes a cut parallel to the nail, and a mess of pus and blood erupts. “It’s like a deflated balloon,” Brown says as the goop continues to flow. “Oh man, you’re going to feel a lot better.”
Shedding his grim expression, the patient giggles when asked if he’s feeling pain. “I don’t feel anything,” he says.
Within a half-hour, “the guy with the finger,” as he’ll be known for the rest of the shift, is bandaged and ready to go home, carrying a paper bag with antibiotics and Tylenol.
It’s Saturday night on the White Mountain Apache Reservation in northeastern Arizona. Brown is just beginning his 14-hour shift at the reservation’s Indian Health Service hospital, a one-story brick building that faces a deep gorge surrounded by pine trees. As the sole doctor on duty—responsible for the emergency room, the urgent care clinic and all the wards of the 30-bed facility—he has to be ready to treat any case, from colds and colic to a stroke or stabbing.
His wife, Molly Pont-Brown, ’94, says he starts getting nervous an hour or two before one of these all-nighters. “It’s pretty daunting being the only doctor for 1.6 million acres,” Steve explains. “Well,” he adds quickly, “not quite the only one.” If the ER is swamped, he can call in some of the 15 physicians who work other shifts at the hospital. And the Indian Health Service airlifts very ill or severely injured patients to Phoenix (about 150 miles away), Tucson or even Denver—though Brown has to stabilize them before the flight. His first night on duty, five patients qualified for such transportation. Tonight, one does—a victim of a brawl whose brain began bleeding after somebody knocked him down and stomped twice on his face. Though the injury sounds grave, the man recovers and is back home within two weeks.
The demands of practicing in an isolated, rural hospital have been a boon to Brown’s training. He covers the ER one weekend in four; he also works days in the ER, handles the family practice clinic and occasionally delivers babies. Faced with a multitude of illnesses and injuries, he’s had to learn fast, particularly about treating stabbings and other kinds of trauma, because he can’t just pass off difficult cases to a specialist. “That’s what makes a doctor really grow, being forced to make decisions,” he says.
Brown grew up on the Stanford campus. His mother, Anne Schmitt, was a social worker at the Medical Center who continued to live at Stanford after her divorce from Steve’s father, J. Martin Brown, a distinguished cancer biologist and professor of radiation oncology. Steve decided not to follow his father into research because, he says, it was “too introverted,” short on the human interactions he likes.
As a Stanford undergraduate, Brown had fun broadcasting baseball games on student station KZSU and shooting the breeze with the interesting people in his dorm. Too much fun, as it turned out. “I definitely underachieved in my first two years,” he confides. By the time he realized he had to buckle down, he’d already scotched his chances to enter a top medical school and ended up at Albany (N.Y.) Medical College. After four years of trudging through snow, he returned to Northern California for a three-year residency in family practice at San Francisco General Hospital.
Treating inner-city residents helped prepare Brown for working on the reservation. The two medically underserved groups pose some of the same challenges. In many cases, they don’t understand how to get the most out of the health care system, he says. They rarely see doctors, they don’t get tested early for controllable diseases like diabetes and, once diagnosed, they may not take their medications. Many of the medical problems are the same—substance abuse, violence, diabetes, heart disease—and so is the underlying cause. “The common thread is poverty,” Brown says. Although the White Mountain Apache are wealthier than many other Indian tribes, thanks to a casino, a timber company and one of the few ski resorts in Arizona, living conditions on the reservation are still “third world,” he says.
During one of the few lulls of the night, Brown and the four nurses on duty nibble on chocolate and peanut butter squares that Pont-Brown baked. The guy with the finger calls back to ask if he can drink alcohol while taking his pills. In a sense, the call is a good sign: at least he’s paying attention to the directions on the bottles. It’s also tragic. Alcoholism is rampant on the reservation. Tonight, alcohol, assault and diabetes—or some combination of the three—account for most of the adult cases treated in the ER.
In between those cases, Brown treats a parade of wheezing babies, hacking teens and adults with sore throats. He also closes head cuts on three children, using skin glue, the medical equivalent of superglue; it definitely beats trying to stitch a screaming, struggling toddler. Even after eight hours, when most of us would be snarling, he manages to joke with the kids and parents.
Another grim truth is that without the Indian Health Service doctors, who often come to a reservation for only a year or two and then move on, many Native Americans would not receive Western-style medical care. Few reservation doctors are tribal members, in part because strong peer pressure not to “sell out to the white man” discourages many Indians from attending college or pursuing careers, Brown says. Five of the registered nurses who work at White Mountain are Apache. The reservation has produced just one Apache doctor, a medical resident who has chosen to train elsewhere.
Itinerant physicians can have difficulty establishing rapport with the Native Americans they serve, says Brown, noting that “a lot of [patients] feel we’re just here for a brief period to learn to be doctors.” Nationally, the average tenure for Indian Health Service doctors is just over a year. At White Mountain, it’s four years, and the clinical director, David Yost, has stayed for more than a decade.
Brown, who arrived in 2001, made his own arrangements with the hospital rather than being assigned by the Indian Health Service. He says he wanted to practice medicine on a reservation in order to help rural patients; he chose White Mountain because he liked the hospital and staff, and because it’s close to Pont-Brown’s family in suburban Phoenix.
He assures his patients that he’s not going to disappear anytime soon. Brown and Pont-Brown, who teaches sixth grade at a local school, are beginning to settle in. They’ve bought a house in nearby Pinetop-Lakeside, a quiet town of about 3,500 that’s a summer haven for heat-weary residents of Phoenix. Brown’s current deal with the Indian Health Service—the organization helps pay off his student loans—will keep him here for at least three more years, and the couple is thinking of staying beyond that.
Practicing medicine on a reservation can be disheartening, Brown concedes. During tonight’s shift, for instance, the paramedics trundle in a 17-year-old girl with possible neck injuries. She was clouted twice across the back of the head with a two-by-four in a drunken fight. After x-rays reveal no skull damage, Brown stitches the puckering gash in her scalp with blue silk. “Now you’ve got some blue hair,” he quips. She’s not in the mood for humor and sinks farther down in the bed. Less than an hour later, tribal police arrest her for being drunk in public, a crime on the reservation.
In the face of entrenched poverty, violence and substance abuse, Brown tries to stay upbeat. The occasional thank-you from a patient helps a lot, he says. “It doesn’t take many of those to brighten an otherwise difficult day.”
Or night.
Mitchell Leslie, of Albuquerque, N.M., is a frequent contributor to Stanford.
