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Ruth (Bazhnibah) Kawano

Photographer/Writer, RN, MSN, Retired CAPT, USPHS, Capt, USAF

She first heard about the Coronavirus (COVID-19) on TV in January 2020 about the virus, “it’s all the way across in China!” This nurse tearfully expressed what it was like in the beginning when COVID-19 came to the Navajo Nation.

Another nurse detailed the preparation of staff and protocols before the virus hit close. A Chief Nurse Executive used her leadership skills to help create solutions for her nursing staff and patients. These professional Registered Nurses (RN’s) voiced their experiences painting painful scenarios of patients and sometimes a whole family suffering with COVID-19 as they stepped onto their Kayenta Health Services Emergency Department. Patients had started coming in late February.

Kayenta Health Center is located on the North Central portion of the Navajo Nation near the border of Utah and Arizona. It is one of the 5 Indian Health Service Units on Navajo. KHC manages the care of over 17,000 people. The Health Center does not have any Intensive Care Unit (ICU) beds but does have a 10-bed Emergency Department with 2 trauma beds, an isolation room and an Obstetrics room. The ED is open 24 hours a day and 7 days a week. During the height of the COVID-19 pandemic, KHC saw approximately 60 to 70 patients a day in their small Emergency Department. Because they do not have an ICU, they transfer out all critical patients to surrounding cities such as Phoenix, Flagstaff, and Tucson in Arizona as well as to other Navajo Area IHS facilities with ICU beds.

The Coronavirus or COVID-19 is a novel virus that has affected millions throughout the world, more than 5 million people as of this writing with more than 340,000 deaths.

This COVID-19 was named Dikos Ntsaaígíí-19 by Navajo leaders in March.

The COVID-19 affects the lungs and its airways. The coronavirus is said to be a lethal virus, easily infecting others through human-to-human transmission. Hallmark symptoms include a cough, high fever, and shortness of breath. Experts believe that the spread is transmitted through droplets by an infected person.

Per research studies, a sneeze, cough, talking, or even just breathing can transmit the coronavirus to others within six feet. The virus can live on surfaces too. On the Navajo Indian reservation, currently, there are over 4,000 positive COVID-19 cases with 2,000 recovering and 153 perishing from the virus. COVID-19 has not left its journey here yet as it continues spreading.

From knowing about the coronavirus in January and February of this year, the Kayenta Health Center’s Nursing staff started their preparation with education. “First I mentally prepared myself to be the cheerleader and quality leader for my team and co-workers. We maintained the daily positive quotes that we already had in place before COVID-19 and I had to be a positive and strong leader in the face of COVID-19,” stated Kathleen Whitehorse, an RN in the Emergency Department.

Kathleen Whitehorse, RN, Clinical Nurse, Kayenta Health Center sews a Tyvek gown for the staff.  Photo by Bazhnibah.

She didn’t know if this virus would be like Ebola, another killer virus responsible for over 20,000 deaths worldwide in 2014. Nurses had questions about the coronavirus, “Would it really come here? To the Navajo reservation? Then soon it wasn’t an ‘if’ anymore, but a ‘when.’” The team exercised scenarios and practiced donning and doffing of PPE (Personal Protective Equipment) such as masks, gowns, face shields, and gloves. They also learned as much as they could of the new COVID-19 virus.

Eileen Russell, RN, a Supervisory Clinical Nurse in the Emergency Department at KHC states, “In preparation, I reminded myself of why I became a nurse and that I will treat others like I would want to be treated if I were the patient or family member, I also prayed for guidance in matters unfamiliar to me and that I will not be fearful of what comes before me and to make the best decision with the best resources available to me.”

Eileen Russell, RN, is the Supervisory Clinical Nurse of the Emergency Department at Kayenta Health Center.  She is demonstrating how to don a

She prepared her Emergency Department Nursing staff “to treat customers to the best of their abilities.” Staff were educated about the proper uses of PPE to protect patients. Eileen stated that she had “to save staff” against the COVID-19 as it was like no virus before. She also knew that the people in her community had to be educated about the virus in careful terms, specifically because the average person did not know about what a virus was and how it caused people to become ill.

A Chief Nurse Executive at the Kayenta Service Unit’s Health Center, Wanda Begay, RN, oversees the Nursing department. To prepare her nursing staff, Wanda ensured that there were adequate supplies to work with and that every nurse was provided education about the types and uses of PPE and about the deadly virus.

Staffing was a big challenge.

To begin with, their nursing vacancy rate was high at 65%. She had to get extra nurses. At the beginning of the pandemic, she was able to get contract nurses and some volunteers such as Team Rubicon, a group of military veterans who help in disaster management around the world where there is a need for first responders, medical professionals, and technology. KHC also received help from the Federal Emergency Management Agency (FEMA) and Doctors Without Borders. These employees went out into the community to help teach about the COVID-19 including masking, social distancing, virus shedding, and even grocery shopping. All resources were much needed and appreciated by the HC staff and the Kayenta community.

The COVID-19 also imparted a lot of fear and anxiety among staff in the beginning. Staff were afraid to go into the ED for lab specimen transport, for housekeeping needs and supply management. Hence, they were educated by professionals to lessen their fears. It was also important for nurses to know as much about the virus as possible.

Kathleen stated, “My expectation was to make sure our team followed our plan on what to do if a COVID-19 patient walked into our emergency room doors; they were donned in PPE and the patient got a mask immediately.” Then followed by other treatment protocols. The more the staff followed the protocols, the easier it got, she stated.

In late February, the KHC got a patient with a high fever and a dry unexplainable cough, “We weren’t sure [if this was a COVID-19 patient,] but with the high fever we had heard about, it got real. Maybe this was a COVID-19 patient! We weren’t sure because we had a lot of “flu” patients with similar signs and symptoms and there was no test yet to see if they were affected by the coronavirus,” explained Kathleen. Initially, it took 5 to 7 days to get COVID-19 test results back, so it was challenging for the ED staff to realize if they were indeed COVID-19 patients or not. But treatments continued to manage the signs and symptoms of all patients. Later in March, they were able to start testing.

As time went by, Kathleen noticed that the situation in the ED got harder to deal with and that nurses got stressed, “The more we found out about the virus, the harder it was to see what every patient endured with the hardship of what this virus was doing to their bodies.”

Knowing that the patient and family were experiencing all the pain and suffering was much to bear. As a nurse caring for COVID-19 patients, she knew that the patient could not have family around and had to be alone, “I let them know how I felt, I touched their shoulder, I asked them if they had any questions and I told them about what the virus was doing to their lungs in laymen terms.” She saw patients having difficulty breathing; even more difficult was seeing the children suffer. Witnessing a whole family with the illness was hard to bear and seeing their oxygenation dwindle was devastating. Nurses here had not dealt with anything like this before!

Because the virus was being very evasive, virulent, and so new to all, Nurses realized how patient education was much more important than in the past. Even scientists, virologists, and doctors still do not know everything about COVID-19 and how it seems to travel around spreading. Currently, there is no cure and no vaccine for COVID-19. An antiviral is said to be in clinical trials the past week.

From reports, world scientists are working around the clock to develop effective treatments like an antiviral and a vaccine for COVID-19. Education was key especially in the early part of the pandemic. As new information arrived, staff were kept abreast. All were able to manage the oncoming updates.

Apart from patient care, medical supplies such as PPE were getting harder to obtain from manufacturing centers. The KHC staff decided to use Tyvek material from a home improvement store to start making gowns that could be wiped down and reused. They got rolls of these materials and staff started cutting and sewing makeshift gowns with ties to the back.

Some rapid test kits and machines came much later. These kits are used for point-of-care testing for COVID-19 offering rapid results. In the past staff had to transport tests to a lab office as far away as Phoenix, AZ, some 300 miles away or a 5-hour drive to the South for a 5-7-day turnaround for test results, sometimes even longer than 7 days.

Staff in the ED also started using industrial face shields for added protection. CAPRs (controlled air-purifying respirators) were ordered by the staff, but not received yet. It is a new PPE that can be a face shield helmet or a shroud with a helmet and face shield which goes around the head and upper body.

Other changes included establishing a nurse call-line where patients could find answers to their questions on COVID-19 in English and Navajo. Their inpatient unit has become an extended Emergency Department (ED) overflow unit for positive COVID patients who were waiting for transfer to an outside hospital or stable patients that needed oxygen, intravenous (IV) fluids, medications, and monitoring. Outside curbside is a drive-through set up used for follow-up of recovering COVID-19 patients. Most of the KHC clinics except for a few have been closed during this time.

As for lessons learned in their nursing care after 2 months, Kathleen states that she “became a stronger advocate for the care of patients, more attentive in helping them understand COVID-19 signs and symptoms.

I helped them think more positively, urged them to stay strong, and let them know how important they were to me. COVID-19 is a strong virus. Nurses can be strong mentally, emotionally, physically too, we let our inner leadership qualities take over. We got this. We can overcome adversity because we are RNs.” For the future, “I will endorse stronger positive team-building skills that can help each team member feel that they count.”

Eileen stressed that any nurse who comes to the Navajo Area must understand the remoteness and culture. “Kayenta is a remote area and families live with extended family members. There are areas of no electricity, heat, or plumbing and it makes our education to wash frequently difficult to implement in family homes. New RNs and nursing students should not fear coming here, there is much to learn here, although we may not have all the modern technology as in the urban areas. We do more hands-on care and have to do a lot of critical thinking.”

As for the future, “I would like to focus on improving teamwork. With this virus, it takes a team to work with each patient.”

Wanda, CNE, found that training and cross-training staff to work in different areas of the hospital such as the ED, the overflow unit, doing education in the clinics, and even directing traffic was important. “Nurses had to work outside in a tent and at curbside.

Nurses and support staff manned the established nurse call line and used the Diné/Navajo language to answer questions on COVID-19 and inform callers on signs and symptoms, testing, and self-quarantine.” She feels that more nurses are needed in the rural communities on the Navajo Nation. “We need to recruit and seek more resources for scholarship and education to send our children to schools. There are going to be more health care challenges in the future, and we need to be prepared.”

Finally, all the nurses agreed that “Our people need education. Whatever comes our way, people need to talk about it like TB, Spanish Flu, or other illnesses. Nurses need to learn more about the Germ Theory and look at evidence-based and scientific research studies. They need to look at data and statistics to help drive decisions on how we can help our people.”

After the interviews, we walked around inside the hospital and saw positive things. The nurses were proud of their “mini gown factory” and a wall inside the hospital where they had patients and staff write notes and posted cards of appreciation. These nurses are tough yet compassionate in dealing with the coronavirus and patients!

Story by Photographer/Writer, Ruth (Bazhnibah) Kawano, RN, MSN, Retired CAPT, USPHS, Capt, USAF

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