An analysis published in 2016 found that Native Americans and Alaskan Natives experience mild-moderate and severe peripheral artery disease (PAD) at a rate of 1.78 and 2.14 higher than whites, respectively1. Further, a study comparing PAD patients found that Native Americans in the Western United States are nearly twice as likely to receive an amputation as non-Hispanic white PAD patients2. Recognizing this population is at a higher risk, yet also a lower likelihood of receiving treatment for PAD is key to making steps toward a healthier future.
As a limb salvage specialist, Dr. Scott Brannan, Chief of Endovascular Surgery at Modern Vascular, has dedicated the majority of his career to serving Native American patients of the southwestern United States. Treating the specific type of arterial disease that affects the Native American population requires a unique understanding of not only the anatomy, physiology, and pathology of diabetic peripheral arterial disease but also, and perhaps more importantly, the fears, hopes, and culture of native patients.
Through his work on reservations, Dr. Brannan has learned the value placed on the connection to the earth. The Navajo people have variations of a prayer that begins with “Walk in Beauty,” or “In beauty I walk.” Each line is centered on experiencing the earth’s beauty and most end with “I walk.” As limb salvage experts, Dr. Brannan explains, “We, at Modern Vascular do all that we can to help our patients practice that faith to walk in beauty.”
Dr. Brannan and ultrasound technologist Denisse Martinez go onto reservations regularly to ensure patients have access to much needed health care. This can include late nights after a full day of procedures at their Modern Vascular clinic in Mesa, and even weekends, as they travel to the nearby reservations to check in on patients. As many patients have advanced disease, these trips are especially important to prevent amputation and promote overall health. Most difficult to treat are patients that are not referred at all during the course of their disease and find their way to Modern Vascular as a last resort. According to Denisse, “Many Native American patients present to our clinic for a second opinion when they have been signed off to have a major amputation.”
Luckily, some patients are referred by doctors who know a multidisciplinary approach is necessary to save limbs. Denisse recalls one patient referred after receiving a partial calcanectomy that would not heal after several weeks. After a significant surgery like this, blood flow is vital to the healing process and closing of the surgery site. With advanced PAD, however, arteries of the leg and/or foot are so clogged that blood is barely circulating through the foot. Denisse remembers, “I thought to myself, ‘I can literally see her bone, there is no way we will be able to turn this around and have her back on her feet.’ Well, I was wrong! Dr. Brannan was able to re-canalize the previously occluded and stenotic arteries which provided her with great run-off. Afterward, with good wound care management, this patient healed!” Between Dr. Brannan reestablishing blood flow to the foot and the wound care specialist treating the wound, the patient was able to keep her foot.
To Denisse and Dr. Brannan, this patient’s story reaffirmed many lessons they’ve become familiar with. First, this patient highlighted the need for preventative care and early intervention in communities that typically don’t receive treatment for PAD until it is too late to save the limb. Second, it showed the importance of coordinating care, as this patient’s level of disease required each of her specialists’ commitment to save her foot. Finally, it revitalized their commitment to spread awareness of the importance of trying all options to save the limb before amputation. Even at extremely advanced stages of disease where amputation seems inevitable, other options should be given a chance first.
Lastly, patients like this one solidify the resolve that Dr. Brannan and Denisse share to do what they can to fill a gap in care that Native Americans experience all too often. The Indian Health Care Improvement Act states, “it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians — to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”3 Yet, for decades Indian Health Services has been underfunded, such that health services are literally few and far between. In 2018, U.S. Commission on Civil Rights stated that “In 2017, Indian Health Services health care expenditures per person were $3,332, compared to $9,207 for federal health care spending nationwide.”4
Needless to say, on the reservations, access to the health care that Dr. Brannan and Denisse can bring is rare. Denisse says, “We routinely go to patients’ homes to check on them, most of which have wounds, so we do dressing changes and check the pedal pulses as well as making sure they have follow up appointments scheduled with their primary doctors and other specialists.”
Due to the extreme need on the reservations for the skills they possess, along with many evenings and weekends, Denisse and Dr. Brannan are out of their Modern Vascular clinic in Mesa at least one business day per month to provide much needed services out of a vascular clinic on the San Carlos Reservation.
Their dedication does not go unnoticed. In an act that surprised and humbled them, Dr. Brannan and Denisse were invited to the funeral of a patient they had been seeing for years. They were honored to have earned the respect of the grandmother in her 90s.
As Native American Heritage Month comes to a close, we will continue to be thankful for our Native American patients and for the lengths that our staff members go to assure they can continue to walk in beauty
- 25 United States Code (U.S.C.) § 1602(1).
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