The Unspeakable

Author: Dr. Andrew D. Saal '87

“Are you sure you’re a doctor?” The young woman smiled at me as I sat on the floor, a cup of coffee in my hand. Her family rested uneasily in the few chairs crammed into the tiny waiting room of the intensive care unit. They watched me with a suspicion reserved for outsiders. “Aren’t you supposed to stand over us and speak with authority or something?” The woman asked this in a hesitant but humorous way, as if she were worried about overstepping some cultural boundary. In a way she had. She was Navajo, and I was yet another Anglo doctor in the hospital. “I thought all you doctors wore white coats,” she teased.

We had spoken several times that weekend at her father’s bedside. She herself was studying nursing down in Phoenix. In her own way, she was an intermediary between the hospital and the traditional members of her extended family. Her humor helped to defuse the tense situation. But still, there was an awkward silent stress.

The family conference was an impromptu update on their father, brother, uncle. The 54-year-old Navajo man was sick and getting sicker. He had battled two months of a slowly worsening pneumonia. Despite multiple rounds of antibiotics and numerous hospital visits all over northern Arizona, no one had been able to cure him. He had come to our office for the first time only five days earlier.

When one of my partners had seen him that day, he was nearly blue with respiratory distress. He had profound dehydration and a soaring fever. Within an hour he was admitted directly to the intensive care unit. His hospital course began like so many thousands of others. We gave him IV fluids, ordered a slew of tests and opened fire with antibiotics. In the words of the police chief from Casablanca, we tried to “round up the usual suspects.”

But something was different about this man and this illness. Something just didn’t fit in the usual patterns. More history was gathered. More specialists were consulted. More tests were ordered. More diagnoses were guessed. Yet the man still lay dying in the ICU. Our best efforts were not good enough.

I leaned back against the wall of the waiting room and sighed. Frustration had been the predominant emotion among the involved staff that morning. Nothing was working and nothing made sense. I could explain the details of what was wrong, but so far no one could explain why. With my cup of black coffee as emotional support, I launched into the family update and fielded their questions. But in truth, I had no answers. The young nursing student translated for the traditional elders present. Her presence helped me bridge the language as well as the cultural gap.

That day did not go well. For some unknown reason, he rapidly deteriorated. He was floridly delusional, seeing animals and hearing voices. When I returned to see him that evening, his daughter was visibly shaken by his abrupt decline. My concern was a bleeding stroke, hers was something else. I sensed that something must have happened earlier that afternoon. She didn’t want to discuss the matter.

While we prepared him for an emergency CT scan of his brain, another visitor arrived. He carried a modest bundle in plain fabric — a medicine pouch. I recognized him as another consultant of sorts. With respectful nods we traded places at the bed. I stepped quietly to the back of the room and silently observed the Navajo healer practice his art. He asked the daughter several questions, and listened patiently.

Although I had been permitted to observe, the conversation was held in Navajo. Some ideas just can’t be conveyed in English. Abruptly they both fell silent. The elder began examining the skin of the patient. He observed the patient’s hands and a small blemish on his neck. Suddenly the healer hissed air between his teeth and shook his head silently at his own conclusion. Several members of the family squirmed uncomfortably.

The medicine bundle was opened at the eastern edge of the bed. The healer sang prayers and burned a very small amount of an herb. After several more prayers, he extracted a tuft of white sage. With gentle yet precise sweeps, he passed over the patient as if he were washing him with the sage. Purification. Cleansing. But why? The answer eluded me. The other Navajos in the room were uncomfortable with the diagnosis. They weren’t discussing it either. Something remained unspoken.

“You feel like a fifth wheel? How about a sixth or seventh?” the pulmonologist on the case asked. He was a friendly middle-aged intensive care specialist. With a humorous twist, he spun my lament back at me with a smile. Like an uncanny percentage of doctors in Flagstaff, he drove a pickup truck and spent his free time hiking the back country of the Grand Canyon. He also seemed to enjoy mentoring the rookie. “You may not be writing all the orders, but your presence on this case is as important as anyone.”

I thanked him with a humble smile. That night had been a long one. Our patient had slowly but deteriorated. He had become more restless as his ability to breathe declined. Finally, just before dawn, we had to intubate him. He was on life support, completely dependent on the ventilator to keep him alive. Several IV medicines were being infused to maintain his heart rate and cardiovascular tone. From my chair at the nursing station, I could see several new colored lines dancing on the monitor over his bed. Nearly every possible vital sign that could be measured was now quantified, computerized and animated on a screen. Two of the specialists on the case debated the intricacies of the man’s unknown disease. I listened for awhile, then graciously bowed out of the conversation. Even with all the tests and machines, we still had no idea what was happening. We knew how to stabilize him but not how to heal him.

I wandered out to the waiting room to meet again with the family. I knew my limitations in the intensive care unit, but perhaps I could gather more history to illuminate his diagnosis. Not surprisingly, a more family members had arrived in the night. I was not prepared for their sheer number. Crammed into the tiny waiting room, almost 20 people had set up a base camp. My friend the nursing student introduced me to the matriarch of the clan, a Navajo grandma dressed in a green velveteen blouse and a dark skirt. The elder had worn her best turquoise necklace for the journey into town. I greeted her with my poor Navajo phrases, but formal respect. She shook my hand loosely in Navajo fashion. Until someone trusts you, a Navajo handshake is usually a loose brushing of hands at best. The handshake was a social form introduced by the Anglo settlers. For a traditional Navajo, an enemy could poison or curse you by simply touching you. Hence, the cautious handshake with a stranger.

I ended up on the floor again, coffee in hand, while the family gathered in the room. I updated them on the recent change of events: the tests, his respiratory failure and what to expect when they saw him on life support. Discussing his overall prognosis, however, was a cultural hurdle in itself. To even mention death as a possibility would invoke fate itself. Speaking of death was taboo. Even mentioning the name of a deceased loved one could bring about horrible things.

So I spoke in vague metaphors and a few facts. I stumbled at times, but the grandmother quickly realized what I was trying to communicate. Their medicine man was also welcome to assist in any way he could. Several people minutely nodded their heads in agreement.

After a few more questions and answers, I gently began to hint at questions of my own. I needed to know more details of the preceding months. Something had happened over the summer, but the details were foggy. Several animals on his farm had died rather abruptly in the weeks before he first fell ill. With that vague piece of history, the infectious disease specialist had already modified the antibiotics. A dozen tests for rare illnesses had been ordered: plague, hantavirus, brucellosis, tularemia and a slew of other unpronounceable diseases. But even with appropriate antibiotics, the man had been slowly slipping away.

Two of the young adults looked at the grandmother, then back at me. Slowly they recounted the details of the animal deaths. Two goats had died within the first few days. Then one of the horses began acting odd. It was warm to touch and sweated profusely. The horse soon broke out in blisters all over its flanks. In the end, it could only lean against the stall. When the horse finally died three days later, the patient had taken the carcass out to bury it.

A man and woman in the back of the room shook their heads and gestured as if purifying themselves. Clearly the animals had something to do with his illness in the Navajo belief system as well as mine. I took a leap of logic, and prayed that I would not break a cultural taboo. “What do you think is going on? Did someone cause this illness to happen?”

I could hear electronic chirps from the ICU and people shuffling about far down the hall. But hardly a sound came from the 20 people gathered in the tiny waiting room. During that infinite pause, I could only wonder if I had made a severe blunder. Had I honored them or offended them by asking such questions? After all, we were the gods in white coats. Didn’t we know everything? Would I undo the prayers of the medicine man by mentioning such a thing openly?

The silence lasted only a few heartbeats, but its duration seemed a lifetime. The silence was broken by the grandmother herself. Slowly and deliberately she told me all she wanted to share. “A man . . . with a tatoo.” Five succinct words, and she was again silent. The others in the room seemed split over the matriarch’s decision to allow an outsider into their family crisis.

The nursing student silenced the dissension with a simple remark. “He asked for our help. They need to know.” The waiting room again fell silent. The student looked at the grandmother, then back at me. She swallowed dryly then spoke. “Yesterday morning I was alone with him in the room.” The patient had been fairly lucid and even able to sit up. “He was happy and seemed to be getting better.” She closed her eyes and shook her head. From inside she gathered her strength to finish the story. “Then that man arrived . . .” Her voice trailed off faintly.

After a considerable pause, I whispered, “The man with the tattoo?” The room fell deathly silent. I suddenly understood just what had happened that previous day, just an hour before the patient had spiraled downwards.

For a traditional Navajo, there is no separation between religion and life. The Navajo Way is a philosophy that is ingrained into every minute of every day. Generosity for one’s family and respect for life are just a few of its elements. Harmony with the world around you is its center. Disease is often a spiritual matter. A person can become ill through his own actions or by the actions of others.

Most people follow the Navajo Way to some degree. Even those on the Jesus Way still respect the traditional philosophy. But in the Navajo world, a few persons actively reject the Navajo Way and hence all that is good. For their own gain and personal power they corrupt the natural order. The most unspeakable of any Navajo taboo is a person who rejects the values of family, community and life. He or she represents corruption and real evil. Rumored to be shape-shifters, they can change into animals to further their malicious desires. Although they can jinx a person with a simple glare, their worst curses are placed by touching the victim. The name of such an evil person should never be mentioned, because surely he or she will hear your voice and come after you as well. So a certain word is whispered but generally not spoken if at all possible: Skinwalker. A Navajo witch.

A skinwalker is far from the European concept of a witch. They are not like benevolent television characters or even the earth-loving Wiccans of the Celtic tradition. They are pure selfishness and hate. I surmised by the family’s silence that the tattooed man was rumored to be one. He had unexpectedly visited the intensive care unit that previous day. And before the daughter could stop him, he had touched her father. Now our patient was on life support and near death. Our machines had managed to save him, if only for the time being.

Anglo physicians likewise have several taboos and unspoken fears. To discuss our actual powerlessness over death is to confront our own deepest insecurities. We fear not knowing the answer. We fear failure.

I still remember a question from my medical school interview. “Are we in the golden age of medicine?” I had replied “no” to the two professors. We’ll never know everything. One has to remain a student their entire life. There will always be new illnesses to unravel and new facets to the ones that we thought we understood.

We as doctors are essentially powerless over the unknown, just as we are powerless over everyday events. No gods walk in white coats. For physicians, the deepest unspeakable fear is inadequacy. Despite our best efforts, we may not be good enough.

Our patient remains in the intensive care unit on life support. The medicine man has conducted several healing ceremonies to restore harmony. The medical team continues to pour antibiotics, steroids and other chemicals into his body. And finally, much to our relief, something finally seems to be helping. In the past few days we have weaned him from the drugs supporting his blood pressure. We’ve even turned down the ventilator a few notches.

Yes, we are powerless over death. But far beyond the realm of antibiotics and technology, both the family and the medical staff are trying to grasp the most potent medicine of all — hope. Because if disease may occur on the spiritual plane as well as the physical, then so must healing.