Project Apache: Bringing Pediatric Care to an Arizona Reservation circa 1972

After graduating from Stanford Medical School, I went to the University of Colorado-Children’s Hospital for my pediatric internship and residency, a rigorous and competitive program under the leadership of the renowned C. Henry Kempe, MD. Neonatology and pulmonology were my favorite subspecialties but all were exciting and taught by excellent faculty.

Early in my second year there, Joe Daily, MD, a brilliant neonatologist at Stanford who had moved to Phoenix with Belton Meyer, MD, to set up a neonatal intensive care unit (NICU) and neonatal transport system for Arizona, recruited me for a United States Public Health Service (USPHS) grant they had secured for the Fort Apache Reservation. Their infant mortality rate was 110/1000, one of the highest in the nation. My vision of Arizona was mostly of hot arid desert and I had always intended to complete my three years of internship/residency uninterrupted. Not deterred, Dr. Daily offered to arrange a visit.

I was flown into Whiteriver Indian Reservation (“the reservation”) on a single engine plane. I was honored to be met by the tribal chairman, Lester Oliver, who was my personal escort for two days. The White Mountains, home of the proud and historic White Mountain Apaches, are lushly forested and rise majestically to more than 11,500 feet. On that October 1971 sojourn a foot of snow had freshly fallen. Chairman Oliver took me to the tribe’s year-old Sunrise Ski Area, then to their Fort Apache Timber Company, and lastly to the Whiteriver Indian Health Service hospital. There I met with the hospital administrator, retired Army Colonel Bill Baker who tried very hard to discourage me from interrupting my training with vivid descriptions of alcoholism, violence, primitive housing, negative attitudes of Apaches toward ‘white man’s medicine,’ and the resulting poor health and medical compliance. It all sounded daunting but a unique challenge I decided to face. There was the bonus of living in a very remote and spectacularly beautiful place.

The author auscultating a male Apache toddler.

Our USPHS grant was designated “Project Apache.” Our group started work in July 1972, with a team of three pediatricians, of which one was a strictly non-clinical administrator, one nutritionist, three trained RN prenatal care practitioners, several Apache women whom we instructed to be field health prenatal aides, plus various Apache office staff. Bob Fukuchi, MD, the other clinical pediatrician, and I served as hospital consultants to the five freshly minted USPHS physicians serving after a lone year of internship following medical school graduation. Bob and I also ran weekly clinics in two more remote communities and attended every delivery at the hospital. One of us was on call all the time.

The Apache women resisted going to the hospital for prenatal care and more so to being examined by male physicians. We devised a plan to find out, via the reservation grapevine, who was pregnant. We then provided home prenatal care visits by the RN practitioners and their female Apache aides. We developed an effective slide show presentation for Apache women about breastfeeding. Breast feeding had been discouraged by previous physicians and by misguided donations of formula. The number of tribe women breastfeeding greatly increased.

Project Apache

Images from Project Apache, counterclockwise from top: Apache women in usual traditional dress/camp dress; baby in cradleboard; Project Apache employees 1974; typical housing and shacks on the reservation; and Apache toddler. Badges/seals are representative of the area.

Child mortality was pervasive and oppressive. All forms of tuberculosis, trachoma, and Hepatitis A were endemic. Most of the infant mortality was due to gastroenteritis causing subsequent fatal dehydration and severe respiratory infections mainly pneumonia. The prevailing attitude of the stoic Apaches was that the hospital didn’t help much when their babies were sick. Consequently they didn’t bring them in until they were moribund. That first 1972 summer Project Apache introduced pediatric expertise of starting IVs (very difficult in Apache infants) and proper rehydration. Our team demonstrated we could save lives thereby winning the trust of most of the tribe. Survival increased as children were brought in at an earlier stage of their illnesses. Our reservation field nurses and aides were ultra-important communicators to the 8,000-plus Apache population. Word soon spread among the people themselves that good things were happening at the reservation hospital with the newly arrived children’s doctors.

A physician group from Johns Hopkins medical school led by Norbert Hirschhorn, MD, who had previously worked in Bangladesh, arrived to work with us that 1972 summer. I collaborated with them doing unique research on oral rehydration of Project Apache children. That work resulted in a publication¹ in the Journal of Pediatrics that introduced the rehydration formula that with slight modification is still used by the World Health Organization (WHO) to the present time.

Winter brought increased respiratory disease most ominously bronchiolitis which at the reservation’s mile high altitude caused significant hypoxia. Project Apache provided the hospital lab with a blood gas analyzer. Bob Borchardt, the IHS lab/x-ray tech, with his willingness and sincere interest in learning new techniques was an important contributor to our success. His diligence salvaged many lives. We were able to draw arterial blood gas samples (pre transdermal oximeters) and deliver oxygen appropriately with nasal cannula.

Among the many lives we saved one in particular stands out. A very cyanotic moribund five-month old presented with a completely opacified chest X-ray and almost no breath sounds. I intubated him and selectively suctioned four of the five lobes and opened all but the right upper lobe. Very bold, but successful and lifesaving.

An even bolder procedure I did was to evacuate a subdural hematoma form a near-dead nine-year-old girl who had fallen in the river and struck her head on a rock. To do this I had to perform some life-saving scavenging. I borrowed a hand drill from maintenance and sterilized the ordinary hardware bit. I used these to do skull trephinations and hematoma evacuation. She did come out of her coma. We flew her to Phoenix for follow up care where as I recall she did recover.

Generally, Arizona reservation hospitals had a delivery room but no operating room. Deliveries that required emergency caesarean sections, or anything else requiring urgent surgical intervention, had to be evacuated by the legendary Cessna Skymaster 337 a tiny ‘push-pull’ aircraft. The Skymaster belonged to the U.S. Indian Forest Service who used it as a spotter for the C-130 fire-fighting slurry bombers based in Whiteriver. I flew at least 50 medivacs as the only medical person on the plane for the seriously ill patient(s). Most flights were for emergency C-sections. I once delivered a single footling breech in the cramped plane quarters. Other memorable flights were a five-year-old GI bleeder (pneumonia and duodenal ulcer) and an ultimately fatal gunshot wound to a three-year-old. He died in the ambulance in Phoenix. The daily summer monsoons and frequent winter snowstorms made many flights risky and sometimes impossible. We did the best we could for the critical patients while waiting for a break in the weather. Phoenix was over 200 miles away by rugged highway.

The days and nights were long but the experience impossible to duplicate and everything I hoped it would be. There were many challenging pediatric illnesses, memorably an infant with adreno-genital syndrome who had wrongfully been assigned male gender. I consulted University of Colorado Endocrinology about her. With the help of the Assembly of God Church in Canyon Day village we put on a baby shower and celebrated with the family a re-baptism. Her parents were very thankful. She later had some reconstructive surgery at Colorado University Medical Center. An infant with Tetralogy of Fallot and absent pulmonary valve I sent to world famous cardiac surgeon and personal friend Norman Shumway, MD, at Stanford. I joined the local Navapache Medical Society to try to establish a working and collegial relationship with the off reservation physicians in Lakeside, 30 miles “up the hill.” Some slow progress was made and I understand that today there is relatively good cooperation.

Because of the depth and breadth of my experience on the Reservation, Dr. Kempe obtained credit for my third year of residency from the American Board of Pediatrics. I thus became Board eligible. After four years, the infant mortality rate had dropped from 110/1000 to 30+/1000. Almost all of those deaths occurred in very hard core alcoholic families. Our USPHS grant ran out after four years and was replaced for one year with a Robert Wood Johnson Foundation grant. Five months into my fifth year I was twice left stranded in Phoenix after medivac flights. With Dr. Fukuchi continuing on, I resigned and picked up my off-the-reservation life. I have been blessed to live a fantastically rich and varied life both professionally and personally. Project Apache was among the most rewarding experiences of my life, and I feel so fortunate to have taken that opportunity when Dr. Joe Daily offered it to me.

Biography

Bobbette Kraft Ranney, MD, FAAP, is from Kirkwood Missouri. A brilliant scholar all her life, she was the first person to graduate from the University of Missouri with a perfect 4.0 grade point average in sciences (physics), and was valedictorian of her medical school class at Stanford University Medical School. (See sidebar). She went into pediatrics and trained at the University of Colorado medical center where she describes in the following article her participation in Project Apache. Severely injured in an automobile accident in 1986, she is retired from medicine but farms and plays viola in the Brighton Colorado Orchestra.

University of Missouri’s Most Distinguished Record of Scholarship: Bobbette K. Ranney, MD.

by John C. Hagan III, MD

Grade point inflation is even more pervasive and pernicious than monetary inflation. The most common grade in two-and four-year colleges is now an ‘A.’¹ At four-year universities the number of A grades has risen 5–6% per decade, and is over 300% higher than in the late 1960s when the regrettable phenomenon began.¹

For better or for worse, at one time competition was felt to be one of the most effective methods of selecting the best and brightest for medicine and science. Grading was rigorous and grades allocated “on the curve.” That meant approximately 10–15% of a college science class might expect to get an A grade in the time frame of 1961 to 1965 when Bobbette Ranney and I were in pre-med at the University of Missouri. A perfect grade point average (GPA) was 4.0 and no one had graduated from MU with straight As in every class they took. That is, until Bobbette graduated Phi Beta Kappa, Summa Cum Laude in 1965 with a 4.0 GPA in physics. While at MU she excelled in sports competing in women’s tennis while on a full academic scholarship. She played viola in the University orchestra. After a summer of working as a lab technician at St. Louis County Hospital she decided to be a physician rather than a theoretical physicist.

I had several biology and math courses with Bobbette and she was modest with a good sense of humor and could explain solutions to our course problems better than most of the professors. Of course any class she took she was sure to get one of the coveted and highly contested “A” grades.

After graduation from MU she spent her summer on Pike’s Peak with seven other female MU grads as high altitude research subjects for the Army Physiology and Nutrition Laboratory. She entered Stanford Medical School where she did original research including study of the properties of toxins used on poison arrows derived from Central American frogs; studied obstetrics in Scotland; and solo backpacked from Lake Geneva to Lake Lucerne. She was selected to the national medical school honor society Alpha Omega Alpha as a junior, and graduated first in her Stanford class.

Besides being Missouri University’s first 4.0 GPA student, Bobbette Ranney starred on the MU women’s tennis team.

In the nearby article she describes a singularly unique experience after her pediatric residency at University of Colorado. Dr. Ranney continued her brilliant career in both academic and private practice of pediatrics. In 1986 she was almost killed in a head-on collision on a one-lane rural road with a large pick-up truck. She had multiple surgeries including an aorta repair in which she twice had cardiac arrest. She was left partially paralyzed and uses Canadian crutches. She became a distinguished disabled athlete enjoying swimming and competing in golf tournaments. She played with the Denver Pops Orchestra, and presently the Brighton (Colorado) Orchestra. She maintains an active farm and raises livestock.

I think a strong case can be made that Dr. Bobbette Ranney created the most distinguished scholarship record of any graduate of the University of Missouri-Columbia, and without doubt a world class level of sustained personal, professional, and athletic achievement.

Contact: goosetrailfarm@q.com