Building and Navigating Connections with Indigenous Patients

Trust comes with being as informed as you can and that again comes with the humility of asking questions and learning, but I think for someone that may have just met me and I identify in that way. They may see me as okay this person is aware of the history of Canada and Indigenous peoples. They are aware of I may not feel that I need to explain myself or explain many things to them, so that trust may come easier. Welcome to season 4 of Radical Nurse Talk, where we explore nurses communication in serious illness and health situations as a radical act of care. I'm Patricia Strachan. Have you ever wondered what it would be like to work in a remote First Nations community where no road access is available where air transport is the common way in and out even when you're a patient? How might that influence your practice? The conversations you have? If you do happen to work in such a place, you might have met my guest, Eric Rankin. I first met Dr. Art Rankin when he was a curious and humble doctoral student with many years experienced working in remote First Nations communities. There and in urban areas he witnessed firsthand the lived realities of health disparities in historical injustices. He described himself then and continues to as a settler Canadian and an aspiring ally to Indigenous communities. In this episode you'll hear Eric describe what respected culture looks like in his work in building therapeutic relationships over and over. You'll hear how his ways of being, of learning, of respecting the dignity of others as he enters into their lives, offers us mentorship in building trust in therapeutic relationships. Dr. Art Rankin lives and works in Hamilton, Ontario, the traditional territory of the Inishinabe and Haudenosaunee peoples. As a nurse practitioner in primary health care, Art works at an urban Aboriginal health care center and has worked with First Nation communities in urban and isolated flying settings for nearly 20 years. Additionally, Art has volunteered with other communities around the world including Haiti, Lasoto, Fiji, and Australia. His experience in working with resilient and vibrant communities who experience disproportionate health disparities in historical injustices motivated his research that is focused on Indigenous health and equity and Indigenous self-determination and specifically the role of the Indigenous patient navigator. First of all, Eric, thank you so much for agreeing to carve out some time for this interview. I know you are a very busy person. Your practice is broad-ranging and you are an educator and researcher on top of that. So first of all, thank you for that and congratulations on all the awards that you've had that really indicate that others are paying attention to the kind of unique work that you are doing in forging new pathways for us. So congratulations and I'm really looking forward to digging into some of your experience and knowledge and wisdom today. Thanks, Pat. I'm looking forward to it too. Okay, so first of all, the focus of this podcast is on nurse's relational work and in the context of serious illness and/or serious health situations and so I'm interested in where you might be having those kinds of conversations in your practice. Can you kind of draw a bit of a picture for us about what that might look like? Yeah, no problem. So I work as a clinician at the Didwata Desney Aboriginal Health Center in Hamilton, Ontario. So that's in an urban setting. So most of the conversations that I would have in this setting are in the office. We are in an older building so it's a you know, everyone has their office. Many of the new indigenous health centers have you know, meeting rooms, family rooms, things like that. We have we have our individual offices but we also have a back patio which sometimes depending on the situation and context and obviously considering confidentiality and privacy, we might use that area. But that's most of my conversations that would be in the office. I also provide home visits but here mainly to the individuals that live here in Hamilton because I patients that live pretty broad ranging from six nations to Credit First Nation to Brandford and even down to Niagara area. But for those home visits, that's usually where those conversations may go to as well with individuals or family members. Okay and so is your practice completely with indigenous people? Yes, yes. So the Aboriginal Health Center, the main focus of its mandate is to provide services for indigenous indigenous individuals so First Nation, Inuit and Métis individuals but also their family. So there may be blended families of individuals that may not identify as indigenous but they also are able to receive services here being part of the indigenous community as members of the family. I find that really interesting that you describe it that way because so often we and institutions have construct practice so that we see it this way is that families are in addition to the patient and it sounds to me like you're talking about the patient and family are the focus of your conversations and practice. Do I have that right or no? Yeah, you do. I mean just it really depends on on the individual and and what that family might look like because what we might think of as a contemporary family as a mother father isn't necessarily what I'm talking about either I'm talking sometimes it might be the auntie or the uncle it might be a grandmother or grandmother or grandfather but it also might be a broader community. Not that they might be coming in on the appointments but sometimes that might be the case it might be a social worker or it might be a substance an addiction scouts or they may come and join an individual. They wouldn't be necessarily part of the family but but I think that we we are very open here and and and I think it's important to involve now what we what we defined as a family but what that individual feels comfortable coming to the appointment to you know whether it's a checkup or whether it's to deliver some serious information really if the patient consents and they want to engage in that conversation with family around because that makes them feel comfortable we've had good success with that. This I think is a bit of a contrast when we think about many kinds of nursing practice where we would be focusing on the individual patient and then consider family that sounds like a little bit of a philosophical difference to me and also a practical one in terms of how you might set things up for a conversation. I think so and I think it really stems from kind of the indigenous paradigm you know of viewing health as not an individual but as a collective right and and looking at the broader community context and and not merely the physical but that emotional emotional spiritual and mental as well as the physical so bringing all those together. So that sounds so central to your practice that I wonder if you can reflect for a minute around how that might be different. Have you practiced in other settings where that wouldn't be true because how does that those tropical framework I guess of your clients your patients affect how you talk to them. Yeah I mean so as a nurse practitioner this is the first kind of role that I came into. I was working kind of an advanced practice role as a registered nurse but even that was working in isolated communities and flying First Nation communities in Ontario. So most of my I guess experience in primary care has been has been focused on this so way so it kind of seems like just a very normal occurrence for me but prior to going into but prior to getting into more primary care I was in acute care so I was in people pediatric children's emergency. And so in that area, again, family was key. I think that's one of the reasons why it would drove me to go towards primary care and family practice was the fact that, you know, you're looking after kids, but ultimately you gotta look after the parents or care providers too, because strengthening those supports ultimately helps to prevent illness, injury down the road and leads to better outcomes. So yeah, so it's kind of hard for me, I guess in that sense, you know, having worked with other nurse practitioner students, residents, medical residents that we have here, clinical clerks that come in, you know, that it is something that I think, at least I've seen through those interactions where individuals are not used to that. They're not used to having, you know, the family, they're as collateral information without being asked specifically for it by the clinician, right? In this case, it's patient-driven, it's like it's, that's, it's not at the case all the time. I mean, certainly patient, I would say the vast majority of interactions are with the individual person. But yeah, I think that, especially if we're doing home visits, it's usually the family that is all there. If I can just focus in a little bit on the specific kinds of conversations that you're having in relation to serious illness or serious health situations, what do you consider the tough or the hard conversations that you have? - I think it's a good question 'cause I was kind of wondering, okay, with serious illness. - Or health situations, so you're talking, yeah. Yeah, that's kind of what I was going, where my mind was going, 'cause oftentimes the health condition might be something that seems pretty benign. Like it might be a common diagnosis of diabetes, but then you kind of layer that with the social determinants of health and experiences, systemic issues, like experiences of racism and discrimination, historical trauma, intergenerational trauma with the history of residential schools and the 60s scoop and so many other traumatic events that have occurred by Canada towards indigenous individuals. And so then something like diabetes can become quite serious very quickly because of a lack of trust in either the healthcare providers or the system in general. And so therefore the individual doesn't attend appointments or the, and that might, and that may be because of fear, that might be because of mistrust, that might be because they're looking for other modalities to reconnect with community, traditional healing, traditional knowledge keepers. And so, yeah, so sometimes those situations, especially when individuals aren't seeking any care at all, we see them in a much more serious situation where they have complications with diabetic foot ulcers or chronic kidney disease or even a recent hospitalization for a heart attack or stroke. - Okay, and so what makes conversations in your practice hard for you or are they hard for you? Do you ever find yourself challenged? - Oh, always. I think if I didn't, if I wasn't challenged, I probably wouldn't be working in this area. But I think the challenge often, I don't think the conversations necessarily are the challenge. Sometimes it can be challenging because I want to be, I really do strive to be culturally aware, culturally safe, trauma informed, you know, to ensure that for somebody that may, and I might be meeting them for the first time or I might have known them for, you know, for over a decade, I want to make sure that I create a space where that individual feels safe and also a space where they feel okay to share information with me, sensitive information with me. And so that, I don't think necessarily comes with much of a challenge, but the challenge comes with, you know, what might be triggering for one person may not be triggering for the other. It is important as a healthcare provider to understand the dynamics of living environments. So sometimes asking, "Do you live in a house or apartment?" You know, that for somebody that maybe has been homeless or perhaps, or houseless, or perhaps they, their history within a living environment has been strenuous, that could be pretty triggering. Also, of course, asking about substance use, which again is really important for us to assess for risk, to look for any potential contraindications between medications. And then also it might be the discussion around other forms of treatment. Perhaps one thing I've learned over the years being here, working with Indigenous community members is around traditional healing and their connection with elders or traditional healers. Is it's not so much important for us to understand as we are taught, right? What are you taking, what over-the-counter medications, what aerobiles are you taking? It's important to, I think it's important when an individual shares with you that they're accessing that and feel safe to mention that without judgment. But one thing I've learned is it's not as important for me to understand exactly what that traditional healer is, quote unquote, prescribing or what the plan is. Because it may not necessarily, it might not be a medicine. It may not even be a tea or other substance. It might be ceremony, it might be dancing, it might be connection to the planet. And so those, that kind of information is sacred to that individual. And so I will usually document to more or less engage in conversation and so that I'm aware in future interactions with that person. But yeah, so the challenge, I guess, is navigating those conversations with each individual in a unique way and while keeping it culturally safe and trauma-informed. - So I think that you have alluded to this notion about trust and safety. So how is it that you create what people would perceive as safe spaces to have a conversation with you and then cultural safety? I guess maybe that's what we're talking about is culturally safe or just safe, you know, or both. What is it? Are you aware of what it is that you do that cultivates that kind of feeling that people would perceive their openness and they have trust in you? - There are a few things. I try not to, so with my doctoral work, the main focus was on the role of the Indigenous patient navigator and really as a way to bridge between traditional communities and biomedical healthcare systems. And so trust came up with every participant, every participant and how important that trust was between that patient navigator and the community member. And so I've learned a lot actually from that research in my own practice and how I practice, but a lot of things were also learned along the way. One of the earliest interactions I can remember, this is when I was working out at the Brandford office was an individual that was really having a difficult time in their life and they were having struggling to kind of center themselves to be able to communicate so that I was, you know, to see if I was able to help. And they asked me if I had something that they could hold. And I, you know, being naive and new, working with this particular Indigenous community, I didn't, I apologized and said I wasn't too sure and would be happy to connect with traditional healing, which we did. And now in the room actually just beside me here, I have, I have Sage, so I have a, a Abolonian shell that individuals can put sage or I have tobacco, deer, sweet grass and cedar. And so individuals are able to access those medicines very easily, not that I'm providing them. They are here and if the person feels drawn to utilize that, even to hold one of those, these are, and I should preface this, these are sacred medicines for many first nations and Indigenous peoples, not necessarily all, but for the Haudenosaunee and the end. Inish Nabi people that are here, those are very connecting so so that's one thing that I now have is I have some of those medicines available and then also I'm very fortunate to have an amazing tradition there's a traditional healing group that's here that's fantastic and very quick to connect with. So I guess how I want to know how does that build trust? Is that a visual cue that people see? It's open like it's here it's here on the shelf so I think there is a visual cue some people will ask I have a piece of actually it was a gift from a patient from a patient who's who's in you it of soapstone and so some patients will come in and just lay their hands you know just put their hands on it it's just it's soft it's like silk right and so you can just and and so I've done I've only had it I only have it in my room I don't make any you know direction towards it or direct the individual towards it they tend to be drawn to it right so there is that visual cue I think in a sense there's also the and this is on my part being the listener right when you and it's being as a practitioner I've learned to be aware of some of those cues when individuals are struggling and I think as nurses I think we have this intuition it's one of those things that I don't think is easily learned but just you have that intuition you feel somebody struggling even though they might not be saying that and so you listen and you hear the story and then in in the case here I might say you know provide some feedback that it of empathy you know saying it sounds like you're going through a very difficult time have you ever would you like to smudge right or have you ever smudged before and this is the process where you would use the cell the shell and and be able to use the medicines to to burn and so and and in some cases you know it's come out of for them interacting with a doctor or an nurse practitioner or even a for a nurse like it they they feel like wow okay this yes I would love to those pieces and then they can do what they need to do for themselves and yeah so that I believe builds a lot of trust and and that only comes from listening so you have the you know the the objective and then you have that also that ability to kind of listen and and also learn I feel because sometimes well I think we are taught to kind of deliver interventions and solve the problems when sometimes these problems are unsolvable maybe or incredibly complex and so by listening we can often learn from that individual strategies that may even help ourselves in our path in life so interesting at the very beginning of our conversation you you talked about the space you were in and it occurred to me when you were saying that how unusual that was for up for me to hear someone talk about that space your physical space so much and it's coming again here you're talking about things that are in your space and awareness of those things as affecting the relational work that you're doing yeah I agree I think even most of the development of the clinic that I work at here a lot of thought has gone into the artwork a lot of even though we're in an old building we we are working towards some some capital planning to build up this beautiful new building but even within this building a lot of thought goes to through the artwork on for my particular door there's actually a picture of a a deer and so my room is the deer room and then there's the ego room down the way and the bear room and so so rather than say go okay go down to RX office or go down to you know room two it's you know head down to the deer room and so those types of things I think are they might not mean very much to some people but for some people it means the whole world right and and just being able to kind of engage in conversations I think that that is so interesting you know when we work in the health care environments we get pretty used to them don't we the sites sound smells the physical layouts and instruments and equipment etc that are in them and that's our world and we become really comfortable in them yes and so it's interesting hearing you reflect on how that is affecting the relationship that you are having with people I guess we might think about that sometimes we know things like ICU's and you know a lot of invasive monitoring equipment etc are intimidating for people but I think you're talking in a much more you know general level around what are the things that people see in their environment that indicate this is a safe place to have a conversation where they could ask something or reveal something yeah I agree completely and in those situations I think where individuals are in a tertiary center where you know it is an ICU I think that is where and the research has suggested this too you know connecting to an indigenous patient navigator you know the nurses are often working short staffed you know under incredible pressure this is the system that we're working in and and and so to have someone that you know is looking towards you for medical advice but I also feel like as human beings we have this innate ability to connect with people at a much deeper level than that and but we also don't necessarily know everything and that's where that being that kind of element which is part of cultural safety is being humble right and humility is is incredibly important I feel to ask questions to be okay to be curious but in a way that it's also sensitive to that person's situation and and so in a in a setting like like a hospital there are there's enough of them but there's indigenous patient navigators that are there specifically for that reason not to answer the questions but necessary but to to be there to help not only navigate individuals that are accessing but also staff members that are are involved in the care of individual indigenous individuals so can you describe what is an indigenous patient navigator so an indigenous patient navigator so patient navigation has been around since the 1980s Dr. Harold Freeman in the United States that's the first kind of documented case where they've looked at working with in their words marginalized communities to increase cancer screening rates but if we look back in Canada's history the the navigation role has been around since the more it's been called the community health representative since the 1960s and probably even before that and and although it was kind of a government initiative it was directed and governed by indigenous communities by having pure pure individuals that would help to bridge individuals from the community to biomedical healthcare systems not direct them to it but help them to navigate an unfamiliar system and so since then there's you know you have patient liaison patient advocates patient navigators even see community health representatives there's so there's so many different names but ultimately the main goal of this particular role is that they help to bridge and can either and also reconnect individuals to indigenous come back to their indigenous heritage but also then to connect them and navigate through healthcare services these these navigators can be preventional so they could be registered nurse or a social worker but they can also be peer and so there are there are different roles that each one of those can can take depending on the individuals they're seeing okay yes I think you know one of the issues here is that most healthcare professionals most nurses are not indigenous and so our knowledge phase from a personal level is inadequate many times and so so you're talking about formalizing a role within a system where you could draw on that that kind of health that you need to be able to properly care for people you have described yourself self as a non-indigenous white settler. And I'm wondering how that affects or how do you understand it might affect the relationships that you can build the communication you do, especially in top times for people. Yeah, I think, you know, it definitely helps to position myself, right? It shows individuals that I believe at least that it shows a sense of allyship with individuals by identifying because I don't have indigenous heritage. My family is of a European ancestry and so I'm a Canadian settler. And so by identifying in that way, it allows to center myself for the individual. Now, I wouldn't I wouldn't necessarily introduce myself as that to say, at a patient interaction each time. But I mean, for more formal events or for anything where there may be an elder or a gathering, then I would introduce myself that way along with with my pronouns. So I mean, I would also introduce myself that way again, showing allyship in multiple different areas. But I think that that I would say to my, you know, that I'm also an aspiring ally, you know, I don't think we can label ourselves as allies. It's up to the communities to determine that. And so this is just one of those, and in order to be an out, the allyship is the actions that are done. And that is one of those actions by identifying that, right? Otherwise, it's a matter of solidarity, right? Solidarity is standing together and supporting each other. But allyship is those are the actions that are done to to stand together and to work together, moving forward. At least in my interpretation. Yeah. And so that's all part of the trust building is people getting a sense that that is your position. Yes. Yeah. I think I think it definitely provides trust because with I think trust comes with being as informed as you can. And that again comes with the humility of asking questions and learning. But I think for someone that may have just met me and I identify in that way, they may, they will, they may see me as, okay, this person is aware of the history of Canada and Indigenous peoples. They are aware of, I don't need to explain my, I may not feel that I need to explain myself or explain many things to them. So that trust may come, may come easier. Again, I'm, I don't know, but I've, that's my impression. Yeah. So I know we can't talk about every situation that a nurse would find themselves in. But in general, when would it be that you would disclose that or that to a patient and or their family? Yeah. Well, I think, I think in most, most situations, if it's something more episodical where somebody's coming in, they've got a sort of boat or something like that. But I think, you know, particularly when we're talking about serious illness, I mean, it may come up. Our, I mentioned about kind of ensuring that you spend that time to listen. I also have learned, we did some work with a new com model, which is a model through, I think it was developed in Alaska with the Indigenous community there. And that particular model really focuses on sharing your own story, which as healthcare providers, you know, we aren't kind of, you know, told, okay, take your history and then actually give your history, right? It's usually take the history, physical exam, determine your, you know, what you need to do next and move on. But so I think with that listening also is, is seeing that opportunity to share. So they might, you know, I might share that I have children. I might share that I'm a settler Canadian heritage from European ancestry. I might share, you know, about my own health experiences. Again, at the direction of the individual or that family, but, but I feel like that is what develops those trusting relationships and, and that's one thing that came out of the research with the patient navigators too was storytelling. And so I think that that as soon as you're able to kind of open yourself, I'm not letting the, you know, I'm not informing of my, my social insurance number or my post of code or, no, it's your, you're connecting, you're connecting, right? And finding those connections, but then bringing it back and, and then maybe, and then listening again, and then bringing it back. And by the end of that conversation, you know, I think that I think that individuals are walking away, feeling like they were heard, feeling that they've learned something about me, I certainly learned something about them. And then ultimately they're more likely to, to follow through because I've listened, I understand what they don't want to do, what they do want to do, and where we might be able to make some sort of, you know, connection or maybe work on something later. So I think, yeah, that definitely helps to build relationships and trust. So in one of your papers, I think 2022, you made a note of our need to be careful about the language and terminology that we use in places where we work, well, and with Indigenous people in particular, noting that we could be doing harm with some of that terminology. So you identified words such as superstition or folklore, you made a comment that those undermine trust building. So has that come up in your practice, or when do you think people might get a sense that we're not taking them seriously, that, you know, in terms of some of the language that we're using to describe perhaps their health practices. And then the other thing is what terminology in your experience is helpful or a trust destroyer. Yeah, I think that particular quote stemmed from my background reading around different stories, some of the major stories that have occurred and re-occurred like Joyce Ashquan as recently or Brian Sinclair. And that particular one was around Mikaela Salt, who was a young Indigenous girl that was diagnosed with a type of cancer that had treatments available from a Western perspective or biomedical perspective. And that family decided, actually Mikaela decided that she wanted to pursue traditional medicine. And, you know, and that was some of those words were what were used. You know, it's not the best of quote unquote best available evidence. Or, you know, it wasn't a randomized control trial. And so those things are, you know, those particular words, although in science, we hold them with such high regard in a way of relationships building it is inflammatory and can really escalate in a negative way. I think we as health care providers have to be sensitive to that. We also have to be aware of the amount of misinformation that's going around and how, you know, I'm very much aware of that. But with regards to traditional healing with regards to traditional knowledge, you know, when we look at the history of much of the biomedical health care practices, certainly they've, you know, developed over the years and have been around. But many of these traditional healing modalities and traditional knowledge has been carried down for time in memorial, right? And so the these have been practices have been practiced by individuals, Indigenous communities throughout centuries. And so, you know, how are we to to make that determination that it's not going to work, right? We know a lot about what we know, but we there's a lot that we don't know in science. And I think that is where my mind goes to at least from from a mind brain sense is there's so much that we don't know there is a possibility and and I try to be rather than putting it off as say folklore or not, not evidence informed. I'll again revert back to listening and understanding and how it's worked for that individual and then and then move and try to understand that a bit more, whether it might be, you know, being involved with ceremony or with a traditional healer or a knowledge keeper. Again, as I mentioned, it's not so much so important that I understand that process, but ultimately look at the outcomes. How is that individual doing at a spiritual level? Physically, they might be struggling, right? But I mean, if we can strengthen some of the other areas around emotion and mental health and spiritual, then the rest will follow. And I've seen that happen in practice. Okay. Okay. How is it then that you talk about Western medicine or treatments with patients? So you sort of want to hear their understanding of what's helped them in terms of traditional healing. And then do you talk about what can be offered from a Western perspective? Or how might that, what might the dynamic of that be? That's a really good question, because I think ultimately my education is from that area. So I think, you know, much of that conversation around understanding the individual comes from the listening. When it comes to our conversation, there is much like any conversation. There's kind of a almost like a 50/50, right? So we're not one particular conversation should dominate, which in health care, it's often, you know, you go into the doctor or you go into the nurse, this is what you're going to do. Okay, we'll see you in two weeks and come back. How much of a conversation percentage was that, right? So I guess in my mind said it's a bit of a 50/50. So if I'm willing and I'm open to learning about what's working for the individual, then from my mindset, I'll usually preface with, okay, is okay if I provide a bit of perspective from what I understand and then I might bring up, you know, it might bring up a randomized control trial and say, oh, you know, it looks like some of your side effects are what they produced in this, you know, this study or this medication might be beneficial for you, but these are the side effects, but these are the potential benefits. And so then it's that decision. Ultimately, I often, I make the reference that I'm the backseat driver, right? You know, I might suggest, and maybe that's not a great analogy, but because often, you know, as we know, backseat drivers, it's not always a positive thing, but I see it as a positive thing. It's like the anti-wrinkle, it's in the backseat saying, you know, go left, go right, but then ultimately it's up to the person that is being treated or that is there seeking health care that makes the decisions based on the information they have. And so that's what I hope to gain from those kind of parallel conversations. So I'm wondering if we could take this into a step further where a situation arises where someone has not chosen to follow a Western treatment, course of action, and how does that affect the conversations that happen? Because I think there must be potential for real, you know, some land mines there are around further care. Yeah, I think the worst thing we can do as a provider is write them off and say, okay, well, you know, I can't help you, right? Or you do what you need to do, right? And then that is just, it just doesn't create an opportunity for revisiting at any point in time. And then really back to trust, right? So if that individual leaves there thinking, well, they really didn't listen, they really didn't care about my perspective. So I'm not going to go back. I think, you know, if so, and I've had, there's been many individuals that have chosen, you know, with significant, you know, blood sugar levels, or they've had significant findings on an ultrasound or MRI. But after discussion, they've decided to pursue another modality, right? And so at that point in time, I take a step back and think to myself about, this is their life, this is their journey. We've had a conversation where I provided my perspective and those risks, they understand those risks from at least, you know, what the evidence we have. And they've provided their input and they've, and their input is pretty founded on, on, on, with a, you know, rational approach, right? And so then at that point in time, I'll say, you know, I'm here. I'd be happy to continue to follow with you and touch base and see how, how you do along the journey. And so then in some cases, they've come back and, you know, their sugars are well under control. They're feeling great. They've reconnected with community and, and in some cases, they've come back and the sugars are okay. They haven't really made an improvement and now maybe they want to engage in a conversation. Maybe they want to continue, you know, with, with, with traditional healing or another modality. But I think the, I think the main thing for us as healthcare providers is, you know, we are not the be all and all. We have to create a space where that individual feels they can, they can come back. Okay. And, and I think that, that's, I think it can be a safe approach. Okay. So that we don't close doors. You have worked in urban settings, which is pretty much the, the setting that you're talking about now, I think. And you've also spent a lot of time remote areas so fly in isolated communities. So are there different conversations there that are hard conversations? I, I think so. I mean, the, the, the conversations can be difficult in those remote areas mainly just by geogography, right? Can you, can you talk about that a little bit? What, what, what does that look like? Yeah. I mean, if you're treating somebody and they're having an active heart attack and you've have the consulting doctor on the phone from the local merge, maybe an ICU on the video and you're snowed in or there's smoke because of the forest fires or there's, you know, or there's not an available plane. And so you're, you're it, you know, with a team of nurses, because many of these communities are, are all registered nurses, nurse practitioners. Some of them have doctors that may come in through local, but usually they're in and then they may leave. So the nurses are the ones providing that healthcare. And so those are difficult conversations because family is usually there and, and, and it may be kind of an end of life type discussion where you're talking about options of making that individual comfortable. You're also making sure that you're keeping your ear to the fax machine or the phones for if, by chance, a flight comes in. And when we say flight comes in, it's not like Pearson Airport, right? This is like we're talking about if you imagine, you know, a soccer field or something like that that when you're out walking, that's basically what, and then there might be a small tarmac and a small plane comes in. And from a nursing station perspective, you hear it, right? They play the plane comes in and lands and, you know, you know, we've got an opportunity. But it, but then, yeah, there have been cases where unfortunately, you know, that that because of geography that person did not was not able to get the care that they needed. And is that something, I guess that's difficult news to deliver or to talk about? Or is that well understood? It seems to me a very difficult situation for everybody to be in. Absolutely. I mean, we typically in the, in the North, I mean, or in anywhere, even when I worked in pediatric emergency, if there was ever anything traumatic where where life was lost, there's always time to to connect afterwards and talk about what, you know, what could have been done differently. How is it, you know, checking in with everyone to see how they're doing and coping with the situation? So that, that is an integral part. That has to, has to happen from a, from a team perspective. And I guess to a certain extent, maybe a community perspective, although, um, that I haven't necessarily been involved with. I've been more on the team side. The, um, but from for communities, I at least I believe that many know the geogra, you know, the geographic issues. I mean, we, the realities. Yeah, the realities that, yeah, it's exactly the realities that they are, um, they, you know, they might not be a flight available. Or, for example, right now, our health center is supporting many different Indigenous communities that are now out of community because of the forest fires in Manitoba. So they're providing care to I think three hotels down in Niagara area and so you know when you have a community or you're from a community that's okay forest fires are here we've got to evacuate and then they go back and then maybe next year it's a flood they need to evacuate and so you know I think I think communities are fair at least the ones that are usually affected are pretty aware of those geographic limitations. So it sounds like as a nurse going into those kinds of care situations these would be things to be preparing yourself for I think about getting counsel about learning about how to respond because that's a different feeling from most other practices in urban areas. It is and I think like we have a pretty robust orientation for nurses that are traveling to the north and part of that orientation is you know how to manage a Medevac so how to send somebody out urgently how to manage a Sketchevac which is like a non-urgent transportation out so for somebody that maybe has a fracture that can go out tomorrow and then how to manage an evacuation and those evacuations have different levels that you know we're going to do children and elders and anybody with significant medical conditions will go first as a stage one and there's different ages. So that is part of the training that comes but you know when you may I think I've had the evacuations that I've been involved with I could count on two hands right and that's that's with over 15 years of experience almost 20 years in the north. Well you certainly have had more experience than most nurses in terms of in terms of that and and so I'm I'm we're listening and learning from you. I guess these are aspects of practice that we seldom talk about and and yet when you're the person that is guiding in those environments you do need to feel confident in your own ability. Yep it's that constant constant learning and um knowing where your resources are I think that's the one guy. Yep that's key. Although your learning has been in the context of providing care to indigenous people and communities I think the ideas around how place environment affects how we build relationships and trust is a really interesting one for us to think about and I'm just so grateful for your humble and open conversation. We've I've learned a lot myself so thank you so much. Well thank you thanks so much Pat for having me and for letting me share some of my stories and experiences. Thanks for listening. We hope that you will follow this podcast on a preferred social media platform. We appreciate your feedback and encourage you to share this podcast with your colleagues and networks. Remember to review our website where you'll find a plethora of resources all episodes over four seasons information about the guests and resources they have recommended. The editor and producer of this podcast is Jeremy Raymond's Foley. Administrative support by Amy Stracken.