Black Man in a White Coat (11 page)

Nor did my family life offer any awareness about the uninsured. My parents and brother all had jobs that came with stable health plans. My grandmother also had employer health insurance, and Medicare by the time she developed serious health problems. Despite working-class roots, I was shielded from the trying experience that someone like Tina could face. How could someone play by the rules as she had—marry, have a family, have a job—and not be able to receive decent health care for a problem, such as fibroids, that was not of her own making? This was a problem that our country should have solved long ago.

*   *   *

When I came back to the free clinic once more that year—about three months later—I didn't see Tina. I had no way of knowing whether that was good news or bad news. Perhaps she had gotten her blood pressure under control and undergone successful surgery for her fibroids. Or maybe one of her problems had caused a heart attack, stroke, or a life-threatening hemorrhage. I could only hope that she had filled our prescription and was on the path to a healthier life.

Over the next several months, as I returned to the hospital wards and clinics, I saw two women very similar to Tina. They both lived in rural towns comparable to where I'd met Tina. Francine, an unusually tall woman in her late forties, visited a local clinic after several months of heavy vaginal bleeding. She was approaching menopause, and sensed that something was wrong, but she avoided seeing a doctor until she developed intense pelvic pain. Uninsured just like Tina, her initial concern was the cost of this medical visit, but Francine soon had far bigger worries: Doctors diagnosed her with widely metastatic uterine cancer.

Stephanie, a struggling, thirty-something, self-employed hairstylist, collapsed at work during a stressful day. She was initially taken to a local hospital and told she'd suffered a stroke. She was then transferred to Duke where she stayed for a week. The doctors did an extensive workup to determine a cause for her stroke; hypertension was the only identified risk factor. She'd had bad side effects from two older, cheaper blood pressure medications and, without health insurance, couldn't afford the newer one that worked well without problems. Thankfully, despite the severity of her initial symptoms, she made a full recovery.

For Stephanie, the silver lining of getting sick in such a drastic way was that it resulted in her getting insurance. She became eligible for Medicaid and could now afford doctor's appointments and the two new medications she'd been prescribed. In short time, her blood pressure came down dramatically. However, it is just as easy to imagine that Stephanie could have had a worse outcome, even a tragic one. Her stroke could have caused permanent paralysis, loss of speech, the inability to swallow, memory loss, or severe depression. It could have simply killed her. These doomsday scenarios, all too common, especially in black people, would have occurred in large part due to her being poor and uninsured.

In the end, while Stephanie ultimately got the care that she needed, this outcome spoke less to the quality of our system than it did to her own good fortune. Francine was not so lucky. Where Tina fell on this spectrum is something that I've wondered about ever since.

For all the billions of dollars in the health care industry, it seemed that there had to be better ways to promote community health. What could be done about all the people in rural North Carolina and beyond, the millions living outside the reach of health insurance and medical charity? Did the government—and wealthy institutions like Duke—have any responsibility to reach them? As a future black physician, did I have some special obligation?

 

4

Inner-City Blues

As I sat alone flipping through a coffee-stained textbook in the hospital conference room, Dr. Collins, the resident doctor on duty, opened the chipped wooden door. “We've got a case of acute chest pain coming in,” he said, excitedly.

I shared his energy. In my fourth and final year of medical school, chest pain was probably the one clinical problem that I understood best. As a second-year student, I received my highest evaluation on the general medicine rotation where cardiology was a core subject. During third-year, I'd gained additional knowledge working in a clinical research lab that studied heart disease. Earlier in my fourth year, I'd spent a month in the cardiac intensive care unit where I'd also done well. At the time, among the array of clinical specialties, cardiology seemed the logical choice for me.

After just a few days on my new emergency medicine rotation in Atlanta, however, the confidence I'd built at Duke had begun to fade. This place—the crowds, the filth, the despair—overwhelmed me. So the thought of evaluating chest pain felt welcome, like a chance to play on familiar turf.

“What's the story?” I asked Dr. Collins.

He told me that the patient was a fifty-year-old woman who'd developed chest pain while arguing with her son that morning. The electrocardiogram (EKG) obtained by paramedics at the scene showed some abnormalities, but not the classic findings of an acute heart attack that required immediate cardiac catheterization or clot-busting drugs.

I grabbed my temporary ID badge off the ink-stained table. It proclaimed that I was in Atlanta, but I might as well have been in a foreign land. The setting—Grady Memorial Hospital, an inner-city public hospital—bore little resemblance to what I'd grown accustomed to at Duke. Grady's emergency department (ED) took up about three times more space than Duke's ED, yet stepping inside it felt like being on a crowded elevator. Everywhere I looked I saw patients. Some were in the single and double-bed rooms I'd seen at Duke, but most were in the hallways. Gurneys were stacked along both sides of the hall like parked cars on a city street.

The patients on this day ranged in age from eighteen to eighty-six. All were black. Some were quite sick—a homeless man with AIDS wore a special blue mask to prevent him from sneezing and coughing particles possibly infected with tuberculosis. Others were there for mundane problems better handled elsewhere—a thirtyish woman with a sore throat, a forty-something man with a sinus infection. A few were downright scary—a heavily tattooed twenty-five-year-old in a bright prison uniform, handcuffed to a bedrail with a corrections officer standing over him, receiving treatment for a hand infection he sustained after knocking out someone's front teeth.

Why was I in an inner-city emergency department? Why had I left the comfort of Duke?

The answer was simple and complicated: love. For the first two years of medical school, my social life consisted of the occasional awkward first date that rarely resulted in a second one. My fortunes changed during my third year, as I started dating Kerrie, a student in the class above mine. She was originally from Jamaica but had spent most of her childhood in Florida. I was smitten by her photogenic smile and radiant eyes as well as her soft-spoken, understated style—she didn't wear heels, makeup, or tight-fitting clothes. We'd chatted from time to time earlier in medical school, but our schedules and social lives didn't line up until her final year. One date turned into two. Soon, we saw each other every day. We had a lot in common; we enjoyed basketball, tennis, and watching TV medical dramas. More important, she shared my insecurities about being a black student at Duke from a working-class family. I was in love for the first time.

But our courtship hit a roadblock. She'd already signed on to begin her three-year internal medicine residency in Atlanta at Emory, the school where she'd also attended college. Just a few months into our relationship, she moved six hours away. Trapped by the brutal schedule of her internship, we decided I should sign up for a visiting clerkship in Atlanta. She'd completed an emergency medicine rotation at Grady/Emory the previous year and suggested I do the same. Since Duke did not have a training program in this field back then, it was an easy sell with the curriculum office. Persuading myself that I could actually do it was proving harder. Taking in my surroundings and the ways they differed from Duke, I wasn't sure I'd make it.

Dr. Collins and I entered the room as two paramedics transferred our patient from a gurney onto a hospital bed. Because of the urgency of chest pain and the need for cardiac monitoring, she had been placed in a single room. The man who had previously been there, and had recently awakened after an accidental overdose, was pushed out into the hallway alongside dozens of other patients. He was no longer sick enough to need a private room.

The paramedics summarized what they knew about our patient, Lucy. Her chest pain had come on abruptly, about two hours earlier, while she was arguing with her son because he'd gotten into some kind of trouble. She had high blood pressure and diabetes, but no record of heart disease. They'd given her the standard medications for someone with chest pain, which had eased but not fully relieved her distress.

Dr. Collins ran his fingers through his sandy-blond hair as he looked at the EKG, taken a few minutes earlier. The narrow peaks spiked in rapid succession. A few were followed by abnormal dips resembling the profile of someone with a double chin: Lucy's heart wasn't getting enough oxygen. Based on the data, Dr. Collins barked out orders to a nurse: blood tests to see if Lucy had had a heart attack; a drug to slow the heart rate and lower her blood pressure; another drug to thin out her blood. Lucy was going to need admission to the hospital.

He then turned from the medical facts to the patient. Lucy was fifty but looked sixty. Her hair was thin and graying. She weighed far too much; her arms were the size of legs and her legs as thick as old tree trunks. Her abdomen seemed as if it had been inflated under high pressure. Her body had put her heart under immense strain.

“Hello ma'am, I'm Dr. Collins.”

“Lucy,” she said, in a frail voice we strained to hear amidst the cacophony of beeping monitors and the background bustle of the emergency room. “I need to go home.”

I recalled what I knew about mental stress and heart disease. Extreme emotional stress, such as in response to an earthquake, had been shown to increase rates of heart attacks in the immediate aftermath. During my previous year in the behavioral medicine clinic, I'd learned that less dramatic but nonetheless mentally stressful scenarios could trigger cardiac events too. I wondered what kind of trouble Lucy's son had gotten into. At this moment, however, it didn't matter.

“We're going to do everything we can to get you back home,” Dr. Collins said. “But you're at high risk for having a heart attack, so you're definitely going to need to be admitted.”

She tried to protest, perhaps having expected to stay only a few hours. But she was too weak and scared to fight. “Okay. I'll do what you say. Just help me, doc.”

We'd been taught throughout medical school about the inherent power imbalance between helpless patient and learned physician. Our instructors implored us to respect this status and to use it responsibly—for good rather than simply for our own benefit. We were reminded what an honor and privilege it was to have someone rely on us in matters of life and death. Some doctors appeared to thrive under this pressure, but as Lucy transferred her fear into our hands, it seemed to me that this privilege could just as easily be an overwhelming burden.

Dr. Collins took his stethoscope from a pocket of his white coat to begin his physical exam just as a nurse started to draw blood. Before they could do either, Lucy's body went limp.

“Lucy!” Dr. Collins called out.

Her eyes did not open. He tapped her face and pinched her hand. No response. He put his fingers on her neck. No pulse. He put his ear to her chest. No breathing.

At that same instant, the cardiac monitor alarm activated. I felt my own heart pounding. On the screen, Lucy's heart rhythm was no longer merely fast. Instead, it showed a classic case of ventricular fibrillation, a life-threatening pattern that any fourth-year medical student could recognize. Her heart had stopped pumping blood to the rest of her body.

“Open the cart,” Dr. Collins screamed. “It's a code.”

Within seconds, the room filled with doctors and nurses. One doctor placed a rubber mask over Lucy's nose and mouth and squeezed a bag to force oxygen into her body. A nurse performed rhythmic chest compressions as if guided by a metronome: one, two, three. As they cycled back and forth, Dr. Collins prepared the defibrillator; its shock was our best chance to get Lucy's heart back in rhythm.

After several months rotating on general medicine and intensive care units, I'd witnessed enough of these codes to know that they rarely worked the way they did on TV medical dramas of the era like
ER
or
Chicago Hope.
Only once had I seen a patient survive such heroic efforts. As physician Danielle Ofri writes: “The majority of times we start a code, we know it's futile.” But absent a do not resuscitate (DNR) order that we sometimes used with terminally ill patients, we were obligated to proceed.

“Everybody clear,” Dr. Collins yelled, an order for everyone to step away from Lucy to avoid getting a jolt of electric current.

He charged the paddles. I held my breath. Lucy's limp body went through three sequentially higher-current shocks to no avail. After the three failed shocks, Dr. Collins directed the nurses to administer various drugs through Lucy's intravenous lines while basic CPR continued. Nothing worked. Finally, after what was probably twenty minutes, Dr. Collins announced: “Let's call it,” he said, shaking his head. “Time of death, ten-thirty a.m.”

The extra doctors and nurses left as quickly as they'd come, back to see other patients, leaving the primary nurses to clean up the pile of medical debris—syringes, test tubes, wrappers, and gauze pads—that every code leaves behind. These nurses moved quickly in their tasks, as did Dr. Collins in starting the death-related paperwork. How did they feel about what we'd just seen? There seemed to be no time for self-reflection. Before long, another person would need the room. The wheels of the ER could not stop for Lucy.