Treating M.

I AM FAIRLY CERTAIN that M. will not come to the ER tonight.

I'm not sure where she lives. I never quite get the whole story when she comes to clinic¹; there are too many other things going on with her. Immeasurable complexities thwart attempts to examine the minutiae — which of her friends or sister's friends she is staying with, who brought her to clinic in the first place, and the nearly unfathomable fact that she managed to enlist someone sober enough to drive.

For M., sobriety and health are unattainable luxuries. Although I am working towards a profession that specializes in providing answers, I believe that for M., the discovery of yet another undoing will be an ungainly albatross and insufferable companion as she slogs through the proverbial marshes of addiction and loss.

It is at once disheartening and reassuring to see how small a thing diagnosis is. I orbit around it constantly, along with a belt of symptoms, pathognomonic phrases and eponyms.

Together we are rings of a giant planet which draws us ever closer, as if all the universe centered on that one, tiny word.

Diagnosis.

Last Saturday, M. was inconsolable. When I arrived at the mobile clinic, she was on the sidewalk, hysterical; she pulled my hand to her chest near her armpit, where I felt the lump.

Words tumbled past me onto the concrete. Words like cancer and anguish, assurances that she's buying black market methadone.

Just booze. No heroin.

Need can be articulated in ways innumerable. The manner in which we choose to express ourselves reveals what is most human in us; the process of asking reflects not only the nature of our desires, but the extent to which they have been sated during a lifetime. I am learning to recognize the ways frailty can be revealed, and believe actual verbalization stems from either wisdom or profound urgency. Since my indoctrination to medical school, M. has been the only person to express such forthright defeat; and in that moment I was released from an almost unforgiving desire to be The Solution.

M. is the epitome of the type of person our clinic hopes to serve. Indigent, uninsured and Hepatitis C positive, she has a long-standing relationship with daily heroin use; it manifests itself monthly with a barrage of purulent abscesses.

Two years ago, her baby boy died after a painful struggle with Ewing's sarcoma. On days when she chooses to discuss it, M. appears to have lost him only the week before. Her grief is palpable, ragged, fresh.

Moreover, she bears the disfigurement seen only in those with the worst of upbringings. Her childhood memories are characterized by a veritable profusion of traumatic events, and at times I am shocked she is still here at all.

Despite the challenges, she retains a remarkable enthusiasm for life. A self-proclaimed regular at our clinic, she bounces into the exam room and rattles off the most recent psychic and health-related nuisances (for in moments they seem no more) that plague her. She shows me her abscesses, describing in an instant details that, with some patients, take 20 minutes to elicit. The art of a focused examination is not yet one I can claim; even with pocket-sized note cards and guides, I manage to overlook important details.

With M., I become an unexpected expert. Drawing on months of experience caring for her son, she remembers terminology I have forgotten, points out signs I would not see. During incision and drainage procedures, she practically wails (her pain tolerance is extraordinarily low) but manages to direct my manipulation of her wounds so that the procedure is successful. Best and always, M. makes me laugh. She is truly remarkable.

But I don't believe she will come to the ER tonight.

The upshot of that last appointment was a decision to refer her beyond the limited resources of our two-room clinic, wheels and engine notwithstanding. True to form, M. has no health insurance and, predictably, her only other access to medical care is the emergency room. She is frightened of a hospital she associates with the loss of her son, a battle with endocarditis or, and not least, necessary but traumatic visits to the ER.

It was lucky, then, that I was to spend a night in emergency services that very week, and M. agreed to come.

So here I am, my first night in this place. The scrubs and stethoscope are delightful sources of pride and I am blissfully enjoying the easy role of knowing nothing, watching everything, and feeling what it is to begin.

In my mind, I am perched at the bottom of a soaring ladder, feet dangling in the sky like specks of light in a vast constellation I have only begun to understand. I am, somehow, happily, no one. My knowledge is meager, rudimentary; relevant experiences I once deemed notable seem very nearly pedestrian. I am naïve and unproven, but know with the strongest conviction that the mystery of becoming a doctor will unfold with great beauty, for I have learned to be compassionate.

At 9 p.m. I walk out to the triage area.

Ah, providence. M. is here.

I am mildly dismayed, though not at all shocked to find her engaging in a psychic and verbal skirmish with the triage nurse, who is cantankerously attempting to take her blood pressure. She is crying, he is carping; she is swearing, he is growling. When I enter she crumples to me in an embrace that belies her inebriation but is dignified by affection.

It is fortunate I was not present to ascertain which of the two — nurse or patient — initiated this little war. I thus remain an advocate for both, knowing the frustration of trying to help a seething patient, yet sympathizing with someone who may never experience the respect and kindness I love so much in medicine. I do not disdain the nurse's demeanor, neither am I spurred to tell M. that her indignation will only make things worse.

After leaving the RN with his umbrage and exasperation, we find — not surprisingly — that the wait is at least 12 hours.

Twelve hours!

I could spend as much time championing the boons of urgent care as I could grumbling about the barriers to its access. My application to medical school was bent around phrases like, Emergency Medicine's uniqueness lies in its connection with the underserved; all that separates these doctors from the streets, the nighttime and afflictions of our communities are a set of sliding glass doors.

The emergency department was never "ER" to me. I've been stirred by NBC's version of life and death and, begrudgingly, will confess to the occasional daydream featuring an impossible me, busting through double doors astride a gurney and patient who's been intubated with a McDonald's straw post-rescue from a frozen lake, burning building, or some place that required rappelling.

But this whimsy is filed away with the sports dreams and Broadway shows of my mind; my vision of emergency healthcare retains a certain nobility that does not tolerate leading roles or background music.

Emergency medicine is alive, has a pulse. It reaches into the community with great tentacles, far into abandoned homes and behind vacant buildings. From my home at night, I hear it breathe: the brusque staccato of helicopter, the urgent keening of ambulances. Doctors, nurses and patients ebb and flow, finding respite in moments spent elsewhere. But the ER never stops, never rests. It is constantly seeking, constantly waiting: a nucleus of hope and chaos and survival. The critic in me will always find faults, but I will never cease to reserve small moments of homage for that which helped shape my commitment to medicine.

Still, the idea of M. and her sister sitting stoically in the marine décor of this waiting room for half a day is laughable. I imagine it: they are two teensy crabs scuttling back and forth among the horde of glum mussels who wait dispassionately for their turn. I look at the rows of chairs, the slumped and sullen patients-to-be, see an uncomplaining mother with a wailing infant, hear the sporadic coughing and sneezing punctuated by an occasional snore.

An inward sigh accompanies the realization that this won't work — not for this patient, and not tonight.

M. evidently feels the same, though likely without the nautical imagery (inescapable to me, given the fish and sea-fauna on the walls).

It is then that the most startling thing happens.

M. turns to me and declares, "I didn't come here tonight for medical care. I came here because I made a promise to you. I want you to trust me, and to believe the things that I say."

She reaches in her pocket and pulls out an orange pill bottle, pours the tablets into her palm. It's methadone, a prescription she filled on Saturday. "Look, you can count them. I didn't sell them, I took the right amount. And no heroin, I swear it."

I learn, then, one of the priceless secrets that all good doctors must hold close to their hearts. My conduct towards M. has been nothing more than a reflection of what kind mentors taught me, yet somehow she finds wisdom in this.

All that the moment could be for her, it feels doubly so to me.

It is as if I have reached an exquisite milestone in my education, a turning in the course of my growth. Becoming a physician is more than acquiring professional skills. Should one desire it, the path is a tutelage born of integrity; it begets both insight and depth of character.

After M. is gone and I am walking back to the code-keyed doors of the ER to rejoin the ranks of healthcare providers, a woman approaches me.

"I was talking to that lady who just left, and she says you are this amazing doctor. I have Crohn's disease; can you help me with that?"

And inside I am laughing, because it was just months ago that I thought this was a disease that an old crone might get — an erstwhile "Learning Objective" that took five weeks of FAP400 for me to understand before subsequently pigeon-holing it as a rare and unimportant gastrointestinal something-or-other.

"No, I'm a medical student," I tell her. "You'll have to wait to see the doctor."

elven@ucdavis.edu

1. The "clinic" is the Joan Viteri Memorial Clinic (JVMC), a free, mobile clinic with the primary purpose of serving injection drug users, sex workers and their families. It is one of six student-run clinics in Sacramento.