100 Words a Minute Tuesday, Jan 19 2010 

I met with a young  woman who had questions about insurance. Four months ago she started feeling a little dizzy and her ability to think clearly slowed down. This worried her because she was a part-time, but mostly unemployed computer consultant whose job was to fix complex problems for corporate clients. She proudly confided she typed 100 hundred words a minute with 98 percent accuracy. The morning she couldn’t type 20 words in two was the day she knew something was terribly wrong. She couldn’t get words out of her mouth. Her husband commented, “Honey, the left side of your face is drooping.” They rushed to the nearest emergency room. The doctors thought she was having a transient ischemic attack (TIA), but weren’t sure because she was so young, exceedingly healthy, didn’t smoke or drink and wasn’t overweight. The ER docs needed to do a CAT scan. She was asked if she had insurance. That would be no. My patient was then informed the charge for the scan would be about $3000. The urgent, potentially life saving CAT scan was politely refused. 

At home the couple did an exhaustive computer search for the cheapest CAT scan. They did exactly as some health care reformers had advised: shop around for the best health care deal. For gods sake go to the website “Price Grabber” and compare prices. They might even have a coupon. Come on! Get a deal on that brain scan! Why pay more? No matter the arteries in your brain might be about to blow or bleed out, or you may lose the ability to use half of your body – find the least expensive CAT scan in the metro Chicago area. Don’t contribute to the high cost of health care in this country. 

The woman’s husband drove her to the County ER a few days later. You see –  there is no affordable CAT scan for the uninsured.

The patient said with gratitude in her voice: “I came to County because I knew they would take care of me.”

I hear these exact words consistently from my uninsured patients: “I came to County because I knew they would take care of me.”

This story has a happy ending. The patient suffered minimal, short-term effects from the TIA and the delay in care, and is on her way back to typing 100 words a minute.

Blue Line Sunday, Jan 10 2010 

It never ceases to amaze me what patients risk to get to County for health care because they’re uninsured and don’t want to incur thousands of dollars in medical bills. The emergency response system works this way: An ambulance by law must take a patient to the closest ER. No exceptions. But that doesn’t work for people who are uninsured and County isn’t the closest ER. So they argue with 911 operators and plead to be taken to County. When the ambulance arrives they beg the EMT’s to take them to County. They refuse to get in the ambulance if it won’t take them to County. An ambulance ride is safe and quick but to avoid medical bankruptcy some choose to drive or take public transportation which is dangerous because care is delayed.

My middle-aged, uninsured patient with diabetic retinopathy and peripheral neuropathies lived far away. He was legally blind. In an emergency he would never be brought to County but instead to the hospital a few short blocks from his home.  He started experiencing stroke symptoms and told his wife. They didn’t even bother to call an ambulance. They jumped on a bus that dropped them at the Blue Line train and came to County. That took almost 2 hours. The patient waited in the ER for 5 more hours until doctors diagnosed him. 

There is a golden window for stroke patients: 3 hours. If they get to the ER within that window and receive a powerful clot busting drug called T-PA (Activase), the chances are good they’ll survive with little to no deficits in brain function. Doctors can even insert the drug directly into the affected artery which is even more effective.

3 hours and the window closes. 7 hours, SOL, shit-outta-luck. The doctors told the patient he would probably suffer residual disabilities from the stroke. And he did. According to his wife his memory was now poor, he was often confused, and he had more falls. The man could never be left alone.     

Over 300 patients are seen every day in the County ER. That’s 10,000 patients a month.

There are over 1 million people uninsured in Cook County.

Add it up: Blue Line, stroke, uninsured, overcrowded ER, 7 hours.  

7 hours too late.

I’ll Be Home For Christmas Thursday, Dec 31 2009 

Here are 2 Christmas stories to both break and warm the heart.

December 22nd, 1 o’clock. My patient, Emmet, drove me crazy. He had signed the list on the counter to talk to me and when I saw his name my heart sank. I dreaded meeting with him, didn’t call his name and instead called patients on the list that signed after him.  I hoped he would get tired of waiting and leave but that probably wasn’t going to happen because Emmet was homeless and had no where to go. He was caucasian, small in stature, sweaty forehead, beady eyes and sooo needy. It wasn’t clear what his diagnosis was. Psychiatrists at Fantus don’t put notes in the electronic medical record. Lovely. So I diagnosed him with a personality disorder. The man monologued in a sleep/deep snore-inducing monotone without pause. It was only necessary to utter an unhuh, okay, every couple of minutes. He would not stop. It was impossible to have a conversation with him – he did all the talking. He talked and talked and talked until I interrupted.

The monologue always covered the same issues: homeless, persistent cough, hep B, hernia; no money to buy transit cards; missing his mother.

A few months before, I had given Emmet $20 to buy a bus ticket to go see his mother. Elderly, sick and frail, she lived in a nursing home. He always referred to her as mother, never “my” mother. He would say, I need to see mother. That irritated me -him not using “my.” But instead of purchasing a bus ticket, he spent the money on other things. Emmet sheepishly apologized the next week in my office. I explained the apology wasn’t necessary because the money was given with no strings attached.

I went over to Firm A and found my buddy Ben, one of the attendings. I needed some advice. I knew Emmet was going to ask for money and I wasn’t sure what to do. I wanted to give him the money because it was Christmas and he should be with mother, but I didn’t want to set up a dynamic where I’d constantly be asked for money. I told Ben, “I’m running out of empathy for this patient.” He said he understood and asked if the patient drank or used drugs. He didn’t. Ben said he had given patients money before. We talked some more, he jokingly asked for money to buy a plane ticket to Nigeria, then I went back to Firm C with a plan A and B and called Emmet’s name.

The monologue began. Ugggh! Shoot me now!

It was almost Christmas and Emmet didn’t have money for a roundtrip Greyhound ticket to Moline to see mother. He wasn’t asking me for money though, he just wanted to let me know he was desperately trying to get back there to see mother for the holiday. And on and on he went, pulled back down into the whirlpool of his sad life, spinning the same sad stories in a circle without end. Mother, mother, mother… I stopped listening and thought about how to give him the money and get him out of my office. Once given the cash I wanted him to leave immediately. I couldn’t stand to hear him thank me profusely and submissively as he’d done when I gave him money the first time. I felt profoundly embarrassed by the cash transaction. The only way to do it was to be firm and rude if necessary – tell him I had another patient waiting and he had to go. I said, “Emmet, if I give you $20 will you accept it?” He said yes. I went to my green coat, took the blue wallet out and grabbed a crisp, green twenty-dollar bill and handed it to him. He was stunned and said thank you, Helen, and launched into another monologue. I got up from my chair and went into the hallway and replied, “You are welcome, Merry Christmas, but now you have to go, I have another patient.” Still launching. I got rude, “Now Emmet, you have to leave right now,” and I left him in my office and walked to the waiting room. Lucky for me another patient had signed the list and I called out the name as Emmet came through the door. He put out his hand to shake and said thank you again.

All I felt was relief that he was finally leaving the clinic. 

I sincerely hoped Emmet used the money this time for a bus ticket to Moline to see mother. I vowed not to give him money again.  

                                                             *****

December 22nd, 2:30pm.  Louva, of the clerks at the front desk, was on a mission.  She had one of the smokiest, raspiest, gravel-coated voices I had ever heard. And she was loud. She  informed me she was helping a patient get out of a nursing home in time to be home for Christmas. Nursing home staff insisted the woman had to have an appointment with her primary care doctor and get prescriptions filled. Louva  was working on that  – could I arrange transportation? Yes. The thought of anyone spending Christmas in a nursing home made me want to cry and was all the motivation I needed to make sure she got home to her family. I started making calls immediately.

Transportation arranged, patient left the nursing home and came to her clinic appointment the day before Christmas. Louva came to my office and said the woman and her husband wanted to meet and thank me for arranging transportation. I felt profoundly embarrassed. I didn’t need thanking. I was just doing my job, but I couldn’t say no, that would be rude. I wasn’t prepared for the train wreck that she was. The husband wheeled her into my office and she declared she was exhausted and in pain from sitting up for 5 straight hours (she had been laying in bed in the nursing home for weeks and didn’t realize the waits at County are killer.) 

The woman had stroked out; the right side of her face and cheek were contorted into a bulbous, super-tight knot and she spoke awkwardly out of the side of her mouth. Her pants were too short and exposed both calves. One was necrotic shades of blue, grey and purple. The other was encased in a hard, plastic, black boot that made me think of the villains in James Bond movies whose artificial limbs and gold teeth become dangerous weapons. The boot was very cool. But the purpose of the villainous, black boot was to heal the bone-deep, diabetic ulcers that were eating away at her foot.

They thanked me for arranging the ride and we chatted about life for a few minutes. The two had been married for 40 years. Wow! I asked what the secret was to such a long marriage. They laughed and said in unison – we love each other.

He Had Me At Heroin Tuesday, Dec 29 2009 

Antwoin was scrawny – above all was a businessman. His business was selling drugs and he was extraordinarily good at it. I learned a wild chapter in his life. I was mesmerized and he knew it. He had me at heroin. Black gangsta’ ghetto thug, former drug lord autobiography. Shocking the nice, white social worker who was happy to listen.

Antwoin worked his way into the upper echelons of the Blackstone Rangers. He controlled turf, gang bangers reported to him, he counted the cash, was respected and feared. He made pots of money, what is sometimes called, “fuck you money.”  The cash bought him power and prestige. He was pimping big-time. Shaft. Girlfriends, ho’s, pro’s, baby mamas, addicted desperate drug fucks, back seat crack bangs, sexing any woman he wanted. Driving Caddies, buying large homes with cash (fuck banks and monthly mortgages), clothes, jewelry, Crown Royal, Courvoisier, shooting the best dope and shooting guns. Super Fly. Having fun.The good life! 

He supported his mutha, fahva, sistahs, bruthas, anties, uncles, baby mamas and kids.

Antwoin had been shot, stabbed, beaten by bricks, bats, fists and left for dead many times over the gangster decades. He said he owed his life to the County ER.

He preferred to settle gang and commercial disagreements with calm discussion, not by gun clapping. It was, after all, just business. But he admitted that wasn’t always possible, thus the need for regular, emergency medical care.

He told me about being held captive by a crazy, jealous girlfriend. They spent a drug-fueled night together shooting heroin, drinking and having sex. Antwoin eventually passed out. When he woke up he was tied naked and spread-eagled to the bed. The woman was obsessively in love with him and demanded he profess his love for her only. Antwoin wouldn’t. The woman accused him of killing another man she was having sex with. He smiled and snickered when he told me this.   

Antwoin had a problem with love. At a young age he saw how his sisters treated men: they lied, cheated, played mind games, broke hearts and put male “black asses out on the streets.” Antwoin swore he would never let a woman get close to him or fall in love. Better and safer to be a ghetto enigma. But there was one woman he loved and she rejected him.  She had recently died and that triggered a massive drug binge he was trying desperately to end.

So there he was, tied to the bed. I asked how he urinated and defecated. The woman put a bed pan under his buttocks and his flacid penis in the neck of a bottle. She cleaned his genitals daily. The girlfriend went to work during the day and when she returned, attended to his every need. Food, booze, music and sex. Bondage party time. She performed oral sex on him, sat on his face and they had intercourse. Every night. I said, “Antwoin, she raped you,”and he gave me a confused look. It had never occurred to him that it was rape. That he was violated. Antwoin thought the sex was hot. But he would not be bowed, broken or sexed into saying the magic words that could free him.

The iron discipline he used in the drug trade got him through each day.   

Finally after 5 days someone came into the apartment – the door was left unlocked – and found him. Once untied, murder was on his mind but Antwoin said it was more difficult to kill a woman; and he reasoned, because the girlfriend loved him, she imprisoned him out of love.

                                             ********   

The empire crumbled and all that was left were the addictions and stories of the glory days.

Antwoin was 40, homeless, penniless and wearing green paper pants given to him two days earlier in the ER.

Just another rags to riches, to back to rags prohibition era life.

Moyamoya Sunday, Dec 27 2009 

Moyamoya means “puff of smoke” in Japanese. It’s a rare and bad brain disease that causes transient ischemic attacks (TIA), mental decline, aphasia. My 15-year-old patient had it. Her chart contained the following: plethora of MRI brain findings – aneurysmal outpouchings, sequelae of vasculopathy, parietal-occipital gliosis.

The patient couldn’t speak but smiled brightly and embarrassingly. Imagine a teenager not being able to talk.  The young woman had lost her appetite and looked like a bag of bones in her pretty, pale, blue sari.

She was brought to the clinic by her sister and father and the two switched between Hindi and English effortlessly. The family’s love and devotion to her was absolute – I could see it in their eyes and hear it in the tone of their voices.  But they also exuded the fear, panic and desperation that always accompanies the diagnosis of a potentially, fatal illness.

Two months earlier she was living a normal life. The decline was slow and perplexing. At first they thought she was depressed and sent her to a psychiatrist. She was put on several medications but didn’t improve. Next a battery of neuro-psych testing. Inconclusive. Language atrophy, mental confusion. Finally MRI. Bingo. Tentative diagnosis of Moyamoya. Then definitive.

The teen was uninsured, could I help them get insurance? Then there was the moment I always dread: I have to ask if the patient is documented or undocumented. The answer to that question can mean the difference between life and a hellish and messy death in the greatest Democracy in the world – The United States of A lot of uninsured.

She was born in Chicago – thus documented!

When I said she would definetly get Medicaid, smiles all around. And then tears. Including mine.

Note Found in Clinic/Second Floor Saturday, Dec 19 2009 

There is an area on the second floor in the back of the clinic where all the broken furniture ends up. I found a small white rectangular piece of paper [the ink was blue, the writing in cursive] among the discarded chairs and file cabinets.

It said: “Sorry I took your magazine. Our Daily Bread is one of my all time favorites. I need some spiritual uplifting in these troubled times. Our Daily Bread came to my rescue when I first started searching for God. Each page is a pearl of wisdom. Thank you. A. K.”

Poem/Extra-Pyramidal/Side Effects Saturday, Dec 19 2009 

tics

grimaces

blinking

chewing

lip smacking

puckering

sucking

thrusting lower lip

tongue thrust out

tongue in cheek

tonic tongue

tongue tremor

lateral tongue

pill rolling

foot tapping

toe movement

A Reason to Visit Saturday, Dec 5 2009 

In the electronic medical record there is a column with the heading; Visit Reason. I looked at the column for a patient of mine with a long psych and drug using history. He is homeless. During a therapy session he confessed that he had stabbed six people.

Depressed w/suicidal ideation

Suicidal

SI

Depression /no SI/HI

Med refill

Rt. foot and Rt. ankle frostbite

Swelling left big toe

Difficulty swallowing

G.S.W. (gun shot wound)

Suture removal

Facial hemorrhage/laceration

Hematuria

Left testes swelling

Genital warts

Abnormal lab test

SUICIDAL

We Shall Overcome Saturday, Dec 5 2009 

Mid-morning I had to go over to the hospital for a meeting and as I stepped outside of the clinic building, I heard and saw a heavyset Black woman singing in a loud voice the famous civil rights song, “We Shall Overcome.” Except she added new, original lyrics. “We shall overcome, we shall overcome and if we don’t, fuck it, fuck y’all.” Over and over again, We shall overcome, we shall overcome and if we don’t, fuck it, fuck y’all.

Stumped Saturday, Dec 5 2009 

A doctor left a note on my desk that asked the following:
Helen,
Would you be able to help a patient who had his foot amputated and cannot afford a prosthesis? (He just stuffs cotton into his boot and sticks his stump in) If so page me or leave a message and I will refer him to you.

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